Category: Equipment/Equifactor®

Maintenance Error Causes Fire at Power Plant in Colorado

June 10th, 2014 by


A mechanic opened the wrong end of a filter causing oil to spray on hot piping. The immediate flash fire caused extensive damage at the Martin Drake power plant run by Colorado Springs Utilities.

See the Colorado Springs Fire Department report here:

Best Practices in Equipment Reliability Improvement & Troubleshooting

January 23rd, 2014 by

images_heinz.bloch2-1-tm.jpgLearn Best Practices in Equipment Reliability Improvement & Troubleshooting at the 2014 Global TapRooT® Summit! Join us in Horseshoe Bay, Texas (near Austin) April 9 – 11, 2014 and learn about the business end of equipment reliability and the foundations of Equifactor® from global expert, Heinz Bloch.

The Business End of Equipment Reliability

Reliability engineering efforts often suffer from a fragmented approach. Some companies and facilities repeat consultant-conceived generalities and wonder why they get bogged down in squabbles over definitions and benchmarking numbers. In fact, some could even dispense with the reliability engineering function without seeing a blip in their company’s profitability (or lack thereof).

However, other corporations and business entities are far more structured and productive. Their reliability engineering endeavors are well defined and they have budgets and accountability. For them, reliability engineering is never an afterthought. This presentation shows where the two differ. It is short on vague generalities and long on value-adding specifics.

The Foundations of Equifactor

The presenter has authored or co-authored 18 textbooks on reliability improvement topics. His text “Machinery Failure Analysis and Troubleshooting” is now in its 4th Edition. This book contains time-tested methods of identifying root causes of failures which were subsequently melded into the “Equifactor-approach.” Equifactor is a straightforward and repeatable method which, for many decades, has kept a select few user companies at the top of Best Practices or Best-of-Class performers. The presenter shares several case histories to illustrate how he successfully used its core approach 30 years ago and still practices it today.

LEARN MORE about the equipment track from track leader, Ken Reed (view video).

MAKE A WEEK OF IT by attending the 2-day equipment Pre-Summit Course in addition to the 3-day Summit (learn details about the 2-day).

REGISTER NOW for the 2014 Global TapRooT® Summit!

Fairground Ride Accident Caused By Low Oil Level – Is This An Equipment Failure?

August 28th, 2013 by

CLICK HERE for the article in SHP.

The article says that the ride failed due to a low gearbox oil level. Some would classify that as an equipment failure. But a complete SnapCharT® would consider maintenance and operator checks (should someone check the gearbox oil level periodically?).

How do you analyze the causes of equipment failures?

Perhaps you should consider a 3-Day TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis Course. See the upcoming course schedule by CLICKING HERE.

Food Manufacturing Alert: Metal Objects Found in Doughnut . How Would You Investigate It?

August 27th, 2013 by

donut Material found in a doughnut, see the initial indications from the KAKE media article below. A child is in a hospital bed at an Army Hospital after he took a bite of a glazed cake doughnut from a large retailer bakery. His mother says that the child said the doughnut tasted crunchy and then he chipped a tooth. “There were pieces of black metal, some of them looked like rings, like washers off of a little screw, some of them were black metal fragments, like real sharp pieces,” says the mother. The mother says that the child complained he had abdominal pains after swallowing the objects from the doughnut. Read the article here. The retailer spokesperson said the company’s food safety team is looking into the incident, reaching out to the doughnut supplier and trying to figure out what happened.  Now what? Is this a safety or quality issue or both? If you were the retailer what would you do? Would you quarantine the doughnut and ask for access to the material found in the stomach? Would you be allowed? If you were the doughnut supplier what would you do? Would you look for similar batches and quarantine them? Would you inspect the batches or turn them over to the supply? Would you be allowed? If you were the doughnut manufacturer what would you do? Would you inspect the equipment used for this batch? Would you look for facility work order reports already completed or reported? For all 3 parties, would you work together as one team to resolve the issue? What if you could not find any evidence on your side of missing parts? Everything just discussed would be part of the analysis/investigation planning stage.  The first step of our TapRooT® 7 step investigation process. To learn more about what you would do following a problem, here are a few articles to learn more about are process and courses available. What is Root Cause Analysis? Root Cause Analysis Tip: Why Did The Robot Stop? (Comparing 5-Why Results with TapRooT® Root Cause Analysis Results) Our public course schedule

WD-40 or Duct Tape, You Decide

August 21st, 2013 by

I know, it is too early for Friday’s Joke of the Day, but I could not help it.  I saw this posted recently and had to share.



