Seems like every time a company is faced with the tragic circumstances we have witnessed over the last few weeks with the coal mine explosion in West Virginia that killed 25 workers, and more recently the oil platform explosion in the Gulf of Mexico off the coast of Louisianan, that killed 11 workers and has resulted in thousands of gallons of oil leaking into these waters on a daily basis, our news agencies and people around the world are demanding investigations as to what went wrong with each incident. Human nature demands we investigate what went wrong and who was responsible. There must be a cause, we must find someone to blame and that person should be held accountable. It would seem at times like these that finding those responsible get more attention than making sure events like these never happen again.
In truth the pain for the families who lost loved ones and the companies who will be held responsible has just begun. Moving forward experts in each field will be hired to voice their opinions regarding the likely causes. The news coverage will likely focus on the one or two most likely potential causes and several months down the road a figure head for both companies will proclaim that their company has now addressed these issues removing the chance that this will never occur again!
And, as a seasoned RCM (Reliability Centered Maintenance) practitioner I will close my eyes, say a prayer, and hope that one or two things they focused on are the only things that could have caused these American workers their lives. I say a prayer because I know as other RCM and RCA (Root Cause Analysis) practitioners know that events like these seldom have a single cause. In reality tragedies like these are typically a series or chain of events that lead to catastrophic failure and the only way to reduce the likelihood of these failures to an acceptable level is to identify and mitigate the all the failure modes that could cause them.
The real shame comes in the understanding that what has happened, didn't have to happen. While all failures might not be predictable they are all preventable. Preventing failures takes leadership, structure, discipline, resources, expertise and patience. Being honest, these are characteristics seldom seen or displayed in companies as we face a very tough economy and this being said we all have to make tough decisions so the question always turns to; What would it have cost to put a team of experts together and identify every failure mode that COULD lead to catastrophic failure? And; had we put this team of experts together several years ago, would we now be in the position we find ourselves in today?
Reliability Centered Maintenance is a very structured process that asks a series of questions to discover and mitigate the failure modes that result in functional failure of your assets. In performing this process over the past 15 years I am continuously amazed at the unforeseen failure modes we uncover as a team and while this process is not perfect the companies who elect to perform and implement RCM always see an improvement in equipment reliability as well as a reduction in health, safety and environmental incidents and accidents.
To perform a thorough RCM analysis on your equipment you need to hire a seasoned RCM practitioner who believe it or not has little or no experience in the equipment you are about to analyze (Experience brings bias and leads to missed failure modes), a team of process experts, engineers (Mechanical, Electrical, Process, Safety/Environmental) equipment operators and a cross section of trades people (Mechanical, Electrical, Instrument). This RCM team should be composed of experts who are respected by their peers who are honest and open to change. In performing analyses of asses where failure could result in catastrophic events this team will need the patience required to discuss the causes and effects of all failures that could lead to catastrophic events and in discussing these failures we can then address tasks intended to mitigate each failure mode. The most important thing to remember as you assemble your RCM team is understand that the word "Expert" requires that this person actually has hands on experience working with your equipment and the environment in which it operates.
So, while we all wait to find out what happened and why these events occurred, I really hope that we all take a step back and think what could happen at our workplace. When it comes to our people and our assets we have two choices, the first is to be proactive and identify a team to identify and mitigate failure modes, the second is to cross our fingers and let an outside team of "experts" identify a couple of things we did wrong and hope they were the only causes.