Our Goal : Zero Defect, Zero Breakdown

Root Cause Analysis

Content 1. Objective 2. Basic Approach 3. Example

Our Goal : Zero Defect, Zero Breakdown

Objective
Zero Defect Zero Breakdown Zero Safety Risk Low Maintenance Cost Higher Productivity Effective Operability Low Variability

Our Goal : Zero Defect, Zero Breakdown

Approach
A disciplined method using a logic tree A logic tree is required to represent Cause and effect relationships that lead to surfacing the undesirable event

Our Goal : Zero Defect, Zero Breakdown

Approach

What is the Logic Tree

A graphical way of representing Cause and effect relationship.

What is the cause and effect relationship ??

This will be explained in the coming slides during the presentation

Our Goal : Zero Defect, Zero Breakdown

How to do the 5 - Why Analysis

Our Goal : Zero Defect, Zero Breakdown

How to do 5 - Y Analysis Step 1: Identify the undesirable event and its associated reason with supporting facts

Important
Facts are supported by some essence of science, direct observation & documentation

Our Goal : Zero Defect, Zero Breakdown

How to do 5 - Y Analysis

Step 2:
Once identified the effect and reason. Find the reason as HOW did it fail

Important
Do not work out for assumptions. Only physical evidence, technical reason is valid.
Our Goal : Zero Defect, Zero Breakdown

How to do 5 - Y Analysis Note: The facts cannot be hearsay or

assumptions !!
BUT Supported by

Evidence of MODE/ Reason

Our Goal : Zero Defect, Zero Breakdown

The End !!

Our Goal : Zero Defect, Zero Breakdown

If the above steps are so simple then...

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If two guys are made to do the RCA of the same problem

WHY is Possibility of difference in the conclusions drawn by them

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Where is the Gap ???

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What is required to be done

Thus Improving the credibility and communication of the results

We need to explore the discipline necessary to provide consistency to our RCA Application

Our Goal : Zero Defect, Zero Breakdown

How to do it
How to improve credibility and communication of the results.
Impart training to bring a common understanding into the process Use disciplined thought process to seek true root cause We are not checking the thought process that drew the conclusions Better Understanding

Our Goal : Zero Defect, Zero Breakdown

Now let us do a 5 - Why analysis with an example .Hmmm undesirable Event

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Sir, Pump bearing failed

Ask the fitter to Change it. Pump should start now..

Our Goal : Zero Defect, Zero Breakdown

What was the problem

What did we do
What was to be done

What was the reason

Come on.. lets do the Root Cause Analysis

Our Goal : Zero Defect, Zero Breakdown

Getting Started..

From Where do we start

Why did Pump Failed ??

OR

Why did Bearing failed ??

Our Goal : Zero Defect, Zero Breakdown

Root Cause Analysis

First Why
Our Goal : Zero Defect, Zero Breakdown

From where should I begin...

When the event occurred, why was it brought to our attention

Because the bearing failed OR

Answer :

Because the Pump Failed

It was brought to our attention because

the failed bearing caused a pump to stop pumping Oil. Therefore the last effect that caused us concern was the pump failure

One reason (MODE) that pump failed was due to bearing failure Our Goal : Zero Defect, Zero Breakdown

Objective Evidence
Evidence :
How can you say that it failed because of bearing?

Answer
Physically observed.

Thus we have
Event :Pump Failure Mode : Bearing Failure (Supported by evidence)
Our Goal : Zero Defect, Zero Breakdown

Logic Tree

Effect

Pump Failure
WHY

Reason

Bearing failure

Our Goal : Zero Defect, Zero Breakdown

Cause and Effect Relationship

Thus is any step of evaluation (first Why to 5 why)
One is the effect and Other is reason(s) Each reason is to be evaluated with evidence to justify the reason

Thus the relationship between the cause and effect lies with the

Evidence
Our Goal : Zero Defect, Zero Breakdown

Cause and Effect Relationship Example :Bearing Failure caused a pump to stop working.