As you are laughing, look into your tool cabinet and tell me that you do not have these 2 items in it.

Now if you want to know how to troubleshoot equipment the right way to find the right what’s and why’s and want an Individual TapRooT® Software License (comes with the course), then join us at one of our Equifactor® courses.

Here is the current schedule:

I’ll bring my WD-40 and Duct Tape for the classroom equipment.


Equipment Root Cause Tip: Raise your hand if you have never reset a circuit breaker…….

August 7th, 2013 by


What are the risks of setting a circuit breaker without knowing why it opened?


I just saw this local news article about a father teaching his daughter about the circuit breaker panel in their house after a ceiling fan stopped working. End result….. House on fire.  Read more here.


With eighteen years in aviation and having worked on the  C-141 Aircraft, this incident brought to mind the wrong pump replaced and resetting the circuit breaker during testing explosion. Read more here.

There are additional ways to gain equipment troubleshooting experience without starting a fire. The easiest way is to attend one of our upcoming Equifactor® Course coming up in your local area. See the schedule here:

Root Cause Analysis Tip: Equipment Troubleshooting … What’s Your Approach?

June 26th, 2013 by

Before you can start the analysis of the root causes of equipment problems, you need to troubleshoot the equipment failure to find out what happened.

Some companies do this by using “smart people”.

Others hire outside tech reps to handle their most difficult problems.

I’ve even seen a company that keeps a retired employee on contract to provide expert guidance.

But the majority have NO APPROACH AT ALL. Well at least nothing more than blindly replacing parts until something works.

TapRooT® users have a resource that others don’t. An expert in a box.

What? Well … we’ve taken the expertise of Heinz Bloch (and some others) and built it into our TapRooT® Software.

It’s like having an expert equipment troubleshooter in a box.

Just follow the troubleshooting guidance and learn much more about what is causing equipment problems.

What’s even better is that the expert in a box can also be used proactively before a failure occurs to help keep equipment failures from happening.

Where can you learn about Equifactor® and TapRooT®?

At one of the 3-Day TapRooT® / Equifactor® Equipment Troubleshooting and Root Cause Analysis Courses that we hold around the world.

CLICK HERE for more information about our courses and course locations.

Detailed Up-Front Machinery Quality Assessments (MQA) — a Key Prerequisite to Reliable Major Machinery

March 27th, 2013 by

Heinz Bloch explained how Best-of-Class companies use MQA on critically important compressors, drivers, and essential process pumps at the 2013 Global TapRooT® Summit. The MQA effort consists of structured and well-defined reviews of vendor experience, drawings, calculations, and other documentation. For highest possible value, MQA is often carried out before purchase orders are issued. Mr. Bloch described three distinct phases of successful MQA tasks.

8437Images-Heinz-Bloch-150-1Heinz Bloch is a graduate of New Jersey Institute of Technology (BSME, MSME, Cum Laude). After his retirement from Exxon Chemical Central Engineering (in Baytown, Texas), he worked as a consulting engineer and author of 17 books. He is the equipment/reliability editor of Houston-based Hydrocarbon Processing and has published over 460 papers and articles on reliability improvement subjects. For several decades, he has advised industry on maintenance cost reduction and reliability improvement issues and has taught over 500 equipment uptime improvement courses on all six continents.

Click on the icon below to view the presentation and learn the three phases of successful MQA tasks:

Bloch.Heinz.Detailed Up-Front-1

Monday Accident & Lessons Learned: A Published Use of TapRooT® Following an Equipment Failure

September 10th, 2012 by

This root cause report was prepared for Fermilab Research Alliance (FRA) on September 14, 2007 following the “Large Hadron Collider Magnet System Failure”.

1)  On November 25, 2006 a heat exchanger internal to one of the Fermilab supplied magnets collapsed in a pressure test

2)  On March 27, 2007 structural supports internal to one of the Fermilab supplied magnets failed in a pressure test.

