PowerPoint Presentation

12/4/20141Good Morning

Sarangani Energy CorporationDecember 4, 2014Root Cause Failure Analysis RCFA TRAINING : DAY 1: 221014141212/4/20142You Have to Know What You're Looking for If You're Going to Find ItSarangani Energy CorporationDAY 1Using RCFA and Making it SuccessfulTrue Causes of Plant and Equipment FailureRisk Analysis, Reliability Growth and Failure EliminationApplying RCA Failure Analysis Tools and Their UseDAY 2The RCFA Team and The Role of the FacilitatorIntroducing and using RCFAPractice the RCFA MethodsPropagating Improvements Company-Wide12/4/20143Root Cause Failure Analysis CourseSarangani Energy Corporation3Applying RCFA in the Workplace12/4/20144Cross-functional TeamsThe FacilitatorTeam DynamicsRunning RCFA MeetingCooperation TechniquesThe Six HatsFacilitation TechniquesSarangani Energy CorporationRCFA Process and Rules of ThumbPREPARATIONKeep an Open Mind what you think happened is very unlikely to be the total storyMost problems are due to human factors and poor business processes/controlsGet/keep the evidence concerning the failure from throughout the operation hard evidence from failed items and soft evidence from interviewsIMPLEMENTATIONAppoint Facilitator and cross-functional team - involve specialists as necessaryCome to meetings prepared with the details that you can provide or are asked to provide RESEARCHConduct interviews; collect site informationFully flow chart the process (boxes and arrows), and its interconnecting activities into other processes, and identify the location of the problemProvide a P&ID, drawings, operator manual, maintenance procedures, operating records, maintenance records, etc related to the problemANALYSISFishbone Analysis for thorough coverage and understanding from range of data collection and data analysis tools select those that are appropriateDevelop Is-Is Not Table to identify contributing factorsDevelop Cause and Effect Tree of necessary cause-effect conditions, states and interactionsTest Why Tree with the 5/7 Whys start as low down Why Tree as there is certain evidence5 Why Table with Evidence + personal beliefs, attitudes, corporate culture norms, etc. Understand Latent issuesCORRECTION/CHANGEProve proposal is effectiveRecommendations and report prioritise by payback and ease to implement

(Taproot/Apollo etc. software for complex problems or problems needing deep analysis)12/4/20145Sarangani Energy CorporationCross-functional TeamsRCFA Teams:

A Facilitator with no vested interests but knowledgeable of the organisation, operating systems and cultureContain a wide range of organisational knowledgeInclude the designer or one who has designed similarInclude Operations/Production experienceInclude Maintenance experienceInclude a person intimate with the incidentPermitted to access other specialists as necessary12/4/20146cross-functional team consists of a group of people with different functional expertise working toward a common goal.Sarangani Energy CorporationThe Facilitator and Their Role

Is the Meeting Chairman,Is Independent of the Incident,A Coach,A Guide,A Director of Affairs,A Timekeeper,A Recorder,Is the Project Manager,Ensures resolution of team issues is achievedNOT a Participant of the investigation and analysis 12/4/20147Sarangani Energy CorporationFacilitators Plan Define problem clearly for RCFA Select team with proper mix of skills and knowledge.Advise team members what to prepare for first meeting.Develop meeting agenda and likely list of tools for investigation and analysis.Identify means to measure progress along RCA process (Measure progress in 5%-10% size steps indicate deliverables at end of each step)Responsible to follow-up implementation until complete.Report progress of all RCAs monthly to superiors.12/4/20148Sarangani Energy CorporationFacilitators Problem Solving Toolbox12/4/20149

Sarangani Energy CorporationTeam Attitudes , Challenges and Choices NavigatorSurvivor Victim The PowerfulThegetting byline PowerlessI am going to take the initiative and make it happen Some Body Should do Something Why Bother , there is no Point Proactive Reactive F

U

D12/4/201410Sarangani Energy CorporationFUD stands for Fear, Uncertainty and Doubt , which prevails as changes start coming, or are about to , within an organization , The survivor series of employees start falling into victim category . The navigators also reduce in number . The ratio between Navigators , survivors and victims changes . People become more reactive .

