# Our Goal : Zero Defect, Zero Breakdown

Root Cause Analysis
Content 1. Objective 2. Basic Approach 3. Example

Our Goal : Zero Defect, Zero Breakdown

Objective
• Zero Defect • Zero Breakdown • Zero Safety Risk • Low Maintenance Cost • Higher Productivity • Effective Operability • Low Variability

Our Goal : Zero Defect, Zero Breakdown

Approach
• A disciplined method using a logic tree • A logic tree is required to represent Cause and effect relationships that lead to surfacing the undesirable event

Our Goal : Zero Defect, Zero Breakdown

Approach

What is the Logic Tree
A graphical way of representing Cause and effect relationship.

What is the cause and effect relationship ??
This will be explained in the coming slides during the presentation

Our Goal : Zero Defect, Zero Breakdown

Zero Breakdown .How to do the 5 .Why Analysis Our Goal : Zero Defect.

How to do 5 .Y Analysis Step 1: • Identify the undesirable event and its associated reason with supporting facts  Important • Facts are supported by some essence of science. direct observation & documentation Our Goal : Zero Defect. Zero Breakdown .

How to do 5 . • Find the reason as “ HOW” did it fail  Important • Do not work out for assumptions. Our Goal : Zero Defect. Zero Breakdown .Y Analysis Step 2: • Once identified the effect and reason. • Only physical evidence. technical reason is valid.

Zero Breakdown .How to do 5 .Y Analysis Note: •The facts cannot be hearsay or assumptions !! BUT Supported by Evidence of MODE/ Reason Our Goal : Zero Defect.

The End !! Our Goal : Zero Defect. Zero Breakdown .

Zero Breakdown .If the above steps are so simple then…………. Our Goal : Zero Defect...

If two guys are made to do the RCA of the same problem WHY is Possibility of difference in the conclusions drawn by them Our Goal : Zero Defect. Zero Breakdown .

Where is the Gap ??? Our Goal : Zero Defect. Zero Breakdown .

What is required to be done Thus Improving the credibility and communication of the results We need to explore the discipline necessary to provide consistency to our RCA Application Our Goal : Zero Defect. Zero Breakdown .

Impart training to bring a common understanding into the process Use disciplined thought process to seek true root cause We are not checking the thought process that drew the conclusions Better Understanding Our Goal : Zero Defect. Zero Breakdown .How to do it How to improve credibility and communication of the results.

Zero Breakdown .Hmmm undesirable Event Our Goal : Zero Defect.Now let us do a 5 .Why analysis with an example ……….

Our Goal : Zero Defect. Pump bearing failed Ask the fitter to Change it…..Sir. Pump should start now. Zero Breakdown .

Zero Breakdown ..What was the problem What did we do What was to be done What was the reason Come on. lets do the Root Cause Analysis Our Goal : Zero Defect.

From Where do we start Why did Pump Failed ?? OR Why did Bearing failed ?? Our Goal : Zero Defect.Getting Started………….. Zero Breakdown .

Zero Breakdown .Root Cause Analysis 1 First Why Our Goal : Zero Defect.

From where should I begin…. When the event occurred. Therefore the last effect that caused us concern was the pump failure One reason (MODE) that pump failed was due to bearing failure Our Goal : Zero Defect. Zero Breakdown ... why was it brought to our attention •Because the bearing failed OR Answer : •Because the Pump Failed It was brought to our attention because the failed bearing caused a pump to stop pumping Oil.

Thus we have Event :Pump Failure Mode : Bearing Failure (Supported by evidence) Our Goal : Zero Defect. Zero Breakdown .Objective Evidence Evidence : How can you say that it failed because of bearing? Answer Physically observed.

Logic Tree Effect Pump Failure WHY Reason Bearing failure Our Goal : Zero Defect. Zero Breakdown .

Cause and Effect Relationship Thus is any step of evaluation (first Why to 5 why) One is the effect and Other is reason(s) Each reason is to be evaluated with evidence to justify the reason Thus the relationship between the cause and effect lies with the Evidence Our Goal : Zero Defect. Zero Breakdown .

