Day 2-Failure Elimination and Root Cause Analysis

Elite
Strategy
Failure Elimination and

Root Cause Analysis
CII Virtual Session: Day 2-28.06.24
28-06-2024 © N.P. Sundar-Stellar Innostrat Consulting 1
Elite
Strategy • Overall experience spans Project & Project
N.P. Sundar, Stellar Engineering Management, Commissioning,
Operations & Maintenance Management, Condition
InnoStrat Consulting Monitoring, Asset Integrity & Reliability Management,
Asset Management, Process & Workplace Safety
Management, Planning & Strategy.
• Had held Technical, Functional, Management &
Leadership roles at the Project Office, Manufacturing
Plants, Site Central Reliability and Group/CoE levels.
• Experienced in Step Change and Transformational
Programs in the Management areas of Maintenance,
Asset Integrity & Reliability and Process Safety
including their Governance. Had been core Business
Total 40 years of rich, cross- & Functional Team Member for enterprise
functional and varied experience Digitalization & Business Transformation of
(previous and current roles) in Reliability and Asset Management across.
Asset Management and related
roles, across physical asset • Member of various Professional Bodies.
lifecycle phases, in large, asset • Currently providing value-added Consulting
intensive, multi-locational Solutions & Services to both Asset Owner Operators
organizations in India. and various Solution/Service providers.

Elite
Strategy Cautions and Disclaimers
• This presentation is meant for the intended purpose of knowledge sharing to
the target audience only. This is not to be taken as complete information or a
professional recommendation in any way at this stage. We do not take any
liability, in any way, for any action/s taken by anyone based on this content
and their consequences.
• All the views, opinions, ideas and statements expressed in this presentation,
except for those attributed to others, are our own, in our independent and
personal capacity and made in good faith. Any errors and omissions are
purely unintentional.
• All the illustrations (excluding those specifically attributed and licensed stock
images), are created by the author and their ownership remains with him for
all purposes.
• This Presentation is intended only for the individual consumption of the
participants of this event and is not meant for further distribution.

Elite
Strategy
1. Reliability-The Business Driver
Agenda-Day 1 2. Need for Risk-Based
Maintenance
3. Defect Elimination-
Underpinning the Foundation

Elite
Strategy
1. Failure Elimination and Root
Agenda-Day 2 Cause Analysis Program
2. Common Root Cause Analysis
Methods and Tools
3. Integrated Approach to
Failures and Incidents

Elite
Strategy
2.1 Failure
Elimination and
Root Cause
Analysis
Program

Elite
Strategy
• Defect: A product’s or service’s
RCA-Some Definitions nonfulfillment of an intended
requirement or reasonable
Root cause analysis: The
expectation for use, including
method of identifying the safety considerations.
cause of a problem, • Cause: An identified reason for the
solving it and preventing it
from occurring again. presence of a defect or problem.
Uncovering the correct and • Root cause: A factor that caused a
accurate reason(s) why
something is happening or nonconformance and should be
has already occurred. addressed with corrective action.
Source: ASQ
Elite
Strategy Defect Elimination Vs Root Cause Analysis
Defect Elimination (DE) Root Cause Analysis (RCA)

• Analyses defects, and implements • RCA Process  core of any DE
actions to prevent future similar program.
defects • RCA Process applies a problem-
• DE Program is a structured process solving methodology to identify and
to become more consistent and control the root causes of these
reliable in eliminating defects “defects”.
• Forms part of a broader Quality • Designed to break down a defect or
Improvement program (CI) problem into cause-and-effect
• Applies across Operations relationships.
• Single/multiple methodology w.r.t
complexities, significance and
nature of problems.
Ref. Arms Reliability
Elite Failure Elimination and
Strategy
Root Cause Analysis • Maintenance and Reliability
Program-Key Aspects (M&R) Strategy
• Failure Elimination Strategy
• RCA Process, Procedure,
Failures Practices
• Bad Actor Management
Malfunctions
• Work Execution Management
• Reliability Centered
Defects Maintenance (RCM/FMEA)
• System for managing RCAs

