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OMV Exploration & Production

Root Cause Analysis

Presentation By

Amjad Nawaz
Instrument Engineer
Sawan Gas Field Operations

Move and More.

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.

It is designed to find out what is actually causing the symptoms.Root Cause Analysis A Root Cause Analysis is a structured and thorough review of a problem (or desired effect). Trained analysts act as detectives to find the guilty cause or causes of the problems .

” “This is critical. Symptom Approach Root Cause Errors are often a result of worker carelessness. Root Cause If we do a poor job of identifying the root causes of our problems.Symptom Approach vs. and implement mistake proofs so it won’t happen again. or it will come back and burn us. “Errors are the result of defects in the system.” .” We don’t have the time or resources to really get to the bottom of this problem. We need to fix it for good. 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. we will waste time and resources putting band aids on the symptoms of the problem.

risk management.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. systems analysis .

• Research has repeatedly proven that unwanted situations within organizations are about 95% related to process problems and only 5% related to personnel problems. Yet. . Consider the following two scenarios.Dig! How Deep? • Management decides on depth of root cause investigation through the establishment of SMART goals for each problem solving effort. most organizations spend far more time looking for culprits.

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.

. The operator also indicated that Maintenance had been talking to Purchasing about the gaskets because it seemed they were all bad. Operation Manager: why there was oil on the floor? Operator: it was due to a leaky gasket in the pipe joint above. He called the Operator over and asked him.Scenario # 2  The Operation Manager walked into the plant and found oil on the floor. 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.

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.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. 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. .

"Because you indicated that we had to be as cost conscious as possible!" and purchasing from the lowest bidder saves us lots of money. and asked the VP of Finance why Purchasing had been directed to always take the lowest bidder?  VP of Finance said.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.

Bingo! .Scenario # 2  The Operation Manger was horrified when he realized that “He” was the reason there was oil on the plant floor.

Thought?  You may find scenario # 2 somewhat funny. 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.  Everyone in the organization doing their best to do the right things. It would be better if the situation made you weep because it is often all so true in numerous variations on the same theme. . and everything ends up screwed up. Once simply has to continue to ask "Why?" until the pattern completes and the cause of the difficulty in the situation becomes rather obvious. and laugh at the situation.

. and the issue can easily be made as complicated / painful as your heart desires.How Do you do It……? There are many tools and techniques that apply.

don’t place blame (blame=avoidance and silence 2 ) Creating Options  Investigate and Find Best Solution 3) Implementation  Provide action plan to implement the solution .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.

... skill or motivation? Stress?.etc..vibration.. Management Poor involvement? Inattention to task? Stress demands?Training/Communication/Education/Guidel ine/Experience/lacking? Poor recognition of system limitations? Previously identified limitations were not eliminated?. .etc..Basic Elements of Failure Elements Questions to be ask Materials Defective? Wrong type/Handling/Quality? etc Manpower Inadequate capability? Lack of knowledge.Humidity......noise effect?..etc Methods Missing or poor procedures? Practice not same as procedure? Poor communication?. Environment Work surfaces? Physical demands? Temprature.etc.etc. Machine Incorrect tools? Poor maintenance or design? Poor equipment or placement? Defective?.

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? .METHODS – Was the canister. barrel.

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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. .

Leaky valve Seal failure 5. Fall Wet surface 3. Injury Fall 2. Seal failure 1 2 Not maintained 3 4 5 . Wet surface Leaky valve 4.Cause and Effect are same thing  Effects “caused Causes by” 1.

Why is there gravity? I don’t care) . Now you can do something about the problem OR Keep going until your answer to why is:  I don’t know (ignorance point marked with ?)  I don’t care (it fell because of gravity. STEP 2: Ask "why ?" to the previous answer STEP 3: Repeat step 2 at least five times. STEP 4: Result .a root cause. STEP 1: Define the starting point question.The 5 Why’s The simplest most basic way to find root cause is to ask "why ?" (at least) five times.

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 Why ? No-one was identified to provide the information. 6 Why ? 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 Caused By Person Fell .

Etc. .Phase 2 Hand Stopped Fall Broken Wrist Caused By Caused By Person Fell Caused By Etc.

Caused By .Phase 3 Excess Force Hand Stopped Fall Caused By Evidence goes here Broken Wrist Caused By Evidence goes here Evidence goes here Employee Overweight Wrist Position Evidence goes here Evidence goes here Caused By Etc.

com “Investigate Problems.Most Helpful.” . I thought Think Reliability. Prevent Problems.

Example: The Washing Machine .

Verify the Complain .

Investigate Why .

Investigate Why .

Investigate Why .

Investigate Why .

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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. “There’s more to it than the iceberg…” .com states. 1912  As ThinkReliability.

weak rivets Date: April 14 . Business loss $16.15.The Titanic/Step 1: Problem Outline Problem(s).5million Frequency 1x . ship hit iceberg. 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. Issue(s): Titanic sank.5million Business Liabilities.

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 .

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 didn’t turn sufficiently Why didn’t it turn sufficiently? All factors contributing to unavoidable collision: The speed the ship was traveling Seeing the iceberg late The size of the rudder .

. 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.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 didn’t turn sufficiently Why didn’t 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. BUT why did the ship sinking mean Insufficient lifeboats that 1517 people had to die? . 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.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 didn’t turn sufficiently Why didn’t 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.

you actually determine the ROOT CAUSE(S)! No Cause .The Titanic/Step 3: Solutions When you keep asking WHY. Action Item 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 Owner Due Date Status .

45 ..Thank You .