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Report No.

Root Cause Failure Analysis Report

A) What Are The Details Of The Event/Failure?

Failure Report Title

(May be based on the work order title)

Failure Report Title (May be based on the work order title) Date Of Event/Failure Equipment Tag

Date Of Event/Failure Equipment Tag No Tag Description Equipment Type Equipment Vendor Equipment Serial No CMMS Work Order No Work Order Opened (date) Work Order Closed (date)

NOTE: Complete only relevant sections. If certain sections are not considered relevant, you must state why it is not relevant. Incomplete reporting is unacceptable.

B) Function

What does ‘it’ do?

Very often there is a lack of clarity on, what the equipment should actually do, what the performance standards are for the equipment (e.g. to pump 350cu meter/hour of crude at 40bar). This lack of clarity can make the process of failure analysis very difficult. Consider what the normal operational performance standard is for this equipment in its normal operating mode. It is necessary to know the normal parameters first, as a reference/datum.

In this section record the entire key data regarding the equipment’s primary function.

What is the operating context for this equipment you have worked on? (State the primary function and the performance, throughput, in a specified time, i.e. pressure, temperature, (State the primary function and the performance, throughput, in a specified time, i.e. pressure, temperature, etc?)

in a specified time, i.e. pressure, temperature, etc?) If relevant, please describe secondary functions. 2 State

If relevant, please describe secondary functions.

etc?) If relevant, please describe secondary functions. 2 State what the standard primary function performance
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2

State what the standard primary function performance standard is, i.e., it is the datum for comparison, and who has set this performance standard?

Work - What is expected? Cycles/Load Etc.

Time - How long for? Duration

Throughput - At what rate?

Output quantity & quality. At what quality?

Safety & risk compliance

Standard set by (whom)

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C) Functional Failure

How has ‘it’ not done what it should?

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In what way has this piece of equipment been deemed to have failed to fulfil its function?

Provide a brief statement of the ‘problem’ or failure that Maintenance was asked to

 

investigate/resolve. [This may be the key point from the maintenance work order.]

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4

What change or deviation was observed from the normal operating condition? Compared to the function details previously in Q1 & Q2, e.g. was deterioration, slow down, increases noted, etc? State how? By how much? Over what time frame, etc?

Please describe what changed/deviated below, e.g. reduced by x% in time t.

what changed/deviated below, e.g. reduced by x% in time t. 5 What was the sequence of
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5

What was the sequence of events that lead up to this failure?

Can this be supported with hardcopy documentation such as logs/trends/journals? (Via

SER/DCS/RMPIS/Other

) Consider all aspects.

Yes? No?

If Yes please attach the logs/trends/journals to this report.

The attached documentation demonstrates/proves that:

<caused/occurred> and then subsequently

D) Failure Effect

What happened?

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State in words briefly what happened when the failure occurred? Consider the effect on the equipment, system, and plant.

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How serious was the failure in terms of downtime, secondary damage?

was the failure in terms of downtime, secondary damage? (More detailed consequences analysis, see Section H)

(More detailed consequences analysis, see Section H)

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E) Action to Restore Function

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State clearly what exactly has been done physically to overcome this functional failure?

Explain beneath:-

3

Action Code

Description

 

Cleaned

 
 

Repaired

 

Reset

 

Refurbished in situ

 

Overhauled

 

Recalibrated

 

Adjustment

 

Other, specify

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If the item was replaced please state the condition of the fitted item:

 

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Action Code

 
 

Replaced with new item

 

Replaced with refurbished item

 

Refurbished and then replaced

 

Replaced with modified item

 

Other

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Where are the primary failed components now?

Lost/Discarded

Available for review (tagged and stored) Refurbished and reinstalled

A) Good as new

B) Better than old

Refurbished and returned to store

Returned to vendor

Other, explain

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Has this equipment been returned to as good as new condition and function?

Yes? No? If Yes how did you verify, test and confirm that the equipment meets the required performance standards following the response?

the required performance standards following the response? Note: Attach test sheets, start-up/ acceptance logs to

Note: Attach test sheets, start-up/ acceptance logs to validate.

If you have indicated No:

By how much was it degraded?

Is this considered a temporary repair? or Is this considered a modification temporary or otherwise?

%

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If a temporary repair has been made, what is required and when?

No?

Yes? No?

Yes?

Requirement

Due date:

Consequence if due date missed

Follow on MWO Number

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How long will the equipment run now ? Until what next datum? When?

F) Change Control

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If you have performed a modification that alters the original fit, form or function, (this includes the substitution of components, different manufacturers, in house made) then this may significantly change its life.

These changes must be tracked.

Please explain technically the reason, purpose and who authorised this modification, -

Reason [s]

Purpose

Authority To Modify Is

(Letter No., Engineering Package No, etc)

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Detail what effect this modification will have on the function and performance of the equipment/component?

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Please indicate what updates are needed as a result of this repair?

When permanent changes are made it is very important that all the records, documentation and support are also updated so that the maintenance support remains valid. Remember that Maintenance is mandated to maintain and not modify – without review/approval and disciplined change management.

