RCA by Amjad

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?

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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

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




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 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 ..

RCA by Amjad

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