ROOT CAUSE FAILURE ANALYSIS

• Root Cause Failure Analysis is trying to UNDERSTAND why something went wrong . . . .
• Root Cause Failure Analysis identifies the basic source or origin of the problem so that recurrence of the problem   may be prevented.
• RCFA provides a methodology for investigating, categorizing   and eliminating the root cause   of incidents with safety, quality, reliability & manufacturing process consequences . . .
• Identifying the Root Cause Failure Analysis event allows us to explain the WHAT, HOW and WHY of the failure.
• Root Cause Analysis separates the facts from hearsay. RCFA is not about trial and error and seeing what works and not.
• While there are many techniques in analysing a problem which provide a quick answer, it does not mean that the answer is correct every time. A true and meaningful Root Cause Failure Analysis takes the time to prove that what we say is fact & supports our hypothesis with evidence before we spend our money to improve the design of the equipment
• When the facts are backed up by evidence & science and they are separated from the fiction we now have a better understanding as to the real Root cause of the problem.
• Every system spares or components failure happens for a reason. There   are specific successions of events   that lead to a failure. RCFA follows   the cause and effect path from the   final failure back to its origin.
• The root cause analysis methodology provides specific & solid foundation for preventing the recurrence of the problem or failure.
• Root cause analysis is a tool to better explain what happened, to determine how it happened and to better understand why it happen . . . . .
• Failures have a pattern; we must realize that failure is actually being looked back in reverse. The root causes are actually the point at which failure began and the event is merely the result of   the root cause or how the failure manifests itself. And there is a cause and effect relationship associated with the pattern of failure.
• In performing Root Cause Failure Analysis, we are interested to know the real cause of a particular failure by verifying each hypothesis until we reach the final cause of the failure . . . . .

 RCFA LOGIC TREE DIAGRAM

• In RCFA Analysis a Logic Tree is used to work through a failure.
• The failure event is placed on top followed by all failure modes or possible causes of breakdowns.
• Each of the causes are hypothesis that needs to be verified so that we have an understanding on facts of the causes actually led to the problem
• The next step consists of determining and verifying the physical roots, human roots and latent roots behind the failure. The final   cause will always have to do with   the latent cause of failures.

PHYSICAL, HUMAN AND LATENT CAUSES:

• Physical Cause, this is the physical reason why the parts failed. This is the technical explanation on why things broke or failed
• Human Cause, the human errors of omission or commission that resulted in the physical roots. Someone did   something wrong or did the wrong   thing.
•  Latent Cause, the deficiencies in the management systems or the management approaches that allows the human errors to continue unchecked. Flaws in the systems & procedures.

WHEN TO USE RCFA ANALYSIS?

• On recurring or failures that frequently occurs when the part or component frequently fails. Or parts we replace frequently in our PM.
• When failures have environmental or Non-conformance to regulatory provisions when the cost of failure is high, such as complete shutdown of operations.
• To improve design flaws and weaknesses in our equipment in order to further lengthen   the life of the component or spare parts.
• When the impact of the failure is definitely not acceptable to the user and might cause harm and fatality.
• When the problem definitely cannot seem to go away and Reactive, Preventive and Predictive Maintenance are ineffective.

WHY RCFA INITIATIVE FAIL?

• RCFA is treated as a tool when it is really a process.
• Inadequate failure analysis and inaccurate information–fixing the wrong failure.
• Too many recommendations and poor execution.
• Lack of a discipline RCFA training and lack of documentation of the failures.
• Failure analysis being done by one person.

CONCLUSIONS: POINTS LEARNED

• Never ever accept equipment failures in your plant or equipment. Trouble shooting is no longer an effective strategy. In today’s competitive world, the teams have to find real solutions to the problems.
• Failures have a lesson to teach us and unless we learn from the failure and apply the lesson then only can we realize that failure won’t repeat itself again.
• The new paradigm is that FAILURES MUST  NOT BE ACCEPTED it can be eliminated if   we know the right tools to address them. The true job of maintenance is to eliminate failures & not fixing them all the time . . . . .
• When we get really good at fixing failures it seems that the problem keeps on repeating itself.