The following must be re-validated:

 

Equipment Master Record in CMMS

Yes? No?

Material Spare Parts details, stocking, specifications

Yes?

No?

Drawings & documentation (to be red lined and returned to design

 

agencies to formally update corporate documentation records)

Yes? No?

Support equipment and tools, updated, provisioned

Yes?

No?

Standard Job Plan (PM or corrective)

Yes? No?

Standard Operating Procedure’s

Yes? No?

Start-Up/Acceptance Forms Modified

Yes? No?

Provide details as necessary in the box below

Modified Yes? No? Provide details as necessary in the box below Any items with No –

Any items with No – State Why!

Modified Yes? No? Provide details as necessary in the box below Any items with No –

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G Failure Mode/Cause

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What are the initial recorded CMMS Failure Codes for the work that was conducted?

 

Failure

Failure Code

Problem

Problem Code

Cause Description

Cause Code

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What do you think happened?

What can you prove, support and how? Consider also your comments in section C.

State clearly in words in the box below

-Initially

-Subsequently

Please expand and support your conclusion(s): -

Please expand and support your conclusion(s): - 19 What was the failed component(s) and its mode
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What was the failed component(s) and its mode of failure, e.g., Oil Filter Blocked?

     
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Has this failure occurred on similar equipment or a group of equipment? Yes? No?

If YES, – how often?

in

duration.

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Have you conducted a five-why or other technique to arrive at the Root Cause? Yes? No?

Be aware that the initial reported cause is rarely the root cause codes and a further level of detailed, analysis and comparison is necessary to arrive at the real root cause.

If YES - What were the findings from this kind of techniques?

YES - What were the findings from this kind of techniques? Please list the possible Root

Please list the possible Root Cause of failure into the table below.

NOTE if further investigation is ongoing or required do not complete this section until the investigation is complete.

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Root Cause

Yes

No

Maintenance Related

   

Skills (Competency Deficiency Of Craftsmen)

   

Incorrect Tooling or Equipment Utilised

   

Improper Previous Repair (Rework Issue)

   

Improper Alignment or Field Installation

   

None Standard or Original Materials, Parts Used

   

Original Design or Selection In Question

   

Operational Related

   

Mal-operation. (Improper Operation/Sequence/Etc)

   

Improper Start-up or Shutdown

   

Equipment Overloaded, Operated Too Hard or Too Slow

   

Operating Context/Condition has Changed Since Design

   

Lubrication Issue (Insufficient/Incorrect/Contaminated)

   

Other, explain

   

E.g., design related

   

E.g., purchasing related

   

You must say what it may be and what it is not; i.e. a Y or N is required for each. No omissions allowed.

State what you consider are the real Root Causes. e the real Root Causes.

allowed. State what you consider ar e the real Root Causes. Evaluate the Reliabilit y of

Evaluate the Reliability of this failure? y of this failure?

Based upon the initially reported fault codes, the historical data that has been gathered, the evidence of this event/failure and the basic causes of failure from the table above, from a maintenance perspective would you say this failure is:-

a) Considered ‘normal’ due to appropriate wear & tear.

Yes?

No?

b) Considered abnormal & unusual.

Yes? No?

c) Considered chronic or repetitive.

Yes? No?

If you indicated Yes to either of the last two questions above. I.e. [abnormal/unusual or chronic/repetitive]

What is the historical frequency (number of occurrences)? Attach the support through the relevant CMMS Reports.

d) Considered unacceptably costly.

Please compare these to Nos.1&2 (on Page 1 to define the deviation in performance

Yes? No?

Please support financially with the relevant CMMS report that considers lifetime maintenance costs incurred for this asset. What is the ‘normal’ unit cost per work/time/throughput for this equipment for a comparator?

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<x>

$’s per

<of>

H) Consequences of Failure

Does it matter? How much?

State the consequences of this failure in terms of safety, environment, production, and costs?H) Consequences of Failure Does it matter? How much? 24a Safety: Was there an actual safety

24a
24a

Safety: Was there an actual safety loss associated with this event /failure? (This refers to a

quantifiable safety loss that was sustained.)

Yes? No?

If Yes - then how can this actual safety loss be quantified in financial terms? Indicate the value of this safety loss in the box provided

<X $’s> for

24b
24b

Environmental: Was there an actual environmental loss associated with this event/failure?

(This refers to a quantifiable environmental loss that was sustained.)

Yes?

No?

If Yes – then how can this actual safety loss be quantified in financial terms? Indicate the value of this environmental loss in the box provided.

<X $’s> for

As this was an actual safety and/or environmental loss, has this been documented separately, accompanied

with the near miss or preliminary incident reportage and channelled through to population of, e.g., HAZOP

databases?

Yes? No?

If Yes, - record the transmittal reference to Safety & Environmental Department If No, - why not?

Production: - Was there an actual production loss associated with this failure/event? Note. This refers to a Was there an actual production loss associated with this failure/event? Note. This refers to a quantifiable loss that was sustained that was not recovered by increasing throughput through the plant/unit/equipment once the failure/event was dealt with.

Yes? No?