Last Effect is : - Pump Failure

Mode (reason) - Bearing failed : Evidence of Mode ( Reason)
Our Goal : Zero Defect, Zero Breakdown
Relationship

- Physical evidence

What is Evidence
It can be any clarification based on
Technical Reasoning Physical Evidence Supporting data viz..Asset care, Condition Appraisal, Log book etc

BUT CANNOT BE BASED ON ASSUMPTIONS

Our Goal : Zero Defect, Zero Breakdown

Learning from this

For any undesirable event (Effect) ..there is one or more reason(s)
And we need to hunt them down For any reason (mode) / Cause we find..we need to justify it With a objective evidence

Cause / Reason

Effect
Objective Evidence

Cause Effect Relationship

Our Goal : Zero Defect, Zero Breakdown

MODULE

Second Why
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Often it happens we tend to conclude faster with our preset mind

Jumping to Conclusion

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Why did the bearing Failed ??

Dear brother it failed due to some foreign particle Entering in it Mind Set We perceive a problem to exist and we go right to what the most obvious cause is to US

This is the FINISHED PRODUCT APPROACH

No doubt we cannot deny this reason.but need to have an evidence

Our Goal : Zero Defect, Zero Breakdown

Finished Product Approach : We perceive a problem to exist and we go the right to what the most obvious cause is TO US !! We do not validate any of our assumptions, we just assume a cause and spend money to implement a fix and hope it works Experience shows this approach to be ineffective and very expensive.

Our Goal : Zero Defect, Zero Breakdown

Now Let us find the Second why but in a different way ??

Our Goal : Zero Defect, Zero Breakdown

Why How did can the bearing Fail ??

HmmErosion, Corrosion,Fatigue, Overload

Mind Set For this we need to think we an open mind. At times we need to consult others

This is the DISCIPLINED THOUGHT PROCESS TO SEEK RESULT

Our Goal : Zero Defect, Zero Breakdown

Continuing our search backwards for the cause and effect relationships
We would then ask How can a bearing fail ?? Our Hypothesis may be Erosion, Corrosion, Fatigue, Overload

How can we prove which are true ( Evidence)

Note : We asked How can a bearing fail and not Why did a bearing fail How can it fail -----this is brainstorming Out of the various reasons you brainstormed, you look for the evidence. And then conclude..bearing failed.why.due tofatigueevidence...

Our Goal : Zero Defect, Zero Breakdown

Search for Evidence

Hypothesis Erosion,Corrosion,Fatigue, Overload High Vibration Misalignment Verification Techniques

Metallurgical Analysis Vibration monitoring inst.

Laser Alignment technology

While carrying out the investigation, metallurgical and physical test proved that it failed due to fatigue.

Our Goal : Zero Defect, Zero Breakdown

Logic Tree
Pump Failure
Why

Effect Reason

Bearing failure
How Can ?? Why

Erosion

Corrosion

Fatigue

Overload

Our Goal : Zero Defect, Zero Breakdown

MODULE

Third Why
Our Goal : Zero Defect, Zero Breakdown

You can now see that as we develop new sets of hypotheses, we are proving what we say at each level of the process. This is demonstrating quality of process. When we continue this reiterative process, we are validating our conclusions each step of the way. This way, when we draw our conclusions about root causes, they will be right because we have supported them based on fact and not mere assumption.

Our Goal : Zero Defect, Zero Breakdown

Logic Tree
Pump Failure
Why

Effect

Bearing failure
How Can ??

Erosion

Corrosion

Fatigue

Overload

How Can ?? Reason

High Vibration

Evidence / Notes for clarification: Asset Care Check list states vibration was observed from past 5 days (PAST DATA)

Our Goal : Zero Defect, Zero Breakdown

MODULE

Fourth Why
Our Goal : Zero Defect, Zero Breakdown

When most people conduct their version of Root Cause Analysis (RCA), Where do they usually stop? How do they know they are done? How do they know that the problem will not reoccur? These questions represent reality when we are the ones in the field working on a pressing problem with management on our backs. If we consider ourselves manufacturing detectives, are we content with the stopping at the HOWS or the WHYS

Our Goal : Zero Defect, Zero Breakdown

Logic Tree
Pump Failure
Why

Bearing failure
How Can ??