Here is the link to the Incident PDF:

Here at System improvements, Inc. and in our TapRooT® Root Cause Analysis Courses that we teach, we encourage our process be used for multiple business processes. In this Root Cause Report, the areas below were investigated using our root cause process as one of the investigation tools:

• Project Management

• Agreements

• Specifications

• Design

• Procurement & Construction

• Acceptance & Testing

• Delivery

• Commissioning & Startup

Read the report and see what they determined and also how they integrated TapRooT® into the actual report. Let me know what you think.

Root Cause Network Newsletter – September 2012

August 30th, 2012 by

Click the link below to enjoy our September 2012 issue of the Root Cause Network Newsletter. In it, you’ll learn:

– 4 Ways your root cause analysis will improve performance,

– What we’re doing to help you prevent fatalities,

– Whether more safety regulations mean fewer incidents,

– How to stop picking the low-hanging fruit of performance improvement, &

– How finding root causes saves lives.

Click here to read our September 2012 Newsletter.

Damage to Motiva’s New Crude Unit Seems Like an Excellent Opportunity for Advanced Root Cause Analysis

July 17th, 2012 by

Corrosion because a valved leaked caustic into a relatively new crude unit that was off line for some quick repairs will cause the unit to be down for perhaps a year. Here’s the story:

Human error? Equipment failure? Bad operating or maintenance practices? Unexpected corrosion? Non of these are root causes. To find the root causes you need a systematic process like Equifactor® and TapRooT® to troubleshoot equipment problems and dig down to the real, fixable root causes of the problems. 

For more information about TapRooT®, see:

Time for Fireworks Root Cause Analysis?

July 6th, 2012 by

The Wall Street Journal reported that the was a fireworks malfunction in San Diego on the 4th. It seems all the fireworks went up at once. Here’s a video of what it looked like:

The WSJ says that Garden State Fireworks Inc. issued a statement blaming the mishap on a technical malfunction.

Time for fireworks root cause analysis?

One more idea … was the theme “Fast & Furious Six” or “Shock and Awe”?

Here’s an interview with the owner of Garden State Fireworks (the company that did the display):

Good news … no one was injured.

Might have been the biggest finally ever! (And the only one that was at the start of the show!)

UK Rail Accident Investigation Branch Reports on a Rail Accident Equipment Failure

July 3rd, 2012 by

Here’s the Summary from the UK RAIB:

Detachment of a Cardan Shaft at Durham Station – 10 April 2011


On 10 April 2011, at around 12:30 hrs, a cardan shaft fell from an empty class 142 passenger train travelling through Durham station at 75 mph (120 km/h). The train ran for a distance of approximately 2 miles (3.2 km) before being stopped. A member of the public standing on a platform suffered a minor injury from ballast thrown up as the cardan shaft fell onto the track; the train suffered damage, including loss of diesel fuel.

The immediate cause of the detachment was the complete fracture of a final drive input shaft. The input shaft fractured because a seized input bearing generated a large amount of frictional heat between the shaft and bearing. The input shaft was locally heated to a temperature at which its strength was reduced so that it could no longer carry its normal loading.

The RAIB established that the seizure of the bearing was due to the setup of the bearings during overhaul which resulted in a lack of end float in the bearings when in operation. The final drive failure was not detected by the checks which were in place to identify the onset of such failures. The detached cardan shaft was not retained by its safety loops.

The RAIB has made six recommendations to Northern Rail and owners of class 14x vehicles. Two recommendations relate to reviewing the end float and alignment requirements for the class 14x final drives and ensuring that any changes to the setup of safety critical components are validated. One recommendation covers the detection of impending final drive failures. The fourth recommendation relates to the final drive post-overhaul testing and the fifth covers the provision of key design information to overhaul and maintenance contractors. The final recommendation relates to the completion of the review work associated with the events in the immediate aftermath of the accident.

For the complete report, see:

Monday Accident and Lessons Learned: When High Reliability Systems Fail

June 25th, 2012 by

What if you had a system with two regular power supplies, two back-up power supplies (diesels), and a battery back up with a separate diesel to keep it charged?

Wow!  This should be highly reliable right?

