Professional Documents
Culture Documents
An essential element of Asset Integrity Management and Reliability Centered Maintenance Procedures Dr Jens P. Tronskar
Slide 4
Traditional maintenance strategies tend to neglect something important: Identification and correction of the underlying problem.
Production
Todays level
Reactive
Periodic
Reactive maintenance
Run the equipment until breakdown Overhaul and repair Extensive unplanned downtime and recurrent repair
Periodic maintenance
Scheduled calendar or interval-based maintenance Expensive components exchanged even without signs of wear or degradation Unexpected failures with incorrect schedules and component change-out
Personal Factors
Substandard Acts
Data Collection
Interviews Documents (paper) evidence Parts/component evidence
Interviewing Considerations
Where to interview Who to interview Condition of people at the scene How to handle multiple witnesses How to handle after the incident How to work with teams
Investigation techniques
A number of named techniques that are commonly used within RCA:
Step-method FMEA Bow-tie Event Tree Failure Tree Interview Fish Bone Why-Why
1
Input to Process Off-spec operation / performance : Equipment failure Trips Abnormalities Survey/Inspections/ Audits/Reviews and Condition Monitoring by Maintenance
Purpose : Register Off-spec. Operation / performance, Survey & Condition Monitoring data
Expected output from Process History of Condition Monitoring, Surveys, and Recommended Maintenance Action in Maximo
Maximo
Resources
RAM
Single operation incidents with production loss/repair cost > X Off-spec operation vis-vis (KPI) Multiple operating incidents per Tag no./ Equipment type High risk findings from survey/CM
Prepare quarterly report for HQ Surveys, Audits, Inspection, Reviews and Condition monitoring by Maintenance
No Action
Resources
Larger RCAs:
Leader appointed by the Plant manager Facilitator reliability engineer. Discipline(s) or specialists at specific plant
Optional to involve:
Disciplines from other sister plants HQ-Engineering support and technical staff Vendor Failure laboratories Other 3rd parties Specialist
2 Immediate Cause(s)
The immediate causes of an incident are the circumstances that immediately preceded the contact and can usually be seen or sensed. For example if the incident is an oil spill, the immediate cause could be a broken sealing. The Immediate Causes often are the same as the failure codes registered in Maximo.
3 Basic Cause(s)
Basic Causes are the real causes behind the immediate causes: the reasons why the substandard acts and conditions occurred, the factors that, when identified, permit meaningful management control. In case of an oil spill caused by a broken sealing, the Basic Causes could be that the sealing used was of wrong type, it had a design failure or it might be installed wrong.
4 Lack of Control
Lack of Control means insufficient oversight of the activities from design to planning and operation. Control is achieved through standards and procedures for operation, maintenance and acquisition, and follow-up of these. If an oil spill has occurred because of wrong installation of a sealing, the Lack of Control could be related to inadequate procedures for checking after maintenance.
Loss/Incident
Immediate Causes
Basic Causes
Lack of Control
Actor 1
Event 3
Event 5
Event 7
Accident
Actor 2
Event 1
Actor 3
Event 2
1. 2. 3. 4.
Event 6
Actor 4
Event 4 Actor 5
Comment
OR Intermediate Event
Component 1
And Gate E2
AND
E1
Component 2
Component 3
E3
E4
Basic Event
FMEA:
Getting overview of all potential failure Easy to use
FTA:
Identifies structure between many different failure causes Non-homogenous case (different disciplines)
Bearing Breakdown
Axial overloading Thrust washers fitted in both bearing housings Incorrect assembly Actions/recommendation: Remove thrust washers from one bearing housings
Gear Breakdown
Broken gear tooth. Fatigue initiated from quench cracks. Fabrication induced defects (Basis for discussion of liability and subsequent claims against manufacturer) Actions/recommendation: Fitting of new gears where heat treatment and case hardening procedure had been verified to be correct
Reliability assessment
Management Process-1
Other..
STEP
(Sequentially Time Event Plotting)
STEP Method
(Sequentially Time Event Plotting)
Capturing of the sequential events leading up to an accident. Can be a simple timeline Investigation of larger incidents/accidents where the time sequence is important Handles complex events with:
several actors several events in parallel a longer time horizon
Actor 1
Event 3
Event 5
Event 7
Accident
Actor 2
Event 1
Actor 3
Event 2
1. 2. 3. 4.
Event 6
Actor 4
Event 4 Actor 5
Actors
Engineer
January
May
June
Sealing
Inadequate tightening
Oil leakage
Operator
FMEA Failure Mode and Effect Analysis FMECA Failure Mode and Effect Criticality Analysis
FMEA (Cause-Consequence)
(Failure Mode and Effects Analysis)
Overview of failure mode and effect for a complex machinery/operation Getting an overview of all potential failure causes and effects at an initial stage of an investigation Requires detailed knowledge of the problem in question Easy to use for both events and for potential losses where risk is included Not good at handling time series
Technique/Working Process
Analysis Goal System definition System boundaries Operational state Limitations, assumptions Expert sessions Guided brainstorming to collect information Fill in forms Likely Causes Evidence Finding Inspections Failure Analysis Interview Exclusion
Analysis planning Find expert team Plan expert sessions (when, what, who?)
Final Causes
Cases/Examples
Design 33 %
Immediate causes
100 80 60 40 20 0
e s n ir n it es al s re nc ng tiu m pa ur ti o sti du na ig n er uc ac ed / re r e te c e e ce ls rkp a it ro ted stg pr rr ro nc in g g wo to nt on rm na i tia np ur n a t c o o co te er rki ou rd r in g nf ati i ng op a in ith wo rro er tio ato ki n ur m f r p E o d ra kw low pe d fo no rlo ing pa or os ge tio ra ur ve :O no W a a 1 io To rd ro gp 4. iol at am to rro rin A1 iol :V td ra E u 3 V en pe 3. .1: ed 1: :O 3. A1 10 l ur ip m i 1 A A1 qu 1. Fa A1 :E .4: 3 3 0. A1 A1 e l ur fai
Basic Causes
Basic Causes - work related
70 60 50 40 30 20 10 0
e e n . y k .. ... nc i.. ig PM er CM .. or ns o. s a n t t o cr r. iv w n g n n s de el te sp te in sig ie ie of de af in re td ad A fic nn de fic k a a / A B Q al la sif su or A fm tQ In on tp SW e/w In Q i o n at in g en ie ur in er ici fic n f p ge ff ed n O su an su oc ha In Pl In Pr C
No of events
Debutanizer Column
Longford Gasplant
RCFA of WHRU
Metallurgical investigation
Findings
Explosion caused by trip of turbine and leak from WHRU gas coil to header weld Following gas leak, auto-ignition of air/gas mixture occurred. The auto-ignition temperature was equal to the surface temperature of the equipment based on instrument readings Weld failure due to creep/fatigue and time dependent embrittlement of weld HAZ Damage was caused by air/gas mixture explosion equivalent to 68 kg TNT