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12/4/201411Team Building / Relationship / Partnership

How does RCFA help us in Production?Do you want Reliability, Availability, Throughput, Safety, Quality, Lower Costs, and Less Waste?Identify RCFA value add for people and companyBring groups together in a cooperative, professionally run meetingRequest others ideas/input and discuss/do themContinual communication: changes and assistanceSarangani Energy Corporation11

12/4/201412The RCFA Meeting Identify purpose of the meeting, set priorities, fix times, resource management and allocate responsibilitiesRight mix of people Production decision makers, Maintenance decision makers, plus electrical, mechanical, engineering, OHSW repsProfessional meeting practices Room booked, Agenda, Meeting Timeline, Action minutes listing responsible persons and due datesReport back on decisions and actions performed and their successA face-to-face, people process (trust, belief, honesty, laughter)Sarangani Energy Corporation1212/4/201413Tell-Tale RCFA Meeting Success Factors

Team work of equal partners.Honesty in communication, trusting that each has thebest interest of the business, its people and its future at Heart.Credibility through commitment to agreements and thecontinual improvement of the operation and its people.Consistency of intent by attending regular meetings, providing participants, actioning decisions and delivering results.Sarangani Energy Corporation13Facilitator Ensures Solutions are Implemented Making change needs change management.PlanPrepare - document, tool-up, trainAuthorised by all concernedImplementMonitor and EncourageConfirm adoptionTHE CHANGE MANAGEMENT PROCESS12/4/201414You want permanent improvement throughout the organisation, rather than in one operation or departmentManagement is responsible to provide the resources to make the improvementsSarangani Energy CorporationIf Its Not Written, Its Not RealLearn from the experience act to correct your business systems and processes so it doesn't happen again.ManagersSupervisorsWorkforcePlannersCost QualityTimePlanDoCheckAct

Improve thePlanning, Proceduresand FormsUnless something positive and concrete comes out of a bad situation there has been no learning, and the problem will reoccur.

Improve theJobProceduresand ChecksImprove theTraining andCompetence

Until the new ways are documented, and people are trained to do them right, they will not happen in the workplace.12/4/201415Sarangani Energy Corporation15Unless something positive and concrete comes out of a bad situation there has been no learning and the problem will reoccur. It cannot be otherwise.

Until action is taken to make the necessary changes permanent, there has been no change. These changes need to become improved ways of doing the planning and performing the maintenance. Until the new ways are documented, and people are trained to do them right, they will not happen in the workplace.

The Facilitator Monitors Progress and Schedule Continually ImproveIs the agreed work being completed, at the right time, with the right resources? The Facilitators' responsibility may not include making the changes recommended by the RCA team. It does include reminding management that until the changes are introduced and are in use, the risk remains in the business.12/4/201416Sarangani Energy Corporation16

Using the Six Hats to Help Teams Work

Creative: cultivates, encourages new ideasOptimistic: helps make ideas workAnger: listens to their emotionsPessimistic: looking for problemsObjective: systematic and carefulVisionary: sees things from a higher perspective12/4/201417Sarangani Energy Corporation

Six Hats in RCFA MeetingsAssign hats to people on the discussion team, ideally one colour per person. When each person speaks they must identify with the colour and speak accordinglyThe team discusses the problem (every member can contribute to the discussion) with the following main responsibilitiesWhite hat presents the facts of the problemGreen hat presents the ideas on how the problem can be solvedPossible solutions are discussed with yellow hat focusing on benefits and black hat focussing on drawbacksRed hat encourages all team members to express their gut feelings about the situationBlue hat summarises the discussion and closes the meeting12/4/201418Sarangani Energy CorporationEvaluate and Select the Solution(s)12/4/2014Cause to AddressProposed SolutionSolution Objective

Risks with Implementation

Rating for Objective1, 2, 3Rate for Option1, 2, 3Overall Rating(Obj x Opt)19List the Objectives satisfying to all stakeholder, meet legal requirementsRate the Objectives most important (10) down to least (1) importantRate the Options best outcome (10) to least desirable (1)Review Risks select the highest rated option that meets risk control requirements and is practical to implementTest the Choice get independent expert opinion, do a small scale experiment and adjust as necessarySarangani Energy CorporationPrioritise the RecommendationsEase to ImplementEasyHardLowHighImpactDo these firstDevelop multiple recommendations Make sure there are low cost solutions as well

High PaybackEasy to Do

Gets Management Support12/4/201420Sarangani Energy Corporation12/4/201421The effort expended during an RCFA is justifiable only because it leads to recommendations which, if implemented, will eliminate or minimise repeat occurrences in the future.In preparing the report there may be some unpalatable truths but these must be appropriately stated.adverse events are usually the result of human errorsthese errors must be accepted as system flaws, not character flawsThe report will contain all the documents produced during the investigation and a summary Executive Report at the front. This will enable senior, and possibly non-technical management, to read the recommendations and appreciate the value of the RCFA procedures.The report format needs to be standardised and formatted to a company specification. (In Toyota, investigations and recommendations have to fit on an A3 page)The final task of the Team is the reportSarangani Energy Corporation21Building Failure Elimination into Your Business12/4/201422

Sarangani Energy CorporationDont change people, change their practices!12/4/201423You cannot change peoples internal values, but what you can change is the practices they must follow so that their cognitive dissonance brings about change in their values.

