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Root Cause Analysis (RCA) Investigation Guide

This resource highlights the procedures to follow when applying Root Cause Analysis (RCA)
to resolve equipment-related failures linked to oil rig downtime.

Life Cycle Engineering 2012

www.LCE.com

Root Cause Analysis (RCA) Investigation Guide


This Root Cause Analysis Investigation Guide presents the procedures to follow when applying Root Cause
Analysis (RCA) to resolve equipment-related failures linked to oil rig downtime. You will find instructions for
classifying equipment failures as minor, moderate or significant, and the appropriate investigation procedure
to use for each classification. Also included are suggested root cause and equipment failure report templates
and a visual guide to selecting appropriate root cause analysis tools.
Equipment Failure Classification:
Equipment failures are classified according to the severity of their impact. These classifications help determine
which investigation procedure to use.
General Classifications:
Classification
Minor

Severity of Impact
No impact to drilling operations
Repair costs < $5,000

Moderate

Impact shuts down drilling operations for < 2 hours


Repair costs are between $5,000 - $10,000

Significant

Impact shuts down drilling operation for > 2 hours, reportable environmental impact
and/or causes personnel injury
Repair cost > $10,000

Trigger points that indicate that an equipment failure is significant are different for rig operations and drilling
operations. These specific trigger points are documented below:
Rig Operations

Significant Failure Trigger Point

Availability Impact

> 4 hours of consecutive equipment downtime

Repair Cost Impact

Repair costs > $10,000

Maintenance Impact

Cancellation of > 10% of planned/scheduled maintenance and/or a repeatable


equipment audit discrepancy

Safety Impact

Personnel incident or injury requiring transport to medical facility

Drilling Impact

Causes drilling operation to shutdown > 2 hours

Environmental Impact

Causes a reportable environment impact

Drilling Operations

Significant Failure Trigger Point

Availability Impact

> 2 hours of consecutive equipment downtime

Repair Cost Impact

Repair costs > $10,000

Maintenance Impact

Cancellation of > API Standard planned/scheduled maintenance and/or a


repeatable equipment audit discrepancy

Safety Impact
Environmental Impact

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Personnel incident or injury requiring transport to medical facility


Causes a reportable environment impact

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Investigation Procedure:
To maintain the integrity of failure history and data, and to minimize the level of effort required to prevent reoccurrence, conduct the investigation of equipment-related failures at the level consistent with the Equipment Failure
Classification. Below you will find the recommended procedure to follow and the relevant RCA team members
required for each failure classification:
Class

Minor

Investigation Level
1. Notify Rig Area Manager
2. Record equipment failure in the Failure Tracking System
(CMMS, etc.)
3. Initiate a Work Request for corrective maintenance
4. Record rig downtime in Downtime Log

Class

Moderate

Chief Engineer, Toolpusher, Safety


Representative, Senior Rig
Craftsman

Investigation Level

Investigators

1. Notify Rig Area Manager


2. Record equipment failure in the Failure Tracking System
(CMMS, etc.)
3. Record rig downtime in Downtime Log
4. Investigate using 5 Whys RCA Problem Solving Report
5. Prioritize corrective actions
6. Initiate Work Request for corrective maintenance
7. Submit Equipment Failure Report for review/approval

Class

Significant

Investigators

OIM (Offshore Installation


Manager), Rig Supervisor, Ship/
Barge Captain, Chief Engineer,
Toolpusher

Investigation Level

Investigators

1. Notify Rig Area Manager


2. Record equipment failure in the Failure Tracking System
(CMMS, etc.)
3. Record rig downtime in Downtime Log
4. Submit Equipment Failure Report
5. Initiate Work Request for corrective maintenance
6. Perform Root Cause Analysis
7. Prioritize corrective actions
8. Submit Root Cause Analysis Report for review/approval

OIM (Offshore Installation


Manager), Rig Supervisor, Ship/
Barge Captain, Chief Engineer,
Toolpusher
RCA Team:
Certified RCA Facilitator
Reliability Engineer
Craftsman (mechanical)
Craftsman (electrical)
Craftsman (subsea)
Craftsman (electronics)
Safety Representative
Crane Operator
Driller

On the following pages you will find:


Pg 3: A template for an Equipment Failure Report
Pg 5: A template for a 5 Whys Root Cause Analysis Problem Solving Report
Pg 6: A one page guide to selecting the appropriate root cause analysis tool
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Equipment Failure Report


Equipment Identification
Rig

Location

System

Equipment No.