Cause and Effect Relationship Example :Bearing Failure caused a pump to stop working. • Last Effect is : .Pump Failure • Mode (reason) . Zero Breakdown Relationship .Bearing failed : • Evidence of Mode ( Reason) Our Goal : Zero Defect.Physical evidence .

Log book etc BUT CANNOT BE BASED ON ASSUMPTIONS Our Goal : Zero Defect. Condition Appraisal. Zero Breakdown .What is Evidence It can be any clarification based on • Technical Reasoning • Physical Evidence • Supporting data viz..Asset care.

. Zero Breakdown .there is one or more reason(s) And we need to hunt them down For any reason (mode) / Cause we find….Learning from this For any undesirable event (Effect) …..we need to justify it With a objective evidence Cause / Reason Effect Objective Evidence Cause Effect Relationship Our Goal : Zero Defect.

Zero Breakdown .MODULE 2 Second Why Our Goal : Zero Defect.

Often it happens we tend to conclude faster with our preset mind Jumping to Conclusion Our Goal : Zero Defect. Zero Breakdown .

but need to have an evidence Our Goal : Zero Defect.Why did the bearing Failed ?? Dear brother it failed due to some foreign particle Entering in it Mind Set We perceive a problem to exist and we go right to what the most obvious cause is to US This is the FINISHED PRODUCT APPROACH No doubt we cannot deny this reason…. Zero Breakdown .

Zero Breakdown . we just assume a cause and spend money to implement a fix and hope it works Experience shows this approach to be ineffective and very expensive.Finished Product Approach : We perceive a problem to exist and we go the right to what the most obvious cause is TO US !! We do not validate any of our assumptions. Our Goal : Zero Defect.

Now Let us find the Second why but in a different way ?? Our Goal : Zero Defect. Zero Breakdown .

Overload Mind Set For this we need to think we an open mind. Corrosion. Zero Breakdown .Fatigue.Why How did can the bearing Fail ?? Hmm…Erosion. At times we need to consult others This is the DISCIPLINED THOUGHT PROCESS TO SEEK RESULT Our Goal : Zero Defect.

Overload How can we prove which are true ( Evidence) Note : We asked How can a bearing fail and not Why did a bearing fail How can it fail -----this is brainstorming Out of the various reasons you brainstormed.due to…fatigue…evidence.bearing failed…. Fatigue. you look for the evidence. Our Goal : Zero Defect.Continuing our search backwards for the cause and effect relationships We would then ask How can a bearing fail ?? Our Hypothesis may be Erosion. And then conclude….. Zero Breakdown . Corrosion..why…..

Zero Breakdown . Laser Alignment technology While carrying out the investigation.Corrosion. Our Goal : Zero Defect.Fatigue. Overload High Vibration Misalignment Verification Techniques Metallurgical Analysis Vibration monitoring inst.Search for Evidence Hypothesis Erosion. metallurgical and physical test proved that it failed due to fatigue.

Logic Tree Pump Failure Why Effect Reason Bearing failure How Can ?? Why Erosion Corrosion Fatigue Overload Our Goal : Zero Defect. Zero Breakdown .

MODULE 3 Third Why Our Goal : Zero Defect. Zero Breakdown .

This way. we are validating our conclusions each step of the way.You can now see that as we develop new sets of hypotheses. they will be right because we have supported them based on fact and not mere assumption. we are proving what we say at each level of the process. Our Goal : Zero Defect. when we draw our conclusions about root causes. When we continue this reiterative process. This is demonstrating quality of process. Zero Breakdown .

Zero Breakdown .Logic Tree Pump Failure Why Effect Bearing failure How Can ?? Erosion Corrosion Fatigue Overload How Can ?? Reason High Vibration Evidence / Notes for clarification: Asset Care Check list states vibration was observed from past 5 days (PAST DATA) Our Goal : Zero Defect.

Zero Breakdown .MODULE 4 Fourth Why Our Goal : Zero Defect.