For example, if you want people to always practice creative disassembly, provide a procedure and report sheet they must complete and hand-up at the end of every strip-down so you can encourage and train them. In this way, the organisation's practices brings about the necessary change in the value that people put-on careful observation and recording.

THE GROUP LEADER WILL NEED TO SUPPORT AND ENFORCE THE NEW PERFORMANCE, ELSE PEOPLE WILL RETURN TO THEIR OLD WAYS (The really important people are the Supervisors/Team Leaders)Changing collective values of adult people in an intended direction is extremely difficult, if not impossible. Values do change, but not according to someones master plan. Collective practices, however, depend on organisational characteristics like structures and systems, and can be influenced in more or less predictable ways by changing these.Hofstede, 1997Sarangani Energy Corporation23Understanding what it means to be in control and capable

Out of controlIn control but not capableIn control and capable12/4/201424Sarangani Energy CorporationGetting high task reliability needs qualityIn the end... reliability is a quality control issue.Because all our machines are a series of parts, and all our work are a series of activities, there are endless opportunities for variation many of which will cause failures. Hence, we must set the correct standards of performance for every step in a series so that we deliver only those results that give us the right outcomes. This is quality. The more precisely we approach the standards; the better the quality; the more certain and reliable the series outcome.Number of EventsOnly accept this range of outcomes because they give very low riskAcceptableOutcomeVery Bad OutcomeVery Bad OutcomeValue of a Critical Parameter12/4/201425Sarangani Energy Corporation12/4/201426Quality Management = Continual Business Improvement

Quality Improvement ToolsPlan Do Measure Improve Measure means to check you have statistical controlStandard to MeetTimeRequirements, Needs, ExpectationsPerformance LevelDegree to which inherent quality characteristics meet stated or implied needs.The Meaning of QualityEffect of Using a Quality SystemIn business you need to drive a continuous improvement culture.We want to do all work with certainty that it will improve reliability. To do that we need a business system that promotes and continually improves the accuracy and quality of our workmanship and our operating and maintenance processes. Such system is called a Quality Management System.Sarangani Energy Corporation26The precision principle applies to all operations and business processes. To control a process and to control variations introduce standards and tolerances with measures for how close the process must meet those standards. Set standards for every stage of the process and measure how accurately the operation meets the standards at that point. If the process is controlled to appropriate standards throughout its performance the necessary product quality and throughput specified is automatically delivered. By being everywhere precise you get the end result required. This principle is a sure way to guarantee successful performance. Simply develop appropriate standards with specific targets and tolerances and make sure the real results are regularly measured and compared to the standard. People in charge of the equipment and operation can then adjust their performance, and that of the equipment and process, in a controlled fashion to meet the required accuracy. The standards are the key performance indicators for the process and are used to monitor its quality.Reliability Improvement TeamsSteering Committeee.g., Eng,Tech,and Ops ManagersPlant 1Improvement TeamsPlant 2Plant 4Plant 312/4/201427Sarangani Energy CorporationReliability FrameworkReliability ManagementSteering Committeee.g.,Eng, Tech, Ops ManagersReliability Improvement PlansSimplified RCM, RBI, RCFA, FMEAApproved Action PlansImplementMonitorFocal PointPublicityFeedbackMulti Discipline TeamsRCM Reliability Centred MaintenanceRBI Risk Based Inspections12/4/201428Sarangani Energy Corporation

Create A Business Process to Produce ReliabilityFMEADAFT CostsEquipmentCriticalityLife Cycle Operating RiskReduction StrategiesMAINTENANCE Planned Preventive Maintenance Planned Condition Monitoring Planned Reliability Improvements Precision Maintenance skills and equipment Precision Breakdown Repair Standardise best practicesOPERATIONS Operate within design envelope Precision Operation stress removal Operating Performance Monitoring Operator listen, look, feel monitoring and report problems Operator tighten, lubricate, clean Standardise best practicesENGINEERING Specifications for reliability manufacturing, materials, installation, commissioning Select for life-cycle profit maximising Design-in reliability, maintainability Standardise best practicesReliability Growth

