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Root Cause Analysis
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1
OMV Exploration & Production
Move and More.
Root Cause Analysis
Presentation By
Amjad Nawaz
Instrument Engineer Sawan Gas Field Operations
Why Root cause Analysis ?
-The unfortunate reality is that, when faced with a problem, a common reaction is to fix the obvious symptoms without regard for the actual causes. Unfortunately, it is not the best way to solve a problem, as it leads to the need to solve the same problem over and over again. A better approach is to eliminate the root cause.
A Root Cause is. . .
A process factor which directly defines the reason for the problem when it is present and is having an influence on the process and its output.
Root Cause Analysis
A Root Cause Analysis is a structured and thorough review of a problem (or desired effect). It is designed to find out what is actually causing the symptoms. Trained analysts act as detectives to find the guilty cause or causes of the problems
Symptom Approach vs. Root Cause
If we do a poor job of identifying the root causes of our
problems, we will waste time and resources putting band aids
on the symptoms of the problem.
Symptom Approach Root Cause
Errors are often a result of worker carelessness.
Errors are the result of defects in the system. People are only part of the process
We need to train and motivate workers to be more careful
We need to find out why this is happening, and implement mistake proofs so it wont happen again.
We dont have the time or resources to really get to the bottom of this problem.
This is critical. We need to fix it for good, or it will come back and burn us.
What Type of Root Cause Analysis..?
Types of RCA Used for/by
Safety-based Occupational safety/health
Production-based Quality control/industrial
Process-based Business processes
Failure-based Engineering
Systems-based Change management, risk management, systems analysis
Dig! How Deep?
8
Management decides on depth of root cause investigation through the establishment of SMART goals for each problem solving effort.
Research has repeatedly proven that unwanted situations within organizations are about 95% related to process problems and only 5% related to personnel problems. Yet, most organizations spend far more time looking for culprits. Consider the following two scenarios.
Scenario # 1
The Operation Manager walked into the plant and found oil on the floor.
He called the operator over and told him to have maintenance clean up the oil.
The next day while the Operation Manager was in the same area of the plant he found oil on the floor again .
Scenario # 1
Operation Manager subsequently raked the Foreman over the coals for not following his directions from the day before.
Scenario # 2
The Operation Manager walked into the plant and found oil on the floor. He called the Operator over and asked him;
Operation Manager: why there was oil on the floor?
Operator: it was due to a leaky gasket in the pipe joint above.
Operation Manager: when the gasket had been replaced ?
Operator: Maintenance had installed 4 gaskets over the past
few weeks and each one seemed to leak. The operator also
indicated that Maintenance had been talking to Purchasing
about the gaskets because it seemed they were all bad.
Scenario # 2
The Operation Manager then went to talk with Purchasing about the situation with the gaskets.
The Purchasing Manager indicated that they had in fact received a bad batch of gaskets from the supplier. The Purchasing Manager also indicated that they had been trying for the past 2 months to try to get the supplier to make good on the last order of 5,000 gaskets that all seemed to be bad.
The Operation Manager then asked the Purchasing Manager why they had purchased from this supplier if they were so disreputable ?
Purchasing Manager said because they were the lowest bidder when quotes were received from various suppliers.
Scenario # 2
The Operation Manager then asked the Purchasing Manager why they went with the lowest bidder?
Purchasing Manager indicated that was the direction he had received from the VP of Finance .
The Operation Manager then went to talk to the VP of Finance about the situation. and asked the VP of Finance why Purchasing had been directed to always take the lowest bidder?
VP of Finance said, "Because you indicated that we had to be as cost conscious as possible!" and purchasing from the lowest bidder saves us lots of money.
Scenario # 2
The Operation Manger was horrified when he realized that He was the reason there was oil on the plant floor.
Bingo!
Thought?
You may find scenario # 2 somewhat funny, and laugh at the situation. It would be better if the situation made you weep because it is often all so true in numerous variations on the same theme.
