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Articles: Root Cause Analysis
Basic Elements of a Comprehensive Investigation
By Mark Galley, ThinkReliability
The terms failure analysis, incident investigation, and root cause analysis are used by organizations when referring to their problem solving approach. Regardless of what it’s called there are three basic questions to every investigation: 1 - What’s the problem(s)? 2 - Why did it happen (the causes)? and 3 - What specifically should be done to prevent it.
I suggest that everyone in Reliability read the report Deepwater BOP Control Systems - A Look at Reliability Issues attached below.
An Important Aspect in Root Cause Analysis
by David Gluzman
Follow up to the article, "Preventing Mechanical Failures - An Introduction to Failure Mode Identification" - Feb/March 2012
Is an overload fracture ductile or brittle? This question must be answered when analyzing parts. Mitigating factors that can impact the answer to this question should be considered when analyzing a failed component.
In 1950s Japan, Kaurou Ishikawa became one of the first to visually lay out the causes of a problem. His fishbone, or "Ishikawa Fishbone," helped visually capture a problem's possible causes and,ltimately, has become a standard in corporate-quality and Six-Sigma programs. It begins with a problem, then identifies possible causes by separate categories that branch off like the bones of a fish. Its categories-typically including materials, methods, machines, measurement, environment and people-can be modified to better match a particular issue.
By Thomas Brown
Failure mode identification is often regarded as a specialized skill requiring years of study and training to master. However, it is much like vibration analysis. One does not have to be able to solve mathematics functions like Laplace transforms or Fourier series to be an excellent vibration analyst. Nor does the failure analyst have to solve linear elastic fracture mechanics problems to be effective.
Solving problems effectively is part of being an effective organization. The individuals and groups that tackle problems in organizations today sometimes inadvertently focus on the people or departments involved rather than the specific causes of the problem. This creates an organizational culture that focuses more on blaming other groups and individuals than preventing problems from occurring.
Heinz P. Bloch, P.E.
When performing reliability audits decades ago, pump failure statistics were made available or could be recovered with relative ease. But even then, the sources were usually kept confidential because fire incidents are stressful, to say the least.
(See Figure 1).
Root Cause Failure Analysis (RCFA) has an important place in a complete maintenance program. Root Cause Failure Analysis provides the ability to identify and eliminate preventable root causes of failures.
It can be used in a wide variety of situations and like Reliability Centered Maintenance (RCM) there are a wide variety of technique variations.
Organizations apply a variety of tools to solve problems, improve operations and increase reliability—many times without success. Why? More than likely, they make one or a combination of six common errors:
1. They focus on blame.
2. Conducting root-cause analysis, they focus on finding one “cause.”
3. They consider a problem description and problem analysis the same thing.
4. They start an investigation by trying to find the problem, instead of identifying an organization’s
5. They apply “buzzwords” instead of the basic technique of cause-and-effect.
6. They use select problem-solving tools for select circumstances.
Overcoming these errors involves knowing why they happen and how to prevent them. Armed with this knowledge, both employees and managers can improve problem-solving in any organization.
This paper will discuss advantages of combining Root Cause Analysis techniques and the Navy Work Model.
by Rolly Angles, RSA, Laguna Philippines
Frequent contributor at www.maintenanceforums.com
One of the biggest confusion in an attempt to perform a thorough Root Cause Analysis is understanding how deep should we pursue our analysis or simply stated, where do we stop our investigation in performing a Root Cause Analysis? Going to deep will lead us to the bible, Timothy 6:10, For the love of money is a root of all evil and going to shallow will allow the problem to recur again and again.
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