12/4/201429Sarangani Energy Corporation12/4/201430Sumitomo Chemicals Maintenance Management Cycle

Sarangani Energy Corporation12/4/201431Sumitomo Chemicals Failure Prevention Cycle

Sarangani Energy Corporation12/4/201432Project MANAGEMENT Approach to CHANGESProject ManagementcProject ManagementCommunicationsCommunications - PublicityPerform the range of tasks necessary to organize people, plan activities, measure progress and communicate results over the life of the projectDefine the key messages to build support, identify effective delivery methods and use to create and maintain momentum for the change effortDo I need to change?Create the plan forchangeAssessingPlanning ImplementCreate a view of afuture stateVisioningPutting the Plan into ActionRenew & SustainTo secure and sustain the benefits of change reward people for good role modelingSarangani Energy Corporation12/4/2014Reminder: Identify All Possible Cause and Effect33(Because we do not yet know the real cause)

Sarangani Energy CorporationReminder: Use 5/7 Whys to Confirm Real Failure Path12/4/201434

Sarangani Energy Corporation12/4/2014Case Study 1 Guided Application of RCFA35A real failure of a process chemical reactor.

Defect and Failure True Cost Php24,000,000.00

Apply the RCFA process under guidance

Trace through to the latent root cause

Feedback and discussionSarangani Energy CorporationActivity 6 Do 5 Why RCA of the Roof Collapse

Flow chart the perfect process to safely drive into the filling bayDo Is-Is Not Table of the process5/7 Why the incident12/4/201436Sarangani Energy CorporationReminder: Start with Scientific Cause SequenceFoundation FailedRoof Material FailedColumn Material FailedStopStopStopColumn to Ground Connection FailsColumns TiltColumns TumbleRoof MovesTrailer Hits RoofScientific Event SequenceRoof Fell12/4/201437Sarangani Energy Corporation12/4/201438What Level of RCFA to Apply? What do your business procedures say?Root Cause and EffectTeam of experts in several meetingsHigh cost and timefocus on big problems and you keep having big problemsIdentifies wider perspectivesCatastrophe AnalysisTeam of experts with detailed FTA, failure investigation and reliability analysisProblem of catastrophic sizeNo stone left unturned; the truth comes out11030600Property DamageMinor InjuriesSerious InjuriesIncidentsSAFETY ACCIDENTS110 losses6500 repairs20,000 defectsProcess LossesMinor FailuresSerious FailureProcedural IncidentsEQUIPMENT FAILURES11030600Property DamageMinor InjuriesSerious InjuriesIncidentsEFFECT OF MODERN SAFETY INITIATIVESEscalateEscalateThe Heinrich Accident Pyramid The Failure Pyramid Source: Winston Ledet, Manufacturing GameCreative DisassemblyIndividual persons working on-the-jobLow cost, little timePreventive focusstops the many small causes that lead to large failuresMisses multiple causesSarangani Energy Corporation38RCFA comes in different sizes to suit the situation. We know from modern safety management practices that reducing safety incidents cause a reduction in more serious accidents. The same logic applies to equipment failures; reduce the procedural errors and there is a consequent reduction in production losses. It is more effective to get the trades people solving small problems and preventing failures, than to collect people together after a failure and try to prevent it in future.Precision Maintenance to Investigate Equipment FailureEquipment in ServiceCMPMOPSMaintenance need identifiedCreative DisassemblyPrecision ReassemblyPrecision InstallationPrecisionMaintenanceActivities to ACE 3T ProceduresCMQA Good is not good enough excellence is required and expected. Most machinery problems are preventable.These techniques deliver Machinery ImprovementCM = Condition MonitoringPM = Preventive MaintenanceQA = Quality AssuranceOPS = Operator Sensing (Watch Keeping)ACE = Accuracy Controlled Enterprise3T = Target - Tolerance - Test12/4/201439Sarangani Energy Corporation39Precision skills come into play :

in the disassembly of equipment for maintenance and corrective work. It is when the information is gathered to identify the root causes of failure and to provide feedback information contributing to redesign to eliminate failure and unnecessary maintenance.

during reassembly and repair of equipment to ensure quality work takes place; attention to fits and tolerances, fitting of bearings and other components etc.

during installation to ensure foundations and substructures are sound and highest alignment standards are met.