If Yes, - then how can this actual production loss be quantified in financial terms? Indicate the value of this loss in the box provided. (You may need to discuss this with a performance-monitoring engineer.)

<X $’s> for

<quantity> of <product> for <duration>

24d
24d

Maintenance: When maintenance responded to this event/failure. (It is important to understand if this was a completely unbudgeted/unplanned response.)

Was this a breakdown response?

Yes? No?

Did this occur out of hours and require call out/overtime?

Yes?

No?

Were all the costs directly apportioned to this failure/event?

Yes?

No?

If No, - then what other work (opportunistically) was conducted whilst the event/failure was being dealt with?

What were the total maintenance costs associated with the response to this event/failure?

Total

Labour

Materials

Other

What was the total downtime of the equipment?

Hr’s

Hr’s

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What was the total maintenance time within this total downtime?

Where is the balance of the downtime to be attributed to if the maintenance downtime is less than 50% of the total?

if the maintenance downtime is less than 50% of the total? Non Operational/Other Did this event/failure

Non Operational/Otherif the maintenance downtime is less than 50% of the total? Did this event/failure result in

Did this event/failure result in other non operational cost other than the direct costs of response/repair?

Perhaps taxes, penalties, logistics etc. If Yes what were these costs by type and cost?

Yes? No?

$’s

For

<what>

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Determine the Total Financial Cost Of This Event/Failure. (Add together numbers 24a 24e.)

$’s

I) Preventive Action

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What should (could), be done to prevent this failure from re-occurring? (Brief statement only)

<Why> -------------------------------------------------------------------------------------------------------------------------------------------------

<How>--------------------------------------------------------------------------------------------------------------------------------------------------

<By when>---------------------------------------------------------------------------------------------------------------------------------------------

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Define the tasks or ideas that your work group should do to resolve this issue?

1.

2.

3.

4.

5.

Approximate Cost?

ROI v/s cost @ Number 25 = x:1 in y period

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Have you any other suggestions that would prevent a re-occurrence? (Perhaps outside of your control.)

 

My suggestion is to By

because

This needs to be

,

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Do you consider your suggestions to be: -

 

An in-house maintenance activity(s)

A outsourced specialist maintenance activity

A redefined operations activity (s).

A modification or enhancement.

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Yes? No? Yes? No?

No?

Yes?

Yes? No?

J) Maintenance Strategy Review

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Would checking the equipment at different intervals have been sufficient to detect the failure before it occurred? How would it then become detectable and preventable? Please explain.

We should check would then make

by

<technique> at <what> detectable & preventable because

<interval>. This

<why>

Should we consider a scheduled overhaul / strip down for this equipment? Would the timely replacement of a component have retained the original system resistance to failure Would the timely replacement of a component have retained the original system resistance to failure as a whole? Please expand/support below.

- Wear pattern

- characteristic

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Is this equipment currently in the preventative maintenance (PM) programme? Yes? No?

If NO - What are the reasons why it should be included in the PM program ? What specific individual failure modes would be targeted and how, in the revised preventative maintenance checks?

It should be included in the preventative maintenance program because

We

would target

failure mode(s) with

activities/tasks

using

techniques.

If YES - Why didn’t the current preventative measures avoid this current failure?

The equipment is in the PM program and the current PM activities did not prevent this current failure because

My support/evidence for this conclusion is

If YES - What was the date of the last PM?

Have the PM’s been conducted on time/schedule in the last year?

(Please attach the proof that the scheduled PM’s have been completed on schedule and completed.

Type/Code Used

Yes? No?

Do you still believe a review of the preventative maintenance -content/frequency is warranted? Yes? No?

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Is this equipment currently included in the predictive maintenance program?

If YES, should or could the failure have been predicted?

Yes? No?

Explain

If NO, should condition monitoring be considered?

Explain

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K) Design out.

Do we need to change ‘it’?

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What should be done if no suitable preventative task can be found? Is there an inherent

systemic or equipment ‘problem’ that can only be resolved by a redesign action?

A design out initiative needs to be considered here because

This is supportable, as with

The consequences (in cost, danger terms) of not making this change are

is unacceptable in accordance standard/regulation/required

performance standard.

L) Status/Conclusion

What needs to be done, by whom & by when?

What tangible & supportable actions are recommended?What needs to be done, by whom & by when?   Category Yes No Next Action

 

Category

Yes

No

Next Action To

Due Date.

Inconclusive

Need

to

Send

Failed

Components

For

       

Analysis

Maintenance

Costs

Are

Unacceptable

Consult

       

Vendor/TSD

Design Change Is Necessary

         

Review Materials Of Construction Change

         

Revise Preventative Maintenance Content/Frequency

         

Revise Predictive Maintenance Content/Frequency

         

Review/Revise Operating Procedures

         

Training Is Required

         

Improve, Prove Different Tools/Test Equipment

         

Corrosion/Erosion Issue. Refer To TSD Inspection

         

Other, specify

         

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Scratchpad - Anything To Add or Record?

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Team Leader/Title/Department
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Team Leader/Title/Department

Name:

Title:

Department:

Team Members/Discipline/Dept

Name

Date Report Closed Out:

Discipline

/ /

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Department