Professional Documents
Culture Documents
https://www.youtube.com/watch?v=ESTJC
QpGW3Q
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Learning outcomes
List the 6 most common root causes
Executive Summary
• When a failure occurs, it is important to
find the ‘root cause’
• The ‘root cause’ is usually due to:
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13/09/2022
ge tal
Lubricant
an en
Coating degradation
Su nge
s
ch onm
ch
rfa s
a
vir
ce
En Why
things
fail
rat ive
Hu tors
ion
vib ess
fac
ma
Poor adjustments
c
n
Ex
(e.g. valves) Strength Loosening
Mistakes with controls degradation Mis-alignment
Out-of-balance
Embrittlement
Annealing
Fatigue cracking
Creep
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- Loss of product
- Loss of customers
- Loss of reputation
- Loss of income
Unscheduled downtime
- Environmental
Overload damage
ge tal
an en
- ‘Clean-up’
Su nge
s
- Injury or death
ch onm
ch
costs
rfa s
a
- Damage to
vir
ce
- Prosecution
Hu tors
ion
- Loss of
vib ess
fac
- Financial
ma
reputation.
c
compensation
n
Ex
- Loss of Strength
degradation
customers
- Loss of
reputation
Unscheduled repairs
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Misalignment
Causes include soft foot, pipe strain, inadequate bases etc.
https://www.youtube.com/watch?v=MXAsK
FnCqUE
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Misalignment
Soft foot Pipe strain
https://www.youtube.com/watch?v=9Sb2k6
toAQY
https://www.youtube.com/watch?v=2FNGR
GCo8sk
Imbalance/Unbalance
Click
https://www.youtube.com/watch?v=VKr5RZt6MQo
http://www.lifetime-reliability.com/free-
articles/precision-
maintenance/Rotating_Machinery_Rotor_B
alancing.pdf
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Resonance
https://www.youtube.com/watch?v=iyw4AcZuj5k
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Looseness
https://www.youtube.com/watch?v=dUXtBf
xcpn0
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Bolt tensioning
Bolts are designed to be tightened to a specific clamping force. This clamping force or
tension ensures the joint will not slacken or vibrate loose. There are 3 main methods to
apply/measure the correct preload tension (BS4604):
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Bolt tensioning
http://www.lifetime-reliability.com/free-articles/precision-
maintenance/Summary_of_Bolt_Tensioning.pdf
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(a) What happened? (b) Why did it happen? (c) How can this situation be prevented?
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https://www.youtube.com/watch?v=BaEHV Video
pKc-1Q
https://www.pumpsandsystems.com/centrifugal-pumps/february-2018-
16
centrifugal-pump-primer
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Pump failure
The centrifugal pump in a nitric acid
plant stops working.
The fitter isolates the pump and
removes the outlet pipe to reveal the
impeller.
She finds that there is considerable
corrosion on the impeller
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Why?
Incorrect
material
https://en.m.wikipedia.org/wiki/Five_Whys
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1st Why did this occur?
13/09/2022
Learning What needs to be done to prevent the Root Cause happening again?
and
Your turn!
Prevention
A customer bought a cake that was supposed be topped with coconut but was topped with
almonds instead. This caused a severe allergic reaction which necessitated hospitalisation.
Ted Smith, 20/7/2022
Upon investigation, the following facts were observed.
1. After the cleaning of the manufacturing plant, the removable labels on the separate
1 add more rows if necessary
containers of coconut and almonds had been taken off.
2. The labels were not replaced for 2 days.
3. New operators were given training on the importance of using the correct topping to
avoid allergic reactions.
4. The person who operated the plant when the faulty cakes were produced was ill on the
day of his training and a new training date had not been fixed.
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Good design
Unscheduled downtime
Overload
ge tal
an en
Correct installation
Su nge
s
ch onm
ch
rfa s
a
vir
ce
En
Why things
Accidents fail Pollution
rat ive
Hu tors
ion
vib ess
fac
ma
Preventive maintenance
n
Ex
Strength
degradation
Unscheduled repairs
Good repair work
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Electrical
Electrical Plastic
Plastic
Fatigue
Fatigue Wear
Wear Corrosion
Corrosion Fracture
Fracture
erosion
erosion deformation
deformation
Subsurface
Subsurface Adhesive
Adhesive Frictional
Frictional Excessive
Excessive Forced
Forced
Overload
Overload
fatigue
fatigue wear
wear corrosion
corrosion voltage
voltage fracture
fracture
Surface
Surface Abrasive
Abrasive Moisture
Moisture Current
Current Indentation
Indentation Fatigue
Fatigue
initiated
initiated wear
wear corrosion
corrosion leakage
leakage from
from fracture
fracture
fatigue
fatigue debris
debris
Thermal
Thermal
Indentation
Indentation cracking
cracking
by
by
handling
handling
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22
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Contamination Other
17% 17% Fatigue
33%
Incorrect
lubrication
33%
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Fatigue
Electrical
Electrical Plastic
Plastic
Fatigue
Fatigue Wear
Wear Corrosion
Corrosion Fracture
Fracture
erosion
erosion deformation
deformation
Subsurface
Subsurface Adhesive
Adhesive Frictional
Frictional Excessive
Excessive Forced
Forced
Overload
Overload
fatigue
fatigue wear
wear corrosion
corrosion voltage
voltage fracture
fracture
Surface
Surface Abrasive
Abrasive Moisture
Moisture Current
Current Indentation
Indentation Fatigue
Fatigue
initiated
initiated wear
wear corrosion
corrosion leakage
leakage from
from fracture
fracture
fatigue
fatigue debris
debris
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35,000
N
mm 27
27
Max within
cylinder.
This is
where failure
will occur
Max within
block. This
is where
failure will
occur
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30
https://www.nskamericas.com/flaking-160.htm
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Part: Balls
Symptom: Spalling of ball surface
Cause: Dents due to shock load while
stationary
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https://www.nskamericas.com/flaking-160.htm
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Summary
• When a failure occurs, it is important to
find the ‘root cause’
• The ‘root cause’ is usually due to:
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