The process of moving Toward Improved Plant Reliability through Precision Skills requires a significant change in attitude and thinking at all levels in the maintenance organisation.

A Change in Philosophy

FROM detecting problems and fixing them, which is REACTIVE.

TO preventing failures from happening in the first place, which is PROACTIVE.

Good is no longer good enough excellence is to be expected.

Most machinery problems are preventable.

Everyone in the organization has a role.Parts Fail then Machines Stop

2nd bearing sleeve

2nd bearing bush

1st bearing sleeve

1st bearing bush

Casing wear ringWhat1) HUMAN FACTORS,2) BUSINESS or WORK PROCESSES,3) PHYSICAL PROCESSESAFFECTING EQUIPMENT4) LATENCY FACTORScaused the failure?12/4/201440Sarangani Energy CorporationMachines are systems of parts working together to deliver a function. When a machine fails we replace its parts to return t it to operating condition. In the column pump shown in the slide, the shaft support journals failed from sand ingress. They were worn away. To return the pump back to service required replacing the journals. But if that was all that was done, then the pump will fail again because the cause of the failure was not eliminated. Until the sand no longer gets into the journals this pump will always be repaired regularly.4012/4/201441Tell-tale Bearing Failure Signs

Sarangani Energy Corporation41Each of these pictures of failed bearings tell the story of what caused its demise. When bearings are removed look at the story they tell before throwing them into the bin. You will very likely be able to find the cause of the failure and fix it while doing the job.Creative Disassembly Pre-shutdown of Equipment Thanks to Peter Brown of Industrial Training Associates for the slide12/4/201442Gather historical and background data whilst still in service

vibration, bearing, thermography, oil data for diagnostic purposes. Look at this for varied process conditionscheck for running soft-foot (machine distortion when at operating under load)look for resonance in machine, structure, pipe work, other attachmentslook at the equipments maintenance history for tell-tale evidenceSarangani Energy Corporation42Improving machinery reliability starts with knowing where its current problems are. That information can be found from the equipments history and by collecting evidence of its poor performance and condition while it is running. Creative Disassembly At ShutdownThanks to Peter Brown of Industrial Training Associates for the slide12/4/201443Before Strip-down

where thermal growth is important for alignment, obtain hot alignment readings while still at operating temperaturelook for witness marks, evidence of shifts or relative movementcheck for static soft foot (machine distortion when at stand-still)sample lubricants and other fluidsSarangani Energy Corporation43When the equipment is shutdown look for evidence of abnormal operation and condition.Creative Disassembly At Strip-down Inspection of bearings

when removed, prior to cuttingcut the cage/retainer rather than springing itcut outer race from top centre to bottom centrere-inspect prior to cleaningfilter solvents to see what is in the bearinganalyse bearing and ball path patternsspalling patterns revealing poor fittingfitted surfaces revealing fretting, out of roundness etc. 12/4/201444Look for witness marks, evidence of fretting etc. Disassemble in clean and well lit areasPhotograph damage if applicableAvoid damaging during removalMark the relative locations of bearings in housings, top and side, inboard and outboardGearing wear patterns - eccentricity, backlash, misalignment etc.Sarangani Energy Corporation44As the machine is stripped down look for evidence in its parts and assemblies for signs of what has been happening to it during use. Every part tells us the story of its life, if we look for it.In a Bearing Failure, Dont Destroy any Evidence

What chance has this bearing?12/4/201445EVIDENCESample lubricant prior to removalMark relative locations of bearing in housing, top and side, inboard & outboardDisassemble in well lit areasPhotograph damage, and on parts in contactAvoid further damaging during removalINSPECTIONInspect bearing when removed prior to cuttingCut cage/retainer rather than springing themCut outer ring from top center to bottom centerRe-inspect prior to cleaningANALYSISFilter wash-down solvents to see what is in bearingSpalling patterns revealing poor fitting, high contact stressTest lubricant hot plate test for water; colour; contaminationFitted surfaces revealing fretting, out of roundness etc.Root cause analyze bearing and ball path tracksSarangani Energy CorporationBall Path Patterns - Normal

12/4/201446Sarangani Energy CorporationBall Pattern - Normal with outer race rotation.12/4/201447Sarangani Energy CorporationAbnormal Patterns

ThrustedDouble loading potential cause is Soft Foot12/4/201448Sarangani Energy CorporationAbnormal Patterns

MisalignmentOverloaded12/4/201449Sarangani Energy CorporationAbnormal PatternsPinched Outer Race BearingUnbalance12/4/201450Sarangani Energy CorporationChange Habits: Creative Disassembly

12/4/201451Sarangani Energy CorporationActivity 7 Do a Creative Disassembly

Why is one side of belt glazed? How do you fix it?