Everyone in the organization doing their best to do the right things, and everything ends up screwed up. The root cause of this whole situation is local optimization with no global thought involved.
Scenario # 2 also provides an good example of how one should proceed to do root cause analysis. Once simply has to continue to ask "Why?" until the pattern completes and the cause of the difficulty in the situation becomes rather obvious.
How Do you do It?
There are many tools and techniques that apply, and the issue can easily be made as complicated / painful as your heart desires.
Problem solving Process
1) Understanding the situations (Mess Finding/Data Finding)
What is the problem?
When did it happen?
Where did it happen?
What is the significance?
No Who- dont place blame (blame=avoidance and silence
2 ) Creating Options
Investigate and Find Best Solution
3) Implementation
Provide action plan to implement the solution
Basic Elements of Failure
Elements Questions to be ask
Materials Defective? Wrong type/Handling/Quality? etc
Manpower Inadequate capability? Lack of knowledge, skill or motivation? Stress?....etc.
Machine Incorrect tools? Poor maintenance or design? Poor equipment or placement? Defective?....etc.
Environment Work surfaces? Physical demands? Temprature,Humidity,vibration,noise effect?.etc.
Management Poor involvement? Inattention to task? Stress demands?Training/Communication/Education/Guideline/Experience/lacking? Poor recognition of system limitations? Previously identified limitations were not eliminated?....etc
Methods Missing or poor procedures? Practice not same as procedure? Poor communication?....etc.
METHODS
Was the canister, barrel, etc. labeled properly? Were the workers trained properly in the procedure? Was the testing performed statistically significant? Have I tested for true root cause data? How many if necessary and approximately phrases are found in this process? Was this a process generated by an Integrated Product Development (IPD) Team? Was the IPD Team properly represented? Did the IPD Team employ Design for Environmental (DFE) principles? Has a capability study ever been performed for this process? Is the process under Statistical Process Control (SPC)? Are the work instructions clearly written? Are mistake-proofing devices/techniques employed? Are the work instructions complete? Is the tooling adequately designed and controlled? Is handling/packaging adequately specified? Was the process changed? Was the design changed? Was a process Failure Modes Effects Analysis (FMEA) ever performed? Was adequate sampling done? Are features of the process critical to safety clearly spelled out to the Operator?
Fishbone Diagram or Cause & Effect Diagram
The Fishbone Diagram (also known as the Cause & Effect Diagram) is a technique to graphically identify and organize many possible causes of a problem (effect). When the need exists to display and explore many possible causes of a specific problem or condition.
Cause and Effect are same thing
Effects caused
by
Causes
1. Injury Fall
2. Fall Wet surface
3. Wet surface Leaky valve
4. Leaky valve Seal failure
5. Seal failure Not maintained
1 3 4 5 2
The 5 Whys
The simplest most basic way to find root cause is to ask "why ?" (at least) five times. STEP 1: Define the starting point question. STEP 2: Ask "why ?" to the previous answer STEP 3: Repeat step 2 at least five times. STEP 4: Result - a root cause.
Now you can do something about the problem
OR Keep going until your answer to why is: I dont know (ignorance point marked with ?) I dont care (it fell because of gravity. Why is there gravity? I dont care)
Why?????
STEP Question Answer
1 Why was the meeting unproductive ?
Not everyone was ready
2 Why ? The meeting was called with short notice
3 Why ? Somebody needed a quick answer.
4 Why ?
They had not been provided with all the information they needed
5
6
Why ?
Why ?
No-one was identified to provide the information.
Not in their Job Description
Create a Causal Tree
Find out:
What happened
What usually happens
What policies require to happen
Look for: Human error
Procedural violations
Mechanical failures
Other possible causes
For each effect ask why?
Look for conditions and actions
Connect all causes with caused by
Support causes with evidence
Phase 1
Broken Wrist
Person Fell Caused
By
Phase 2
Broken Wrist
Caused By
Person Fell
Hand Stopped
Fall
Caused By
Etc.
