Page 41 - Root Cause Failure Analysis

32 Root Cause Failure Analysis

quality and capacity and have a direct impact on equipment reliability. The procedures
should be evaluated to ensure that they do not violate the operating envelope or ven-
dor’s recommendations. All deviations must be clearly defined for further evaluation.

Operating Practices
This part of the evaluation should determine if the SOPs were understood and fol-
lowed before and during the incident or event. The normal tendency of operators is to
shortcut procedures, which is a common reason for many problems. In addition,
unclear procedures lead to misunderstanding and misuse.
Therefore, the investigation must fully evaluate the actual practices that the produc-
tion team uses to operate the machine or system. The best way to determine compli-
ance with SOPs is to have the operator(s) list the steps used to run the system or
machine being investigated. This task should be performed without referring to the
SOP manual. The investigator should lead the operator(s) through the process and use
their input to develop a sequence diagram.

After the diagram is complete, compare it to the SOPs. If the operator’s actual prac-
tices are not the same as those described in the SOPs, the procedures may need to be
upgraded or the operators may need to be retrained.

Maintenance History
A thorough review of the maintenance history associated with the machine or system
is essential to the RCFA process. One question that must be answered is, “Will this
happen again?’ A review of the maintenance history may help answer this question.
The level of accurate maintenance data available will vary greatly from plant to plant.
This may hamper the evaluation, but it is necessary to develop as clear a picture as
possible of the system’s maintenance history.
A complete history of the scheduled and actual maintenance, including inspections
and lubrication, should be developed for the affected machine, system, or area. The
primary details that are needed include frequency and types of repair, frequency and
types of preventive maintenance, failure history, and any other facts that will help in
the investigation.

Maintenance Procedures and Practices
A complete evaluation of the standard maintenance procedures and actual practices
should be conducted. The procedures should be compared with maintenance require-
ments defined by both the design review and the vendor’s O&M manuals. Actual
maintenance practices can be determined in the same manner as described earlier or
by visual observation of similar repairs. This task should determine if the SMPs are
followed consistently by all maintenance personnel assigned to or involved with the
area being investigated. Special attention should be given to the routine tasks, such as