When most people conduct their version of Root Cause Analysis (RCA). are we content with the stopping at the “HOWS” or the “WHYS” Our Goal : Zero Defect. If we consider ourselves manufacturing detectives. Where do they usually stop? How do they know they are done? How do they know that the problem will not reoccur? These questions represent reality when we are the ones in the field working on a pressing problem with management on our backs. Zero Breakdown .

Zero Breakdown .Logic Tree Pump Failure Why Bearing failure How Can ?? Erosion Corrosion Fatigue Overload How Can ?? Effect High Vibration How Can ?? Reason Imbalance Misalignment Resonance Our Goal : Zero Defect.

MODULE 5 Fifth Why Our Goal : Zero Defect. Zero Breakdown .

Logic Tree Effectanalysis Rot cause Pump Failure Why 3 4 5 2nd 1st rd th Why Effect Rot cause analysis How Can ?? RootReason Cause Analysis Bearing failure Erosion Corrosion Fatigue Overload How Can ?? Effect Reason Rot cause an Root Cause Analysis Effect High Vibration Root Cause Analysis Reason How Can ?? Reason Effect Imbalance Misalignment Resonance Why Reason No Procedures Inadequate training Improper Tools Our Goal : Zero Defect. Zero Breakdown .

Now tell me when we typically conduct analyses. are we more like a engineer or the prosecutor and the detective looking to win his case? What is the difference between the those roles? Our Goal : Zero Defect. Zero Breakdown .

How to do it This means that a certain sequence of cause and effect relationships linked up and resulted in the undesirable event. Then what is the role of prosecutor and detectives?? Engr’s role is to determine with science HOW event occurred ? Role of prosecutor & detectives is typically to determine WHY. Their role is to prove that each hypothesis did or did not occur. Zero Breakdown . Our Goal : Zero Defect. Yes !! they in essence will map out HOW the crime occurred and be able to prove that it happened just that way.

Summary: First WE must provide the HOW pieces of puzzle and then determine why decisions that lead to the undesirable outcome We should use our Technology to prove or disprove our hypotheses and then explore Why people make decisions that result in the undesirable outcomes or failure Our Goal : Zero Defect. Zero Breakdown .

Let us look at the example we studied………. Zero Breakdown . Our Goal : Zero Defect.

Zero Breakdown .Logic Tree Pump Failure Why Bearing failure How Can ?? Erosion Corrosion Fatigue High Vibration Overload How Can ?? Physical How Can ?? Reason Effect Imbalance Misalignment Human Resonance Why Improper Tools Reason No Procedures Latent Inadequate training Latent Latent Our Goal : Zero Defect.

Corrosion.Fatigue. Overload High Vibration Misalignment Verification Techniques Metallurgical Analysis Vibration monitoring inst. Laser Alignment technology These questions answer how?? But what about why Our Goal : Zero Defect.The undesirable event is : pump failure We must understand the cause and effect relationships that lead to the event This will require evidence to prove our hypothesis Hypothesis Erosion. Zero Breakdown .

Zero Breakdown .In this case someone misaligned a pump and that decision resulted in a sequence of cause & effect relationship that caused the pump to fail prematurely. Our Goal : Zero Defect.

Zero Breakdown .Now the question is WHY would a person choose to align in that fashion !! Our Goal : Zero Defect.

I got it!! It means that either he was not trained No SOP available. tools worn out or inadequate Our Goal : Zero Defect. we would uncover the REAL ROOT CAUSE.If we were to go deeper & understand the thought YES process Exactly or !! the rational for such a decision (Latent Root). Zero Breakdown .

Zero Breakdown .If we do not explore the WHY. then HOW is likely to reoccur Our Goal : Zero Defect.

do you stop at the how or at the WHY Our Goal : Zero Defect. Zero Breakdown .If you now reflect on your current RCA efforts.

Zero Breakdown .Think about it………………. Our Goal : Zero Defect.

Zero Breakdown .Thank You !! Our Goal : Zero Defect.