What caused this marking? How do you fix it?Why is there corrosion? How do you fix it?What caused the track in the race? How do you fix it?Read the Creative Disassembly Explained article in the workbook and then do the activity.12/4/201452Sarangani Energy CorporationHow do You get Full Marks?

How do You know You have got full marks?12/4/201453Sarangani Energy CorporationWhat do we mean by.Frequency of OutcomesVariability =Range of OutcomesSpecificationPrecisionAccuracyFrequency of OutcomesRange of Outcomes = VariabilitySpecificationHighQualityQualityRepeatabilityQuality, Precision, Repeatability, Variability

PrecisionAccurateRepeatability is low in this processUnwanted Variability= Unwanted OutcomesXXX12/4/201454Sarangani Energy Corporation12/4/201455Reliability Creating 3T Error Proof Procedures3Ts of FailurePrevention -. Target. Tolerance. TestFrequency of OutcomeOutputRange of Possible OutcomesQuality improvement occurs when variation is reducedSpecificationTargetPrecisionProof Testfor ReliabilityTolerancefor Quality

Bands of Lesser Quality(Decreasing Accuracy)

Good, Better, Best

Bronze, Silver, Gold Build Mistake Proofing into SOPsSet a target for each task.Specify the acceptable tolerance.Do a test to prove accuracy.Sarangani Energy Corporation55How many defects, errors and failures can your operation afford each day? Do your people have the time to go back and do a job twice or three times because it was done wrong the first time? Are people happy to regularly accept wasted production and lost time due to mistakes and poor quality? If not, then do your internal work procedures support doing the job right the first time?

The elimination of error is vital in business operation. Problems drastically reduce profits. Errors produce bad, unwanted outcomes. They are wasteful. They take resources and money away from where they were intended to be used. They use valuable time to correct what should have been done right in the first place. Worst of all is that they did not need to happen. Business systems need to prevent errors, and if not they must quickly detect and stop them from going further. The longer an error is undetected during production the more work is performed on the product, and the more money and time is wasted when it is finally scrapped.The best failure prevention strategy is to proactively stop problems from entering the business. This requires that pre-emptive practices and methods are built into all business processes and systems as the normal way of doing work. Fortunately the business systems are in the written standard operating procedures and we can prevent errors by writing suitable preventive practices and measures in the operating procedures and teaching them to people.

Controlling Accuracy Removing ErrorIf it is important to be correct it will be necessary to introduce procedures to guide people to constantly attain the necessary standards of performance that deliver the desired results. Test laboratories, such as materials testing, pathology testing, etc, have long recognized that if they want consistent, reproducible, correct results they need to work to proven and endorsed procedures. The test procedures provide clear guidance, set the required standard and stop variations in work performance. These standard operating procedures perform the role of helping employees efficiently (i.e. with the least use of resources) and effectively (i.e. in the least time required) deliver a specific result with certainty. The standard operating procedure, if followed faithfully, will produce the required outcome. But if there is no procedure to follow it is uncertain what the actual result will represent and the testing is invalid.

Standard operating procedures are much more valuable than normally understood by many managers. Not often appreciated is their ability to greatly improve the likelihood of top quality performance from employees. They are a quality control device which has the power to deliver a specific level of excellence. They should be used to step-by-step take people through both simple and complex tasks so that they are done correctly every time. For the best results include the 3Ts -target specification, tolerance and a test for proof - in the procedure to ensure people get feedback on how they are performing the tasks as they do them.Having targets in your procedures to aim for will remove many current business problems. Target-based procedures recover great amounts of time and money. Adding targets, tolerances and tests in standard operating procedures will detect problems and prevent them from progressing further. They maximize productivity from current operating methods and turn-in a bigger profit.

A classic example of what great value an accuracy-focused SOP can bring is in this story of a repair on a piece of production equipment. A shaft bearing of a fan regularly broke down. Instead of giving many years of reliable, failure-free service, the rear roller bearing on this fan never lasted more than about two months after a repair. Each time the bearing failed the production downtime caused by the breakdown was an expensive and great inconvenience. To take it out of the realm of a breakdown the bearing was replaced every six weeks as planned maintenance.

