FRACAS - Failure Secene Investigation

by Jim TaylorCRE, CPE, CPMM

Director of Operations, Machinery Management Solutions, Inc.

www.machineryhealthcare.comhttp://blog.machineryhealthcare.com

FRACASFailure Scene Investigation

Key Takeaway: Effective root cause elimination can be done by

the average maintenance professional

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You work in a facility or plant.

You’re a Maintenance professional: A Crafts Person, a Planner, a Supervisor, a

Maintenance Manager, or an Engineer.

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Low availability and repeat failures on your equipment is affecting your production and

customer service.

You want to find and eliminate these failures.

To keep track of it all, you need a

system.

A Failure Reporting,

Analysis, and Corrective Action

System (FRACAS).

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First, You must capture as much information about the Event as you

can.

FSI

Failure Scene

Investigation

You must capture the details of the Event in enough detail to do effective failure analysis.

As found condition

Failed components

Operating parameters

Sequence of events

Fluid levels

Signs of over temperature or pressure

You are the designated

Failure Scene Investigator.

 by  West Midlands Police 

You are not the repair person.

You must capture the timeline of the Event in order to reconstruct the event.

T0 – time of eventT1 – time of trouble reportT2 – maintenance on sceneT3 – trouble shooting complete, parts orderedT4 – parts on siteT5 – repairs completeT6 – test completeT7 – system back on line

The four basic components of the failure scene

investigation process are:

The accident sequence

Physical Evidence collection

Digital evidence collection

Narrative evidence collection

The nature and complexity of the accident determines the extent to which these components are evaluated.

Arriving at the scene: Initial Response

1. Initial Response/Receipt of Information

2. Safety Procedures

3. Emergency Care

4. Secure and Control Persons at the Scene

5. Boundaries: Identify, Establish, Protect, and Secure

6. Turn over Control of the Scene and Brief Investigator(s) in Charge

7. Document Actions and Observations

Preliminary Documentation &

Evaluation

1. Conduct Scene Assessment

2. Conduct Scene ”Walk-Through“ and Initial Documentation

Processing the scene

1. Determine Team Composition

2. Contamination Control

3. Documentation

4. Prioritize Collection of Evidence

5. Collect, Preserve, Inventory, Package, Transport, and Submit Evidence

Completing & recording scene

investigation

1. Establish Failure Scene Debriefing Team

2. Perform Final Survey of the Failure Scene

3. Documentation of the Failure Scene

The key to an effective failure analysis is having the right information.

To do that, you must systematically collect that information.

765-366-4285Jim.taylor@machineryhealthcare.com

www.machineryhealthcare.comhttp://blog.machineryhealthcare.com