Elite
Asset Strategy Cycle
Strategy
Asset Maintenance
Performance Management
Reliability Actions
Risk Execution
Strategy Doing The Work
Doing The Right Right
Work Efficiency
Effectiveness

Elite
Strategy Reliability and Maintenance Strategy (Typical)
Reliability & Maintenance Strategy
Maintenance
Reliability Strategy
Strategy
Routine Turnaround
Operations Asset Reliability
Maintenance Maintenance
IOW Failure Operator Annual Plan &

ODR Risk Analysis
Monitoring Elimination Maintenance Budgeting

Elite
Strategy Failure Elimination Strategy-Some Thoughts…
1. What all will be included in Failure Elimination and Root Cause
Failure Analysis (RCFA) Program (e.g. Potential
Failure/Functional Failure/Physical Failure/Breakdowns)
2. Distinction between “Failure” and “Incident” (Scope of
FE/RCFA Vs Incident Investigation)
3. Where will the Failures be initially reported? (e.g Maintenance
Notification, FIR, FRACAS, IM)
4. How will the Failures be reported? (e.g. Format, Access,
Authorization)

Elite
5. Where and how will Asset/Equipment Failures that are also
Incidents be reported?
6. How will the initial Failure Report be validated and then
prioritized? Consequence/Risk-Based Categorization and
Prioritization
7. Will ALL Failures be reported (Record of all Failures in System)
8. Who will perform the RCFA (Team formation-Practioner, OEM)

Elite
9. What will be the approach for analysis of Failures? e.g. Risk-
Based Failure Analysis Strategy
a) Analysis of high/medium/low risk failures
b) RCA Methodology/Tools
c) Physical Failure Analysis
d) Hypothesis-development and validation
10. To what extent will the Root Causes be determined. Root Cause
Levels: Physical, Human and Latent/Systemic Causes
11. Validation and Approval of Failure Analysis and
Recommendations
Elite
12.How will we disseminate and apply the Learning across
Assets/Plants/Organization
13.Where and how will the Recommendations be tracked?
14.Will the Recommendations be tracked through their
implementation?
15.How will we measure their effectiveness?

Elite
12.Sporadic/Crisis Failures Vs Chronic Failures
13.How will we measure the performance of FE/RCFA Program?

Elite
Strategy What is a Failure?

Elite Failure
Strategy • Do we have a definition of failure?
Elimination…Points to • Potential Failure? Functional Failure?
Ponder… • Breakdown?
• Sporadic/Crisis Failures? Chronic
Failures?
• Are all failures reported & captured?
Do we analyse all failures?
• How do we treat our Failures? Do we
have a Procedure for FE?
• Is there a Differentiated/Risk-Based
Approach to Failure Elimination?
• Is there any relationship of Incident
Investigation (WSM/PSM) and Failure
Analysis (M&R)?

Elite
Strategy
Failure…and What it • Failure
means? • Loss of ability to perform as
required
• Functional Failure
• The inability of an item (or the
equipment containing the item) to
meet a specified condition or
performance standard.
• Potential Failure
• Point at which we can first detect
the failure
This Photo by Unknown Author is licensed under CC

BY-SA

Elite
Strategy
Failure Vs Incident
An Asset Failure Asset HSEF
can result in an Failure Incident
Incident
An Incident can
result in an Asset
Failure

Elite
Strategy
Reporting Failures FIR/IFR-First Information Report/Initial
Failure Report
(Typical Systems)
FRACAS-Failure Reporting, Analysis and
What system Corrective Action System (FRACAS)
do you use DRACAS-Data Reporting, Analysis and

Corrective Action System (FRACAS)
for Failure
Reporting RCA/RCFA-Root Cause (Failure) Analysis
and RCA? IM-Incident Management

Elite
Strategy Risk-Based Approach for Failure Analysis…
Failures Failure Elimination

High- RCFA
Risk
Medium Failure
Analysis/Problem
Risk Solving
Low Risk Troubleshooting

Elite
Strategy
Importance of Physical
Failure Analysis RCFA
Failure
RCA PFA
Symptoms
Failure Modes
Failure Causes (Physical)

