Professional Documents
Culture Documents
Version Number:
Version Date:
Problem
When Date
1.
Time
Different, unusual, unique Timeline
Notes
Date Tim e Description Diagram Photos
Where Facility, site Use the drawing tools to add any diagram to this work sheet.
Delete these object s if they are not needed.
Ex amp le objec ts
(indust rial) I nsert any pictures on this worksheet .
Cylinder Drum
Unit, area, equipment
Task being performed Pump
Impact to Environment
Impact to Customer Exchanger
Impact to Regulatory
Production/ Schedule
Capture specifics about the problem as well as the
Impact to
Expander,
Compressor
Property/ Equipment
Turbine
Impact to Use t hi s box a picture label
Labor/ Time
impact to each of the organization's overall Goals.
Impact to
This incident $0
Frequency
Additional Tools - Use as needed to capture specific information during the investigation.
Annualized Cost $0
Step 2. ...add as much detail as necessary to thoroughly explain the issue Work Process
Start a 5-Why Cause Map Step 2. Analysis Possible Solution: AND Why? Process Map Decisio n point
The flow of a
Analysis
Copy and use as needed
Steps within a Task
Effect Cause
2.
YES
Title
OR
Process
NO
work process
that is relevant
Evidence: AND/OR Basic Cause-and-Effect Relationship
Cause Map
to the incident.
Im pact t o AND
Safety
- Write down one of the Goals that was impacted. need to be collected
- Write the impact to that Goal in the next box. Basic AND
during the investigation
- Answer the question "Why did that happen?", then ask Im pact to
Production
Goal
Investigation Action List
"Why" again.
This tab is used to track specific information gathering or support task s for the investigation.
The 'Solutions' tab will capture the action items that are selected by the investigation team.
AND
No. Action Item Owner Date Created Due Date Status Completed
1
Detailed
4
5
6
Step
3.
Propose Possible Evaluate Select Best Specify Each action item is essentially a project.
3. Solutions Solutions
Capture ideas in a solution box and
Solution Options
Consider the Effort IN to the
Solution versus the Result OUT
Solutions
Impact and Risk to each
Goal should be reduced to
Action Plan Follow-up should evaluate its effectiveness.
Solutions may be a change in work process.
attach it to the cause it controls. an acceptable level. Ref Possible Solution Cause Controlled
Work Process
(process to be improved)
Implement?
(yes or no)
No.
Specific Actions
(specific actions to be taken)
Owners
(names)
Due Date
.
Measurable
(how will we verify completion
and effectiveness)
Risk Curve
A
B
Risk
Medium
Benefit
Map.
H
- Evaluate the different possible solutions. Select the best. Low Medium
Effort
High
Cost
Effectiveness of Solution(s)
What Problem(s) Grúa no levanta o sostiene, pérdida de dinero por grúa parada -
por paro de operaciones hasta 1 00 millones en pérd ida
When Date Lunes 11 de Noviembre
Time 11.00 am hasta las 10:30 pm
Different, unusual, unique La grua llega tarde a la zona de operación
Where Facility, site Tribal PARK, Llanogrande
Unit, area, equipment Zona de operación plana (Estable)
Task being performed Levantamiento de mesa de comensales
Impact to each GOAL
Customer Cliente Insatisfecho
Production, Schedule Perdida de utilidad por hora $765,000
Property, Equipment Costo de válvula holding + Costo de Motobomba hidraúlica $5,000,000
Clien te Cliente Cliente Cliente Cliente Cliente Cliente Cliente Cliente Cliente Cliente Cliente C liente C liente C liente C liente C liente Cliente Cliente Cliente Cliente Cliente Clie nte Cliente Cliente Cliente Cliente Cliente Cliente Cliente Cliente Cliente Cliente Cliente Cliente C liente C liente C liente C liente C liente Cliente Cliente Cliente Cliente Cliente Clie nte Cliente Cliente
Rent Area del patio destinado para la grúa por paro de operaciones $350,000 Customer Insatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerIn satisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerIn satisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe CustomerInsatisfe Customer
Labor, Time cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho cho
15 dias maximo por importación de pieza, 1 día Reemplazo pieza,
$122,400,000
10 horas / día
This incident $127,750,000
Frequency
Mantenimiento correctivo de la válvula y la motobomba , según la
hoja de vida proporcionada por la empresa , ning uno de los dos se
1
suele cambiar durante el año y solo en 2018 se desintalo la Bomba
para hacerle mantenimiento
¿Porque?