Read about how this system failed here:


Now here’s the question …

What did they miss in their “root cause analysis”?

I think they had great troubleshooting.

They even had actions to address generic problems.

But I don’t think they found the root causes of the “cloud failure” incident.

What do you think? Leave your comments here…

Equipment Troubleshooting: Taming Those Misbehaving Motors

May 18th, 2012 by

The points in the May 2012 edition of Maintenance Technology’s article, “Taming Those Misbehaving Motors,” (Thomas H. Bishop, P.E.) can help the most seasoned maintenance pros become even better equipment troubleshooters.

“Given the number of motors in most plants, it’s not surprising that they sometimes misbehave.  While maintenance professionals are typically well equipped to tame the unruly motors that come their way, they’re occasionally puzzled by the following three behaviors” (Learn 3 behaviors and troubleshooting tips).

Need to find the root causes of equipment and machinery problems at your plant? Learn more about our Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis course  (view info).


Root Cause Analysis Tip: Best Practice Sharing #2 – TapRooT® Summit

April 25th, 2012 by

In today’s Root Cause Analysis Tip, Phil Goodman shares his TapRooT® best practice at our 2012 Global TapRooT® Summit.

Today is Part 2 of 12. Click here for Part 1.

Next week, hear Jeff Cooper of Boart Longyear share his TapRooT® best practice.

Time for Equifactor®? Maybe Past Time!

January 25th, 2012 by


Here the text that came with the picture ,,, don’t know if it is true …

Here are some photos of what happens when bearings overheat
in the transmissions of these monster windmills.

To date no gear oil  has been invented to withstand the pressures produced within these transmissions.

Most recently, the government gave Dow-Corning a big  grant to work on it.

Previously, many others had tried and failed.

As they age there will be many  more bearing failures.



Hard to believe that every wind turbine will fail due to inadequate gear lubrication.

I had heard that many wind turbines are not getting proper maintenance.

Wonder what Equifactor® has to say about this?

Investigation of Fatal Elevator Accident in New York Continues – Maintenance Work May Be the "Cause"

January 24th, 2012 by

The New York Times reported that Robert LiMandri, the Commissioner of the Buildings Department in New York City, said:

We know that there was work being done right before the unfortunate event, and we do believe that is a contributing cause, or the cause.

He also said:

We know for sure that those events directly before this unfortunate accident clearly are part of our investigation.

Suzanne Hart was killed while when the elevator suddenly shot upwards as she boarded.

The story also says that the about 60,000 elevators in New York produced 53 accident in the previous year.

Great Human Factors: Wrong Tools, Bad Access by Design, Per “Ingenuity” or All of the Above?

January 19th, 2012 by

As an ex-aircraft mechanic and a “sometimes gotta work on my own car” mechanic, I have in the past borrowed or made some of the tools pictured below. The questions remain:

Wrong Tool?

Bad Access by Design?

Mechanic’s Ingenuity?

Or a little bit of them all?

Finally, ever have one of your modified tools bite you back?  Share your stories in the comment section.



Oil Cooler Line Wrench #2 009 (Medium)

Drinking Water Emergency at Point Hope Caused by Pump Impeller Problems

December 27th, 2011 by

How can bad equipment reliability cause a crisis? Imagine losing the water supply at your house or business for an extended period.

It seems that all five impellers on their five pumps failed due to corrosion on pumps at the Point Hope, CA, water plant.

The previous impellers lasted lasted 67 years without failure but the new pumps at a new plant commissioned in 2005 only made it until 2011. The first impeller inspection wasn’t even scheduled until 20012.

For complete details, see these stories:–upkeep-issues-ruled-out-as-port-hope-water-emergency-cause

And if you want to learn more about troubleshooting pump problems, attend the TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis Course. CLICK HERE to see the public course schedule for 2012.

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Better Initial Information Collection Submitted by: Bill Missal, Senior Aviation Safety Inspector Company: FAA, Alaska Challenge Field investigators that, unfortunately, may not be trained in the use of TapRooT® collect initial information and then send it to trained investigators to analyze the root causes of aviation accidents using TapRooT®. The untrained field investigators may not …

In March of 1994, two of our investigators were sent to the TapRooT 5-day Incident Investigator Team…

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