Erosion

Corrosion

Fatigue

Overload
How Can ??

Effect

High Vibration
How Can ??

Reason

Imbalance Misalignment Resonance

Our Goal : Zero Defect, Zero Breakdown

MODULE

Fifth Why
Our Goal : Zero Defect, Zero Breakdown

Logic Tree
Effectanalysis Rot cause

Pump Failure
Why

3 4 5 2nd 1st rd th Why Effect Rot cause analysis

How Can ??

RootReason Cause Analysis

Bearing failure

Erosion

Corrosion

Fatigue

Overload
How Can ??

Effect Reason Rot cause an

Root Cause Analysis Effect

High Vibration

Root Cause Analysis Reason

How Can ??

Reason Effect

Imbalance Misalignment Resonance

Why

Reason

No Procedures

Inadequate training

Improper Tools

Our Goal : Zero Defect, Zero Breakdown

Now tell me when we typically conduct analyses, are we more like a engineer or the prosecutor and the detective looking to win his case?

What is the difference between the those roles?

Our Goal : Zero Defect, Zero Breakdown

How to do it
This means that a certain sequence of cause and effect relationships linked up and resulted in the undesirable event. Their role is to prove that each hypothesis did or did not occur. Yes !! they in essence will map out HOW the crime occurred and be able to prove that it happened just that way.

Then what is the role of prosecutor and detectives??

Engrs role is to determine with science HOW event occurred ?

Role of prosecutor & detectives is typically to determine WHY.

Our Goal : Zero Defect, Zero Breakdown

Summary: First WE must provide the HOW pieces of puzzle and then determine why decisions that lead to the undesirable outcome

We should use our Technology to prove or disprove our hypotheses and then explore Why people make decisions that result in the undesirable outcomes or failure

Our Goal : Zero Defect, Zero Breakdown

Let us look at the example we studied.

Our Goal : Zero Defect, Zero Breakdown

Logic Tree
Pump Failure
Why

Bearing failure
How Can ??

Erosion

Corrosion

Fatigue
High Vibration

Overload
How Can ??

Physical

How Can ??

Reason Effect

Imbalance

Misalignment

Human

Resonance

Why Improper Tools

Reason

No Procedures

Latent

Inadequate training

Latent

Latent

Our Goal : Zero Defect, Zero Breakdown

The undesirable event is : pump failure We must understand the cause and effect relationships that lead to the event This will require evidence to prove our hypothesis Hypothesis Erosion,Corrosion,Fatigue, Overload High Vibration Misalignment Verification Techniques Metallurgical Analysis Vibration monitoring inst. Laser Alignment technology

These questions answer how?? But what about why

Our Goal : Zero Defect, Zero Breakdown

In this case someone misaligned a pump and that decision resulted in a sequence of cause & effect relationship that caused the pump to fail prematurely.

Our Goal : Zero Defect, Zero Breakdown

Now the question is WHY would a person choose to align in that fashion !!

Our Goal : Zero Defect, Zero Breakdown

If we were to go deeper & understand the thought YES process Exactly or !! the rational for such a decision (Latent Root), we would uncover the REAL ROOT CAUSE.

I got it!! It means that either he was not trained No SOP available, tools worn out or inadequate

Our Goal : Zero Defect, Zero Breakdown

If we do not explore the WHY, then HOW is likely to reoccur

Our Goal : Zero Defect, Zero Breakdown

If you now reflect on your current RCA efforts, do you stop at the how or at the WHY

Our Goal : Zero Defect, Zero Breakdown

Think about it.

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Thank You !!

Our Goal : Zero Defect, Zero Breakdown