• Engineering Study/Analysis
• Physical/Metallurgical
RC1 RC2 Phy
Study/Analysis

Elite
Strategy
Hypotheses
Development and
Validation Reliability
Principles RCA RCM
behind RCA and Past Future
RCM What Did What Could
Reactive Proactive
• Cause and Effect
Feeds RCM Feeds RCA
• Systems Thinking Experience Troubleshooting
• Work Processes
Ref.: Accelix

Elite
Root Cause Failure Analysis (The Real
Opportunities)
Strategy
Opportunities
Physical Causes
for Growth
Reliable
Human Causes Assets
(Proactive
Organization)
Systemic
Causes

Elite
Strategy Sporadic Failures and Chronic Failures
RCFA for both Sporadic and Chronic Failures
Source-
Linked
In/Slidesh
are

Elite
Strategy
Bad Actor Bad Actor Equipment
Management 14
Bad Actors
12
10
• 80 -20 Principle 8
• Bad Actor-by 4
Failure Count 2
• Bad Actor-by 0
Failure Cost
Category 1 Category 2 Category 3 Category 4
Series 1 Series 2 Series 3

Elite
Strategy FE/RCFA Program Performance
Leading Indicators Lagging Indicators
• Time between Failure and • Trend of Failure/Corrective

RCA initiation Repairs
• Aging of approved RCAs • Effectiveness of RCA
• Approved RCA Recommendations
Recommendations • Repeat/Recurring Failures
• Open/Outstanding RCA • Bad Actor Assets
Recommendations

Elite
Strategy Effectiveness of Root Cause Analysis
Ineffective RCA Program Ineffective RCA Program
Sound
Sound
Recomm-
Recomm-
Analysis
endation
endation
Analysis
Poor
28-06-2024 Poor
© N.P. Sundar-Stellar Innostrat Consulting 29
Elite
Strategy
2.2 RCFA Process

and Tools

Elite
Strategy
RCA Categories in
Manufacturing/Operati
ons Root Cause Analyses
Problem • HSEF (Incidents)
• Production/Quality (PLA/Off-
spec/Waste)
Analysis • Process Incidents(Upsets/
Slowdowns/Underperformance)
• Asset (Asset/System failures)
Solutions • Security Incidents

Elite
Strategy
RCA-Point to Ponder
Symptom or Cause?
• Symptom: A condition that is
Poor RCA leads produced by a problem, not
to acting on the the actual problem.
symptoms vis- • Problem: A perceived gap
à-vis the root between the existing state and
causes of the a desired state, or a deviation
problem from a norm, standard or
status quo
Ref.: Reliability Web
Elite
Strategy Failure Elimination
The minimum requirements of Failure Elimination is to
1. Know what an Asset Failure is (vis a vis Incident)
2. Determine and Report all the Asset related Malfunctions and
Failures and their details
3. Capture and Report on the Impact of Failure (HSEF
Consequences, Production Loss-Complete or Partial, Asset
Maintenance Costs, Downtime of the Asset)
4. Decide on the Failure Analysis as per Site Failure Elimination
Strategy
All Malfunctions/Failures/Breakdowns at Plant to be reported & captured on Daily Basis
Elite
Strategy Risk-Based Approach for Failure Analysis…
Failures Failure Elimination

High- RCFA
Risk
Medium Failure
Analysis/Problem
Risk Solving
Low Risk Troubleshooting

Elite
Strategy
Root Cause Failure
Analysis What? •Failure
Root Cause
Analysis helps
When? •Sequence
structured analysis
of asset related
faults and failures
How? •Analysis
to identify the
Why? •Root Causes
Elite
Strategy
Root Cause Analysis 1. Form the RCA Team (Team
Lead/Multi-Disciplinary Team/RCA
Steps - Typical Facilitator/OEM SME)
2. Collect relevant Data and preserve
them (field, control system, logs)
3. Describe the Failure Event along
with Data, Chronology of Events
4. Describe the Logic Tree (e.g. Failure
Mode/s  Hypothesis)