The bearing was also put on regular observation using bearing vibration condition monitoring. After several replacements enough vibration data was collected to diagnose the problem as a pinched outer bearing race. The bearing housing had been machined oval in shape when manufactured and it had squeezed the new bearing out-of-round, every time it was bolted up.

You could say that vibration analysis was applied wonderfully well, since it identified the cause of the recurring problem. But the real truth was the repair procedure failed badly. If there had been a task in the procedure to check and measure the bolted bearing housing roundness and compare the dimensions to allowable target measurements, it would have been instantly noticed at the first rebuild as having an oval-shaped hole. There was no need for the bearing to fail after the first time! A badly written standard operating procedure had let bad things happen! A failure prevention focused SOP, with target, tolerance and test for proof, (the 3Ts) would have found the problem on the first repair and it would have been fixed permanently.12/4/201456 How 3Ts guide workmanship qualityGOODBETTERBESTPerfect ResultWorld Class TargetCertain FailureTolerance LimitPASS / ACCEPTFAIL / REJECT

As BAD as allowedAs GOOD as it needs to beSarangani Energy CorporationBy using the 3Ts you create statistical process control in human dependent activities. The target is set as the very best results that you want. The Tolerance is set as the very worst results that you will accept. The proof test confirms that the result is correct. Target provide precision, Tolerance set the quality standard, and Test delivers reliability work.56The Purpose of Accuracy Controlled Enterprise SOPsTimeOutputPeople in Processes Produce Variable OutcomesTimeOutput3Ts in SOPs Remove Volatility from ProcessesInstead of doing the task and measuring at completion to see if it is accurate, the 3Ts require measuring during the task so nothing proceeds until it is accurate.12/4/201457The 3T method - Target, Tolerance, Test - introduces quality control into human-dependent processes. It keeps a procedure in-control and capable. It greatly increases repeatability and reliability of work results.Sarangani Energy Corporation57ACE 3Ts with tolerance banding procedures are the best way known to proactively introduce statistical quality control so that work only proceeds when the inputs are proved correct and the process is in control and is capable of producing correct outputs. We build understanding and predictability for users of ACE procedures by including the 3Ts into every task.Standardize Human Dependent ProcessesSpecify the 3Ts (Target, Tolerance, Test) for precision, accuracy and error proofingRange tolerance good, better, bestMake best the world-class performanceMake a SOP with a table of successive activities in each rowProvide columns for good, better, best tolerance range Give all tasks a proof testAdvise what to do when out of toleranceGet a signature when 3T is done to toleranceNo.Range of OutcomesSpecificationGoodBetterBest0.90.90.9nWarning This is a series system!3T SOPs give feed forward control* It is this test that makes an activity error proof!0.90.990.990.912/4/201458Mistake Proofed SOPs to Prevent VariationSarangani Energy Corporation58Procedures in companies that are controlled by accuracy and precision (Accuracy Controlled Enterprises) use the 3T methodology. To make a game out of work incorporate good, better, best banding in the tolerance. People will naturally want to do well, and if you set clear and demanding targets, they will self-direct their efforts to try and meet them.

ACE procedures also become excellent training documents because perfect performance, and how to do it, is written down in the text, along with the necessary standard to achieve and the means to test progress toward it.

12/4/201459Why Quality Control in ProceduresNOTE: None of these task will prevent the pump and piping from failing. These tasks find future repairs and you want a healthy, reliable pump set...

prevention is easier than cure

Sarangani Energy CorporationAccuracy Controlled Enterprise 3T ProcedureTask Step No.Task Step OwnerTask Step NameFull Description of TaskTest for CorrectnessRecord Actual ResultAction if Out of ToleranceSign-off After Complete1(Max 3 4 words)(Include all tables, diagrams and pictures here)Describe the test and below specify the target as BEST and range of acceptable results that are Good enough.Good

BetterBestOne Layout for an Accuracy Controlled ProcedureTarget bringsPrecisionTolerance bringsQualityTest bringsReliability12/4/201460An organisation that applies 3T accuracy controlled procedures at every level of operation.Sarangani Energy CorporationContinuous Improvement = Accuracy Controlled Procedures Task Step No.Task Step OwnerTask Step NameTools & ConditionFull Description of TaskTest for CorrectnessTolerance RangeRecord Actual ResultAction if Out of ToleranceSign-off After Complete(Max 3 4 words)(Include all tables, diagrams and pictures here)GoodBetterBestAccuracy Controlled 3T Procedure LayoutNow you know what good enough is!Continuous improvement: Make better good, make best better and set a new standard for best. In this way, you will drive quality improvement and innovation in your company. Good enough never is!Drive ImprovementTargetPrecisionProof Testfor ReliabilityTolerancefor Quality12/4/201461Sarangani Energy Corporation61The way we write our procedures needs to change to the layout shown in the slide. This layout makes it clear to users exactly what they must achieve in every task. Each task has a boundary and test to confirm compliance. The only rule is that no new task is started until the previous task is proven to be done right.