Caused By
Etc.
Phase 3
Broken Wrist
Excess Force
Caused By
Wrist Position
Hand Stopped
Fall
Employee Overweight
Caused By
Caused By
Etc.
Caused By
Evidence goes here
Evidence goes here
Evidence goes here
Evidence goes here
Evidence goes here
Most Helpful, I thought Think Reliability.com
Investigate Problems. Prevent Problems.
Example: The Washing Machine
Verify the Complain
Investigate Why
Investigate Why
Investigate Why
Investigate Why
Cause Mapping: The Titanic
What happened 99 years ago today?
The Titanic hit an iceberg at 11:40 on April 14
The Titanic sank at 2:20am on April 15, 1912
As ThinkReliability.com states, Theres more to it than the iceberg
The Titanic/Step 1: Problem Outline
Problem(s), Issue(s):
Titanic sank, ship hit iceberg, weak rivets
Date: April 14 - 15, 1912
Physical Location North Atlantic Ocean
Company Identification White Star Line
Process (task being done)
Passengers UK to US
Impact to the Goals:
Safety 1517 Fatalities
Property Lost entire ship $7.5million
Business Liabilities, Business loss $16.5million
Frequency 1 x
The Titanic/Step 2: Cause Map Safety Impact: Loss of 1517 Lives
Why loss of 1517 lives? Titanic Sank
Why did Titanic sink? Ship Hit Iceberg
The Titanic/Step 2: Cause Map Safety Impact: Loss of 1517 Lives
Why loss of 1517 lives? Titanic Sank
Why did Titanic sink? Ship Hit Iceberg
BUT Why did the ship hit the iceberg?
The ship didnt turn sufficiently
Why didnt it turn sufficiently? All factors contributing to unavoidable collision: The speed the ship was traveling Seeing the iceberg late The size of the rudder
The Titanic/Step 2: Cause Map Safety Impact: Loss of 1517 Lives
Why loss of 1517 lives? Titanic Sank
Why did Titanic sink? Ship Hit Iceberg
BUT Why did the ship hit the iceberg?
The ship didnt turn sufficiently
Why didnt it turn sufficiently? All factors contributing to unavoidable collision: The speed the ship was traveling Seeing the iceberg late The size of the rudder
BUT why did hitting the iceberg cause it to sink?
Water filled the hull of the ship.
Why did water fill the hull of the ship?
The steel plates buckled on the hull of the ship, causing it to open and fill with water.
Why did they buckle?
The rivets holding them together were not strong enough and the hull was not strong enough to withstand the impact.
The Titanic/Step 2: Cause Map Safety Impact: Loss of 1517 Lives
Why loss of 1517 lives? Titanic Sank
Why did Titanic sink? Ship Hit Iceberg
BUT Why did the ship hit the iceberg?
The ship didnt turn sufficiently
Why didnt it turn sufficiently? All factors contributing to unavoidable collision: The speed the ship was traveling Seeing the iceberg late The size of the rudder
BUT why did hitting the iceberg cause it to sink?
Water filled the hull of the ship.
Why did water fill the hull of the ship?
The steel plates buckled on the hull of the ship, causing it to open and fill with water.
Why did they buckle?
The rivets holding them together were not strong enough and the hull was not strong enough to withstand the impact.
BUT why did the ship sinking mean that 1517 people had to die?
Insufficient lifeboats
The Titanic/Step 3: Solutions
No.
Cause Action Item Owner Due Date
Status
1 Insufficient Lifeboats
Add more lifeboats
2 Speed (18 knots) Slow down in areas with known icebergs
3 Saw iceberg late Improve bow watch communication process
4 Strength of steel Change steel hull design, materials
When you keep asking WHY, you actually
determine the ROOT CAUSE(S)!
45
Thank
You ..