Elite
Strategy
Root Cause Analysis 5. Verify and Validate each
Steps - Typical Hypothesis (Data analysis, PFA,
Interviews)
6. Determine Physical Root Causes
7. Determine Human Root Causes
8. Determine Latent/Systemic Root
Causes
9. Make Recommendations
addressing every Root Cause

Elite
Strategy
RCA Tools Causal Factor

Five Why Barrier
Root cause analysis Tree
(RCA):
-not a single well-defined Cause and
method Cause Change
Effect
Mapping Analysis
- many different Analysis
processes and methods
for RCA
Fault Tree Pareto
- defined by their FMEA
Analysis Analysis
approach or field of origin

Elite
Strategy Failure Analysis Tools
• Everyday problems and failures limitation of time and resources
 Considered application of RCA
• Segregation of problems and failures (prevention of reoccurrence)
• Consider:
• Current actual (consequence) impact
• Potential impact if not solved
• Level of acceptable risk (e.g. ALARP) from various aspects
• Acceptable outcome of RCFA (risk, cost and benefits)
• Proper focus for productivity in the exercise

Elite
Common Root Cause Analysis (RCA)
Techniques
Strategy
• Five why – Asks why, why, why until fundamental causes are identified.
• Ishikawa/fishbone diagram – Causes and effects are listed in
categories.
• Cause and effect analysis/Causal factor tree – The causal factors are
displayed on a tree so that cause-effect dependencies can be
identified.
• Failure modes and effects/criticality analysis – Possible failure modes
are defined; the effects and probabilities of those failures are
described to identify appropriate countermeasures beginning with the
most critical equipment.
• Fault or logic tree analysis – A failure is identified and the failure modes
are described and tested until the roots are identified.
Ref.: Failure Analysis Tools: Choosing the Right One
for the Job-Thomas Brown, Reliability Solutions
Elite
Common Root Cause Analysis (RCA)
Techniques (contd.)
Strategy
• Barrier analysis – Examines pathways through which a hazard can

affect a target and barriers in the pathways.
• Change analysis/Kepner-Tregoe – Comparing a situation that does
not exhibit a problem to one that does in order to identify the
changes or differences that explain what happened.
• Pareto chart – Shows the relative frequency of problems or failures
in rank-order so that process improvement activities can be
focused on the significant few.
• Data analytics – Is a process of transforming and modeling data
with the goal of discovering useful information.
Ref.: Failure Analysis Tools: Choosing the Right One for the Job-Thomas Brown,
Reliability Solutions
Information, Advantages
Elite
and Limitations of
Strategy
various Root Cause

References:
Analysis Techniques • Failure Analysis Tools: Choosing
the Right One for the Job-
There are numerous sources of Thomas Brown, Reliability
the Techniques used for Root
Cause Analysis, Problem
Solutions
Solving. • Failure Analysis Tools: Choosing
Understanding their intent, the Right One for the Job
design, advantages and (reliableplant.com)
limitations is required for
selection of the appropriate • American Society of Quality
technique or techniques in
combination, based on the
• Quality Tools & Templates - List of
specific context. Healthcare Tools | ASQ

Elite
Strategy Pitfalls in RCA
• Attachment to particular RCA models (proven to work Templates)
 answers may lie outside a chosen process  Use w/o
knowledge (assumptions and limitations) leads to missing
important facts and misdirected analysis.
• Too much analysis (adding every possible cause)
• Not verifying all the evidence and hypothesis  very easy to take
the wrong path if a hypothesis is wrong.
• Deciding where to start and how you describe the failure 
impact on the time effort and outcome
• Functional Failure of asset or Component Failure
https://www.reliableplant.com/Read/31171/failure-analysis-tools
Elite
Strategy
RCA of Component
Failures-Resource
Requirements (Example)
Involvement of shop floor/field
technicians and front-line
supervisors in the RCA
Training on appropriate RCA

Technicians
Role of RCA Facilitator
Ref.: Failure Analysis Tools: Choosing the Right One

for the Job-Thomas Brown, Reliability Solutions
Elite
Strategy
1.3 Integrated
Approach to Failures
and Incidents

Elite
Strategy
Failure Vs Incident Failure Incident
Failure • Assets • Operations