¿Porque?
No levanta la No se despliega
carga el Boom
¿Porque? ¿Porque?
¿Porque?
¿Porque?
Perdida de
No sostiene la
fuerza
carga
hidraulica
¿Porque?
Possible Solution:
Cambio de mangueras
Cristalizacion de exposicion a la
Mangueras rotas
las mangueras interperie
Possible Solution: En lo
posible masillar, sino
cambiar tanque.
tanque
fuga de aceite
contenedor Desgaste
hidraulico
perforado
Possible Solution:
Cambio de pieza.
Racor defectuoso
Possible Solution:
cambio de empaque
O-Ring
cristalizado
Obstrucción
Possible Solution:
Rosca del tornilloCambiar tornillo.
No sostiene la Piston hidraulico desgastada
carga se contrae
Possible Solution:
unir y aislar cables
Possible Solution:
Falta de contacto
Cambio de pastas. Señal electrica
entre cables
interrumpida
electricos
Tambor de hilos Freno del tambor
defectuso desgastado
Possible Solution:
Capacitar operario.
Impact to Mal
Cliente No recive señal Conexion Mal manejo del
funcionamiento Joystick en falla
Customer insatisfecho de despliegue desgastada
de la grua operario.
Possible Solution:
Cargar el
acumulador .
Perdida de 765 No cumplimiento
Impact to mil pesos por de estandares de Acumulador
Labor, Time hora de grua calidad exijidos hidraulico
parada por el cliente despresurizado
Possible Solution:
Cambio de fusible.
Falla de la fallas en la carga
Fusible fundido
bomba hidraulica electrica
Possible Solution:
Cambio de filtro.
Obstrucción de la
Cavitación del linea de succión de Desgaste en filtros.
liquido hidraulico la bomba
Possible Solution:
Calibrar valvulo a
Possible Solution: condiciones optimas
Cambiar eje.
Vibraciones Valvula de alivio en
Rotura del eje
excesivas falla.
el boom no se Presion
despliega insuficiente
Possible Solution:
Cambiar manguera
Mangueras rotas
Tanque perforado
High
Payback
Benefit Medium
High
Timeline
Used this tab to capture details of the sequence of events leading up to the problem in chronological order.
Insert process
name here
Notes
Use this tab to keep track of any supporting notes, emails or documents.
Info To Get
Use this tab to keep track of any information required to complete the investigation.
Info To Get
No. Investigation Action Items To Get: Owner Date Created Due Date Status Completed
1
2
3
4
5
6
Started here
If you have placed the Elbow Arrow Connector in the
first position, then tapping the 1 key will give you a
connector that can be added to the Cause Map.
with alignment
(c lock) )
1 Da te
July 9, 2014 Conference Call De scription
Initial information captured 1.00 Update
John By
Smith Tom K., Robert C.
Ve rsion Interaction Type Time Dura tion Contributors
1 2 JulyJuly 10, 2014
9, 2014 Meeting (in
Conference Callperson) One
Initial on one with
information operator, initial map build, updated timeline 1:00 PM 1.000.50 John
captured John Smith
Smith TomJim
K.,P.Robert C.
2 3 JulyJuly
10, 10,
2014 Remote
(in person) OneMap
Cleanup
0.500.75 John
John Smith
2014 Meeting on one with operator, initial map build, updated timeline 1:00 PM Smith Jim P.
Meeting with Operations - expanded Cause Map, added Operations Team -
3 July 10, 2014 Remote Map Cleanup 0.75 John Smith
4 July 13, 2014 Meeting (in person) Actionwith
Meeting Items
Operations - expanded Cause Map, added 8:00 AM 1.50 John Smith Jim, Kathy,
Operations TeamPhil
-
4 July 13, 2014 Meeting (in person) Action Items 8:00 AM 1.50 John Smith Jim, Kathy, Phil
Hazard OR
Impact to Employee contacted Fire Fuel
Safety injured hand unprotected
hand
Out of paper ?
AND