Category: Equipment/Equifactor®

Rail Accidents: It’s the Entire System that Matters

May 2nd, 2016 by

amtrak

 

On April 3rd, an Amtrak passenger train collided with a backhoe that was being used by railroad employees for maintenance.  Two maintenance workers were killed, and about 20 passengers on the train were injured.  For those that are not familiar with the railroad industry, I wanted to discuss a system that was in place that was designed to help prevent these types of incidents.

Many trains are being back-fitted with equipment and software that is collectively known as positive train control (PTC).  These systems include sensors, software, and procedures that are designed to help the engineer safely operate the train.  It is designed to allow for:

  • Train separation and collision avoidance
  • Speed enforcement
  • Rail worker safety

For example, as the train approaches a curve that has a lower speed limit, a train with PTC would first alert the engineer that he must reduce speed, and then, if this doesn’t happen, automatically reduce the speed or stop the train as necessary to prevent exceeding tolerance.  Another example is that, if maintenance is known to be occurring on a particular section of track, the train “knows” it is not allowed to be on that particular section, and will slow / stop to avoid entering the restricted area.  The system can be pretty sophisticated, but this is the general idea.

Notice that I described the system as a series of sensors, software, and procedures that make up PTC.  While we can put all kinds of sensors and software in place, there are still procedures that people must follow for the system to operate properly.  For example, in in order to know about worker safety restrictions on a particular piece of track, there are several things that must happen:

  • The workers must tell the dispatcher they are on a specific section of track (there are very detailed procedures that cover this).
  • The dispatcher must correctly tell the system that the workers are present.
  • The software must correctly identify the section of track.
  • The communications hardware must properly communicate with the train.
  • The train must know where it is and where it is going.
  • The workers must be on the correct section of track.
  • The workers must be doing the correct maintenance (for example, not also working on an additional siding).
  • If being used, local temporary warning systems being used by the workers must be operating properly.  For example, there are devices that can be worn on the workers’ bodies that signal the train, and that receive a signal from the train.
  • Proper maintenance must be performed on all of the PTC hardware and software.

As you can see, just putting a great PTC system in place involves more than just installing a bunch of equipment.  Workers must understand the equipment, its interrelation with the train and dispatcher, how the system is properly initialized and secured, the limitations of the PTC system, etc.  People are still involved.

For the Washington Amtrak crash, we know that there was a PTC system in place.  However, I don’t know how it was being employed, if it was working properly, were all the procedures being followed, etc.  I am definitely not trying to apportion any blame, since I’m not involved in the investigation.  However, I did want to point out that, while implementation of PTC systems is long overdue, it is important to realize that these systems have many weak points that must be recognized and understood in order to have them operating properly.

Humans will almost always end up being the weak link, and it is critical that the entire system, including the human interactions with the system, be fully accounted for when designing and operating the system.  Proper audits will often catch these weak barriers, and proper investigations can help identify the human performance issues that are almost certainly in play when an accident occurs.  By finding the human performance issues, we can target more effective corrective actions than just blaming the individual.  Our investigations and audits have to take the entire system into account when looking for improvements.

Ken Reed Invites You to The Asset Optimization Track at the 2016 Global TapRooT® Summit

April 22nd, 2016 by

The Global TapRooT® Summit offers multiple focused learning tracks for performance improvement. This video introduces the Asset Optimization Track. Come to the Summit and maximize improvement at your company!


Starring Ken Reed. Produced by Benna Dortch.

Learn more about the Summit!

REGISTER NOW

Interested in the Safety Track?  Learn about it here!

Interested in the Investigator Track? Learn more about it here!