• Loss of ability to • Failure • Incident
perform as required Response Response
Incident • Analyze • Investigate
• Unplanned event or • Root • Root
occurrence resulting in Causes Causes
damage or other loss

Elite
Strategy
Incidents and Assets

Incident
Incidents
• Asset/s (e.g. asset failure
leading to a production
loss or safety incident)
• Operations (e.g.
production/quality/ HSE
incidents due to Assets Operations
operational
disturbances/causes)

Elite
Strategy
Incident Management Asset Involvement
Incident Management
– Some Aspects (failure, damage)
Production/Operation
(disturbance, quality)
Incident
Safety & Fire (workplace
Management safety, process safety)
System
Environment (spills,
emissions)

Elite
Strategy Similarity in Approaches
Asset Failures Operational Incidents

• Corrective Maintenance • Incident Response
• Failure Details/History • Incident Details/History
• Failure Reporting • Incident Reporting
• Root Cause Failure Analysis • Incident Investigation (for
• Recommendations (CAPA) Root Causes)
• Recommendations (CAPA)

Elite
Strategy
Asset Failures Operational Incidents

Major Major
Incidents Incidents
Minor Minor
Incidents Incidents
Repairs Near Misses
Defects Unsafe Acts

Elite
Strategy Operational Risk Management
Business • Security/Finance/HR/Others
Operations • Mgmt. System Incidents
• Incident without Asset

Operations Damage
• Incident with Asset Damage
• Failure without Incident

Physical Asset • Failure with Incident

Elite
Strategy
Operations Assets
Integrated • Incident
Response/
• Failure
Response/
Approach for Management Management
• Incident • Physical
• Asset Failures Investigation Failure
and (RCA) Analysis
• Operational • Systemic Root • Physical Root
Incidents Causes Causes

Elite
Strategy
Integrated Approach to
RCFA and Incident
Investigation
Management
Management
Incident Asset Incident
Failure
• Failure Occurs • Incident Created

• Corrective • Incident
Maintenance Investigation
• Work History • Physical Root
Causes

Elite Work History in
Object
Strategy
Maintenance
Notifications
• Bearing
Part
Capturing Maintenance Damage • Seized

Work History in a
structured format is the
key for Data Analytics
and identification of Cause • Lack of lubrication
chronic failures that
require a systematic
Root Cause Analysis Action • Bearing Replaced

Elite
Strategy
Capturing Work
History – Food for Actual Hours
Thought
From Material &
• How do You capture the a) Cost PM/PdM Task Service Costs
of Improvement Maintenance?
b) Cost of Workshop Jobs?
Work History
• How do You know Your Bad (Catalogued)
Actors? Corrective
• Performance: Downtime- Work
Actual Hours
Planned & Unplanned; (BD Dur.)
Availability, Reliability (MTBF)
• Risk: Failures, Failures with From Failure/ Material &
HSEF and/or Production Loss Breakdown Service Costs
Consequences
• Cost: Material, Services and Work History
Manpower Cost (Catalogued)

56
28-06-2024
End of Day-2
Strategy
Elite
© N.P. Sundar-Stellar Innostrat Consulting

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Elite

Failure Elimination and

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Defect Elimination (DE) Root Cause Analysis (RCA)

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IOW Failure Operator Annual Plan &

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This Photo by Unknown Author is licensed under CC

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do you use DRACAS-Data Reporting, Analysis and

and RCA? IM-Incident Management

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Failures Failure Elimination

Low Risk Troubleshooting

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Failure Causes (Physical)

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Series 1 Series 2 Series 3

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Leading Indicators Lagging Indicators

• Time between Failure and • Trend of Failure/Corrective

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Ineffective RCA Program Ineffective RCA Program

2.2 RCFA Process

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Failures Failure Elimination

Low Risk Troubleshooting

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RCA Tools Causal Factor

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• Barrier analysis – Examines pathways through which a hazard can

various Root Cause

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Training on appropriate RCA

Role of RCA Facilitator

Ref.: Failure Analysis Tools: Choosing the Right One

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Failure Vs Incident Failure Incident

Failure • Assets • Operations

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Incidents and Assets