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(RCA)
Dr Jens P. Tronskar
Definition of Root Cause Analysis (RCA)
Can be;
Single or multidiscipline cases
Small or large cases
Some other definitions
Failure Cause
The physical or chemical
processes, design defects,
quality defects, part Failure Effect The
misapplication, or other consequence(s) a
processes that are the basic failure mode has on the
reason for failure or that initiate operation, function, or
the physical process by which status of an item.
deterioration proceeds to failure.
The circumstances during Failure The termination
design, manufacture, or of its ability to perform a
operation that have led to a required function
failure.
Failure Mode The effect
by which a failure is
observed on the failed item
Root Cause (RCA)
Slide 4 Edit in Veiw > Header and footer Edit in Veiw > Header and footer
Traditional maintenance strategies
tend to neglect something important:
Inadequate
System Personal Substandard
Factors Acts Inadequate Unintended
Inadequate Controlled Harm or
Standards Event Damage
Job/System Substandard
Inadequate Factors Conditions
Compliance
to
Standards
Data Collection
Interviews
Paper and technical evidence
Methods for RCA
STEP
FMEA
FTA
STEP 1: Register Equipment Incidents
Purpose : Register Off-spec. Operation /
performance, Survey & Condition Monitoring data
Operation
log
Operation Maintenance
department department
Maximo
Resources
STEP 2: Trigger Mechanism for RCA
Purpose: Evaluate need for RCA
Expected
Input to Process control output
process from
process
Incidents above trigger level
Surveys, Audits,
Inspection, Reviews
and Condition Incidents below trigger level,
monitoring by and mitigation not cost No Action
effective
Maintenance
Optional to involve:
Disciplines from other sister plants
HQ-Engineering support and technical staff
Vendor
Failure laboratories
Other 3rd parties
Specialist
STEP 4: The Root Cause Analysis
The main RCA report
1 Description of the Incident(s)
An incident is the event that precedes the loss or potential loss. This section should include a description of what happened.
Include all aspects related to the incidents, like outage time, cost of repair, people involved, tools in use, operational status,
weather conditions etc.
2 Immediate Cause(s)
The immediate causes of an incident are the circumstances that immediately preceded the contact and can usually be seen or
sensed. For example if the incident is an oil spill, the immediate cause could be a broken sealing. The Immediate Causes
often are the same as the failure codes registered in Maximo.
3 Basic Cause(s)
Basic Causes are the real causes behind the immediate causes: the reasons why the substandard acts and conditions
occurred, the factors that, when identified, permit meaningful management control. In case of an oil spill caused by a broken
sealing, the Basic Causes could be that the sealing used was of wrong type, it had a design failure or it might be installed
wrong.
4 Lack of Control
Lack of Control means insufficient oversight of the activities from design to planning and operation. Control is achieved
through standards and procedures for operation, maintenance and acquisition, and follow-up of these. If an oil spill has
occurred because of wrong installation of a sealing, the Lack of Control could be related to inadequate procedures for
checking after maintenance.
Loss/Incident
Immediate Causes
Basic Causes
Lack of Control
RCA reporting system
Methods for RCA
Actor 2 Event 1
1. Identify actors
Actor 3 Event 2
2. Identify events
3. Link 1&2
4. Mark Substandard
Actor 4 Event 6 acts/deviations
Event 4
Actor 5
MAIN BEARING
Heavily worn raceway, cracking of
casehardened surface, plastic deformation of
sealing groove
The main cause of failure was overloading of
the bearing.
Actions/recommendation:
Reanalysis by FEM and redesign
Root Cause Failure Analysis Disclosed
Failure of:
O-RING
Four gas leaks on TLP
platform equipment in HP &
IP service
Caused by explosive
decompression (ED) of O-
Ring
Actions/recommendation:
Change to another O-Ring
type with other elastomer
Examples of problems disclosed by
the laboratory investigation as part
of the RCFA:
DRIVE SHAFTS
Incorrect material quality Surface defects
Incorrect design Corrosion
Poor quality manufacture Incorrect balance and
Geometric imperfections alignment
Incorrect operation Incorrect assembly
Fatigue or overloading
ROOT CAUSE FAILURE ANALYSIS
DISCLOSED:
Bearing Breakdown
Axial overloading
Thrust washers fitted in both bearing housings
Incorrect assembly
Actions/recommendation:
Remove thrust washers from one bearing
housings
ROOT CAUSE FAILURE ANALYSIS
DISCLOSED:
Gear Breakdown
Broken gear tooth. Fatigue initiated from
quench cracks.
Fabrication induced defects (Basis for
discussion of liability and subsequent claims
against manufacturer)
Actions/recommendation:
Fitting of new gears where heat treatment and
case hardening procedure had been verified
to be correct
ROOT CAUSE FAILURE ANALYSIS
DISCLOSED:
Management Process-1
SW: Other..
Operator Process-2
Actor 2 Event 1
1. Identify actors
Actor 3 Event 2
2. Identify events
3. Link 1&2
4. Mark Substandard
Actor 4 Event 6 acts/deviations
Event 4
Actor 5
Sealing Inadequate
Sealing becomes dry tightening
and brittle
Manually
Operator Moving the
valve
FMEA
Failure Mode and Effect Analysis
FMECA
Failure Mode and Effect Criticality
Analysis
FMEA (Cause-Consequence)
(Failure Mode and Effects Analysis)
Overview of failure mode and effect for a
complex machinery/operation
Getting an overview of all potential failure
causes and effects at an initial stage of an
investigation
Requires detailed knowledge of the problem in
question
Easy to use for both events and for potential
losses where risk is included
Not good at handling time series
Technique/Working Process
Analysis Goal Expert sessions
Guided brain-
storming to collect Likely
information Causes
System definition
System boundaries Fill in forms
Operational state Evidence Finding
Limitations, assumptions Inspections
Failure Analysis
Interview
Exclusion
System description
Documentation
Division into sub-systems
(e.g. functional decomposition)
Final
Analysis planning Causes
Find expert team
Plan expert sessions
(when, what, who?)
Make documentation available
Cases/Examples
Offshore Gas production
Statistics from 320 incidents/ RCA cases
Total Losses;
Ca. 100 mill$/yr
Other
18 % Personal related
26 %
Preventive
Maintenance
8%
Lack of
management of
work
15 %
Design
33 %
Immediate Causes - Substandard Conditions
180
160
140
120
Immediate causes
100
N
80
60
40
20
0
20
15
10
l ur
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Basic Causes
Basic Causes - work related
70
60
No of events
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40
30
20
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i gn P M ... . M se rk n ce er
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Explosion and fire at refinery
Refinery Explosion & Fire
Localised
Corrosion in
overhead
Piping
Debutanizer
Overhead
Receiver
Debutanizer
Column
Longford Gasplant
Rich oil de-ethanizer reboiler
Root Cause Failure Analysis
DISCLOSED:
Actions/recommendations:
Reconstruct using low temperature steel
grade, carry out proper UT. Modify operation
procedure and controls to prevent
Damage mechanism: future process upsets.
Brittle fracture
RCFA of LNG Plant Failure
RCFA of LNG Plant Failure
RCFA of WHRU
Metallurgical investigation
Findings