Heavy Equipment Maintenance Tips

April 21st, 2016 by

Detail

I ran across these tips for keeping your heavy equipment operating at peak performance. Some may seem obvious, but it is amazing how many times I’ve seen these simple maintenance actions ignored, especially at smaller companies. Larger companies often have staff dedicated to their maintenance programs, but smaller companies sometimes just don’t feel they have the resources.  I was working with a company just recently who had had a near miss due to a missing equipment guard.  As we dug a little deeper, we realized that there was no formalized maintenance system in place for there basic equipment.  They expected the operators to notice, report, and oftentimes actually fix any issues with their equipment on their own.  That was the extent of the maintenance program!

Please take a look at your equipment maintenance programs.  If you have planned maintenance in place for most of your equipment, take a hard look at your other, ancillary equipment.  You may find the big stuff has a good program, but the smaller (yet still critical) equipment is missing required maintenance and inspections.

Navy Ship Damaged During Startup – Root Cause is Human Error?

April 9th, 2016 by

Here’s the article …

http://www.bloomberg.com/news/articles/2016-04-07/damage-extensive-for-crippled-u-s-littoral-ship-in-singapore?cmpid=yhoo.headline

They have already fired the Commanding Officer … so don’t worry … they won’t start up gears without lube oil again. More video below.

Pump Maintenance Tips

April 7th, 2016 by

pump repair

Here’s an article describing some great tips to keep your pumps operating at peak performance. You can use these tips, in conjunction with the Equifactor® equipment troubleshooting tables, to ensure you’re getting the most out of your pumps.

Equipment Safety Alert: Counterfeit Crosby Shackles

March 28th, 2016 by

Crosby

The problem with fake Crosby shackles has actually been around for quite a while, but companies are still finding these shackles in their inventories. I thought I’d put this out there again and make sure we are still thinking about it.

Additionally, this might be a good time to verify your other lifting gear is meeting your specs.

– Are we using trusted suppliers?

– Are we researching the equipment and making sure there are no safety recalls issued?

– Do you have a program in place to periodically check for safety bulletins in your departments?

Go that extra step to make sure we are giving our teams the very best equipment, and helping them properly maintain it.

Worlds Easiest Equipment Troubleshooting Chart

March 21st, 2016 by

 

 

EngineeringFlowchart

I can’t tell you how many times I used this method in the Navy. Just substitute “EB Green” for “Duct Tape.”  Wasn’t a great permanent fix, though.

We use a slightly more comprehensive set of troubleshooting charts in our Equifactor® Equipment Troubleshooting courses!

Equipment Failure: Washington Metro Shutdown for Emergency Maintenance

March 18th, 2016 by

Metro

 

How much does an equipment failure cost? Washington Metro, after having a repeat failure on power distribution jumpers (2 in the past year, with one fatality), decided to shutdown the entire Metro system for a full day. Lost revenue (counting only lost fares) is estimated to be $2 million. This doesn’t count inspectors’ pay, cable replacements, etc.
Effective root cause analysis is critical to maintaining equipment reliability. It’s not good enough to have equipment fail, and then just replace the equipment. Your RCA must look at other possible human performance issues:

– Maintenance procedures
– Inspection periodicity
– Inspection requirements and procedures
– Inspector training
– Reasons for having a repeat of a supposedly corrected failure
– Generic cause analysis

These are the types of things that must go into an equipment failure analysis. Repeat failures cost money, convenience, and possibly lives.

Friday Joke: Equipment Troubleshooting Flowchart

March 11th, 2016 by

EngineeringFlowchart

This works great for me at home.

Air Compressor Maintenance Tips

March 10th, 2016 by

compressor

Here are some simple tips to protect your investment, whether it is an industrial machine or the compressor in your garage.  Simple maintenance can prevent costly failures and analyses in the future.

Centrifugal Pump Reliability – Heinz Bloch Tips

March 4th, 2016 by

Centrifugal

Here’s a great article by Heinz Bloch on centrifugal process pump reliability. His tips include purchasing strategies, operational considerations, installation ideas, and maintenance requirements. Always a pleasure to read his tips!

 

Monday Accident & Lessons Leaned: Sure Looks Like an Equipment Failure … But What is the Root Cause?