Tour/Crew

Reported By

Equipment Description
Event Description
Time

Date

Summary of Costs
Estimated Repair Cost:

Attach Equipment Failure Photos

$
-

Estimated Downtime: (hours)


Estimated Production Impact: $
Estimated HSE Impact:

Failure Description (Initial Observations)

Immediate Actions Taken

Immediate Corrective Maintenance Authorized (WO#)

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Consequences:
Address with continuous
improvement

GREEN

YELLOW

Incorporate risk
reduction measures

RED

Intolerable

Risk Assessment Matrix


Potential Consequence of the Incident

Increasing Probability
A

Rating

People

Environment

No injury

Zero
effect

Zero
damage

No impact

Slight injury

Slight
effect

Slight
damage
< US$ 10k

Slight
impact

Minor injury

Minor
effect

Minor
damage
< US$ 100k

Limited
impact

Major injury

Local
effect

Local
damage
< US$ 1MM

Considerable
impact

Single
fatality

Major
effect

Major
damage
< US$ 10MM

National
impact

Multiple
fatality

Massive
effect

Extensive
damage
> US$ 10MM

International
impact

Assets

Reputation

never
heard of in
industry

heard
of in
industry

happened
before in
Company

reported
< 3x/yr in
Company

reported
> 3x/yr in
Company

Recommended Corrective Actions to Prevent Recurrence:


Action Items

Completed By

Due By

Reviewed/Approved By

Status

Signature

Chief Engineer
Toolpusher
Ship/Barge Captain
Rig Supervisor
OIM
Reliability Engineer

Life Cycle Engineering 2012

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5 Whys Root Cause Analysis Problem Solving Report


What Happened:
1. Why Did it Happen:
2. Why:
3. Why:
4. Why:
5. Why:

Root Cause(s) Identified

Short-term Countermeasures

Long-term Countermeasures

Report Completed By

Signature

Chief Engineer
Toolpusher
Safety Representative
Equipment Craftsman/Operator

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Product design, troubleshooting, generation


of proactive measures for prevention. Good for
complex systems with multiple failure modes.

Analysis of accidents and undesirable events


Particularly effective for incidents that have
primary and secondary events.
Where a simple, fast method for analyzing a
single chain of events or conditions. Very
effective for simple shop floor problem solving.

Identifies most probable modes


of failure, occurrence frequency
and detection for a given system,
component by component.

Describes graphically the sequence


of contributing events and existing
conditions associated with an
incident.

A simple drill-down approach Ask


Why 5 times. Each answer contains
the next why.

Situations in which a change from normal


configuration, operation or activity is likely to
contribute or lead to an undesirable condition.
Asks question: What is different now?

Compares the normal situation


to the undesirable situation and
determines changes that have
occurred.

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5 Why

(ECF) Analysis

Event &
Causal Factor

(FMEA)

Failure Mode &


Effects Analysis

Change
Analysis

(FTA)

Fault Tree
Analysis

Systems wherein undesirable end events are


linked to all contributing factors - equipment
failures, design reviews. Analyzes only one failure
mode, but all causes.

Incidents where the time sequence is critical to


the evaluation of combined contributing factors.

Graphically displays the sequence of


events leading to a failure, event, or
incident .

Sequence
of Events

(Ishikawa or fishbone)

For a single failure mode (top event),


examines many cause scenarios in a
branched method.

Quality systems, product design, troubleshooting,


brainstorming where multiple interactions may
be occurring.

Plots the relationship between


various factors that contribute to
a specific event.

Cause & Effect

Applies to all problemsnot just asset related.


Non-asset problemsevaluate processes and
practices. Starting point for many RCA types.
Examines the gaps between Intent and Actual.

Compares system design to how


it is applied. Specifically, the areas
of installation, maintenance, and
operating requirements and limitations.

Design &
Application
Review

Application

Purpose

Technique

Root Cause Analysis (RCA) Tool Guide

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