With the ACE 3T layout you still use your current procedures text. The one new requirement is to incorporate the 3Ts to provide the statistical control needed to ensure task accuracy.Activity 8 Standardised Accuracy Controlled Procedure12/4/201462In the workbook complete the pump set inspection procedure with quality standards to meet and checks to prove they have been met or bettered.Sarangani Energy CorporationSee page 48 in your workbook62Activity 9 RCA Cable Reel Near-Miss

12/4/201463Sarangani Energy Corporation12/4/2014Activity 10 Group do Motor Failure RCFA64An electric motor bearing failed on a piece of critical plant.

Team-up to make a group

Appoint a Facilitator who controls team situations

Develop the cause and effect tree

Using the evidence, identify the root cause

Use any tools you wish for analysis

Develop a secure prevention against future failures

Rate the proposed solutions and prioritise

Feedback and discussionSarangani Energy Corporation12/4/2014

The Power of RCFA comes from PropagationFailureEvidenceInvestigationAnalysis Corrective ActionImplementationPermanent ImprovementPropagationBeyond RCFARCFA ProcessEach failure is a symptom of a business system problem.Take what is learned in each RCA across the whole business so the systems are improved.Train relevant people in the new ways so everyone does them well65Sarangani Energy CorporationManagement Make the RCFA Process Work for the BusinessSet expectations for RCFA in a corporate policy/vision on the purpose, usage, outcomes and business improvement required of RCFAEstablish a core group of people passionate for failure elimination and teach them the tools and methods of root cause analysis and business process auditingDevelop RCFA processes at three levels 1) defect removal, 2) problem prevention, 3) disaster eradicationTrain people in the methodologies everyone on defect removal, team leaders and above on problem prevention, supervisors and above on disaster eradicationEstablish internal auditing half-yearly (by people from outside the department) of samples in each RCFA level and adjust processes and training accordinglyReport on RCFA completion at monthly management meetings all uncompleted RCFAs findings, and monitoring pace of action on required resolutions12/4/201466Sarangani Energy CorporationDocument and Describe Your RCFA Process StepsPreserve and collect evidenceAppoint experienced facilitatorAssemble a cross-functional team of persons involved in the incident and others knowledgeable in plant/process design and operationCost total impact of the incident to give power to the investigationInterview for what persons involved were doingInvestigate the physical evidence for its historyTeam brainstorm, starting at failure, to develop a cause-and-effect tree of sequential steps that may have led to failure (only grow the real branches)Use the evidence and interviews to confirm the failure pathDevelop a 5-Why Table using the evidenceRecord the findingsIdentify what can be done at stages along the path to prevent the failure and how they should operateCommunicate the findings and necessary changes company-wideAppoint a person to put the changes in place, including doing necessary training, using change management methodologyReview and monitor that progress is made towards the improvementsUse Hierarchy of ControlsTotal business losses impactNO BLAME... else truth disappears and fear reigns 12/4/201467Sarangani Energy Corporation67Some final closing thoughts for youMany have said that RCA is more art than science. (It is if there is no RCFA process.) Indeed, it seems to draw from a range of skills, talents, experience and knowledge. Some investigators seem to have a special knack for it while others toil through the process. (A diverse mix of team members makes for more success.)Even if an RCA is unsuccessful at uncovering the root cause, the process usually brings forth new knowledge and greater awareness of reliability risk factors to the team. This new knowledge can then be rolled into criticality studies, such as FMEA, leading to an overall improvement in machine reliability. (Only if newly discovered knowledge is written into the corporate memory for all to find and use.)The greatest successes come when you take the learning from every RCA across the entire business. (This is lateral development and it brings companies much success.)Its always wise to ask, Why was this allowed to happen? What latent thoughts, values and beliefs in the organisation and its people that let the situation arise?12/4/201468Sarangani Energy Corporation