February 25th, 2016 by

Screen Shot 2016 02 25 at 11 27 20 AM

When you look up in the air and this is what you see … it sure looks like an equipment failure. Bit what is the root cause? 

That’s what DTE Energy will be looking into when they investigate this failure.

How do you go beyond “It broke!” and find how and why and equipment failure occurred? We recommend using techniques developed by equipment expert Heinz Bloch and embedded in the Equifactor® Module of the TapRooT® Software.

For more information about the software and training, see:

http://www.taproot.com/products-services/equipment-troubleshooting

Equipment vs. Human Performance Failures in Aircraft Accidents

February 23rd, 2016 by

sw airlines

Here’s a good discussion of the causes of airline accidents. As aircraft reliability and maintenance practices have improved over the years, the leading cause of aircraft accidents has shifted dramatically away from parts failures and toward human mistakes. Yet, polls have shown that most people think that aircraft accidents are usually caused by a mechanical breakdown.
It’s important to consider the human element whenever we assume a mechanical failure. Make sure you’re looking deeply enough into an equipment malfunction and make sure you understand, even when equipment does fail, how the human was involved.

Equipment Failure Risks Injuries

February 16th, 2016 by

Here’s another quick verdict of “crane failure.” I’m guessing the hoist was not designed to fail in this scenario! We probably need to look a little deeper at what allowed this hoist to fail. What safeguards do you think should have been in place here?

The “Force” was with HSE this time in Star Wars Accident

February 11th, 2016 by

“The actor, Harrison Ford, was struck by a hydraulic metal door on the Pinewood set of the Millennium Falcon in June 2014.”

“The Health And Safety Executive has brought four criminal charges against Foodles Production (UK) Ltd – a subsidiary of Disney.”

“Foodles Production said it was “disappointed” by the HSE’s decision.”

Read more here

 

Equipment Failure: Blackout for 46,000 Residents

February 8th, 2016 by

Blackout

Here’s another example of generic “equipment failure.” Not a lot of details, but I’m pretty sure the substation was not designed to fail. We should look at not just the equipment, but what additional safeguards are in place to prevent a single-point failure from blacking out a large section of a city.
Again, we don’t have details yet, but the label of “equipment failure” should make you think about digging a little deeper.

Equipment Failure? Parachuting Accident

February 5th, 2016 by

formation

I’m going to be bringing you some examples of accidents and problems that are quickly listed as “equipment failure.” Take a look at these problems and ask yourself:

– Is this really an equipment problem?

– Have we looked deep enough into the actual reason that the equipment did not work as intended?

– Were there any safeguards that were in place that failed, or should have been in place and were not?”

Here’s an example that is just quickly labeled “equipment failure”. List the safeguards that you think should have been in place (and maybe were, maybe weren’t) to prevent the accident’s outcome.

SpaceX Rocket ALMOST Lands – Equipment Failure?

January 18th, 2016 by

So close!

SpaceX attempted to land the first stage of their Jason 3 launch vehicle on their Autonomous Spaceport Drone Ship this weekend. The video shows the stage softly touching down, and then toppling over. Elon Musk tweeted that the leg did not fully latch prior to touchdown, and folded up when the stage weight was applied. He said it looks like the collet between the leg extension tube segments did not hold due to icing prior to launch.

While this is a cool video, it got me thinking about using the correct type of equipment for the application. for example, Musk said they use a “collet” between the leg segments. A collet is a friction device that holds 2 tubes together. Not necessarily a positive locking device. It appears that ice prevented full extension and therefore full friction from being applied, and the leg collapsed.

What do you think? Is a collet the correct type of device to hold a static load like this in place? My thoughts: I think a more simple locking pin that drops into place, or a circumferential collar that drops into a slot, would be a much more reliable locking device, rather than something that depends on friction for support.

Still, what an awesome landing attempt!

Politician Calls for Root Cause Analysis

September 4th, 2015 by

This is not the Friday Joke.

