INTRODUCTION

Reliability engineering and predictive maintenance have two major objectives: pre-
venting catastrophic failures of critical plant production systems and avoiding devia-
tions from acceptable performance levels that result in personal injury, environmental
impact, capacity loss, or poor product quality. Unfortunately, these events will occur
no matter how effective the reliability program. Therefore, a viable program also must
include a process for fully understanding and correcting the root causes that lead to
events having an impact on plant performance.

This book provides a logical approach to problem resolution. The method can be used
to accurately define deviations from acceptable performance levels, isolate the root
causes of equipment failures, and develop cost-effective corrective actions that pre-
vent recurrence. This three-part set is a practical, step-by-step guide for evaluating
most recumng and serious incidents that may occur in a chemical plant.

Part One, Introduction to Root Cause Failure Analysis, presents analysis techniques
used to investigate and resolve reliability-related problems. It provides the basic
methodology for conducting a root cause failure analysis (RCFA). The procedures
defined in this section should be followed for all investigations.

Part Two provides specific design, installation, and operating parameters for particu-
lar types of plant equipment. This information is mandatory for all equipment-related
problems, and it is extremely useful for other events as well. Since many of the
chronic problems that occur in process plants are directly or indirectly influenced by
the operating dynamics of machinery and systems, this part provides invaluable
guidelines for each type of analysis.

Part Three is a troubleshooting guide for most of the machine types found in a chemi-
cal plant. This part includes quick-reference tables that define the common failure or

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4 Root Cause Failure Analysis

deviation modes. These tables list the common symptoms of machine and process-
related problems and identify the probable cause(s).

PURPOSE OF THE ANALYSIS

The purpose of RCFA is to resolve problems that affect plant performance. It should
not be an attempt to& blame for the incident. This must be clearly understood by the
investigating team and those involved in the process.

Understanding that the investigation is not an attempt to fix blame is important for
two reasons. First, the investigating team must understand that the real benefit of this
analytical methodology is plant improvement. Second, those involved in the incident
generally will adopt a self-preservation attitude and assume that the investigation is
intended to find and punish the person or persons responsible for the incident. There-
fore, it is important for the investigators to allay this fear and replace it with the posi-
tive team effort required to resolve the problem.

EFFECTIVE
USE OF THE ANALYSIS

Effective use of RCFA requires discipline and consistency. Each investigation must be
thorough and each of the steps defined in this manual must be followed.

Perhaps the most difficult part of the analysis is separating fact from fiction. Human
nature dictates that everyone involved in an event or incident that requires a RCFA is
conditioned by his or her experience. The natural tendency of those involved is to fil-
ter input data based on this conditioning. This includes the investigator. However,
often such preconceived ideas and perceptions destroy the effectiveness of RCFA.

It is important for the investigator or investigating team to put aside its perceptions,
base the analysis on pure fact, and not assume anything. Any assumptions that enter
the analysis process through interviews and other data-gathering processes should be
clearly stated. Assumptions that cannot be confirmed or proven must be discarded.

PERSONNEL
REQUIREMENTS
The personnel required to properly evaluate an event using RCFA can be quite sub-
stantial. Therefore, this analysis should be limited to cases that truly justify the expen-
diture. Many of the costs of performing an investigation and acting on its
recommendations are hidden but nonetheless are real. Even a simple analysis requires
an investigator assigned to the project until it is resolved. In addition, the analysis
requires the involvement of all plant personnel directly or indirectly involved in the
incident. The investigator generally must conduct numerous interviews. In addition,
many documents must be gathered and reviewed to extract the relevant information.
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In more complex investigations, a team of investigators is needed. As the scope and

complexity increase, so do the costs.

As a result of the extensive personnel requirements, general use of this technique

should be avoided. Its use should be limited to those incidents or events that have a
measurable negative impact on plant performance, personnel safety, or regulatory
compliance.

WHEN TO USE THE METHOD

The use of RCFA should be carefully scrutinized before undertaking a full investiga-
tion because of the high cost associated with performing such an in-depth analysis.
The method involves performing an initial investigation to classify and define the
problem. Once this is completed, a full analysis should be considered only if the event
can be fully classified and defined, and it appears that a cost-effective solution can be
found.

Analysis generally is not performed on problems that are found to be random, nonre-
curring events. Problems that often justify the use of the method include equipment,
machinery, or systems failures; operating performance deviations; economic perfor-
mance issues; safety; and regulatory compliance issues.