Root cause analysis has become so popular that politicians are now calling for companies to complete a root cause analysis and implement corrective actions.

NewImage

Massachusetts Governor Charlie Baker wrote a letter to Entergy Nuclear Operations calling on them to “… perform an appropriate root cause analysis …” of safety issues the NRC had announced “… and to complete all necessary repairs and corrective actions.”

The letter was in response to an unplanned shutdown at the Pilgrim nuclear power plant in Plymouth, Massachusetts caused by a malfunctioning main steam stop valve (one of eight valves that is designed to shut off steam from the reactor to the turbine that generates electricity). The valve had failed shut.

For all those not in the nuclear industry, note that in the nuclear industry, a failure of one of eight valves that failed in the safe direction (shut) and that has backup safety systems (both manual and automatic) can get a public letter from the Governor and attention from a federal regulator. Imagine if you had this level of safety oversight of your systems. Would your equipment reliability programs pass muster?

The response from Entergy to the Governor noted that, “We have made changes and equipment upgrades that have already resulted in positive enhancements to operational reliability.” (Note that these fixes occurred in less than a week after the original mechanical failure.)

For more about the story, see: http://www.wbur.org/2015/09/03/baker-pilgrim-nuclear

Note the local NPR story at the link above is inaccurate in its description of the problem and the mechanical systems.

For those interested in improving equipment reliability and root cause analysis, consider attending one of our 3-Day TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis Courses. See the upcoming course list at:

 http://www.taproot.com/store/3-Day-Courses/

Now for the biggest question … 

When will government authorities start applying root cause analysis
to the myriad of problems we face as a nation and start implementing appropriate corrective actions?

What does equipment failure cost your company?

September 1st, 2015 by

Screen Shot 2015 08 31 at 11 30 53 AM

Do you know what equipment failure is costing your company?

An ocean going drilling rig had a failed oil/water separator. The device is a required piece of pollution control equipment. When it failed, someone made a makeshift fix to keep things operating. The Coast Guard discovered the makeshift repair and fined the company $12.2 million dollars.

In this example, the cost of failure was in a Coast Guard fine. But often the cost of failure occurs because of lost production, repair costs, and unnecessary repetitive repairs.

What are you doing to understand your equipment failures?

You should be using Equifactor® to improve your equipment troubleshooting and the TapRooT® Root Cause Analysis System to improve your root cause analysis.

Equifactor® Equipment Troubleshooting has many troubleshooting tables for common pieces of equipment. But what if a piece of equipment doesn’t have a troubleshooting table? You can get your company and vendor experts together to make a custom troubleshooting table so that everybody can troubleshooting problems using the tables and get the results the experts get.

Don’t wait until a:

  • major process safety incident,
  • major loss of production,
  • large fine from a regulator,
  • piece of equipment failed for the tenth time, or
  • maintenance budget gets out of hand.

Act now! Send someone to one of our public 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course. Find out how it can help you stop equipment reliability problems with proven equipment troubleshooting and root cause analysis tools. See the upcoming course dates at this link:

http://www.taproot.com/store/3-Day-Courses/

Get More from TapRooT®: Follow our Pages on LinkedIn

August 13th, 2015 by

Do you like quick, simple tips that add value to the way you work? Do you like articles that increase your happiness?  How about a joke or something to brighten your day? Of course you do! Or you wouldn’t be reading this post.  But the real question is, do you want MORE than all of the useful information we provide on this blog?  That’s okay – we’ll allow you to be greedy!

A lot of people don’t know we have a company page on LinkedIn that also shares all those things and more.  Follow us by clicking the image below that directs to our company page, and then clicking “Follow.”

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We also have a training page where we share tips about career/personal development as well as course photos and information about upcoming courses.  If you are planning to attend a TapRooT® course or want a job for candidates with root cause analysis skills, click the image below that directs to our training page and then click “Follow.”

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