Category: Equipment/Equifactor®

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

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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.

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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

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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.”

linkedinheader

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.”

training page

Thank you for being part of the global TapRooT® community!

What is the burden of unsolved problems at your company?

May 4th, 2015 by

Do you have incidents that happen over and over again?

Do you have repeat equipment failures?

Does your hospital have similar sentinel events that aren’t solved by your root cause analysis?

How much are these repetitive problems costing your company?

Stop making excuses and try something NEW that can help you stop repetitive problems…

IDEA #1: Attend at TapRooT® Course to stop repeat incidents.

Choose from the:

These courses are guarantee to help you find root causes that you previously would have overlooked and develop corrective actions that both you and your management agree are more effective.

IDEA #2: Attend the Creative Corrective Actions Course.

Hurry, this course is only offered on June 1-2, prior to the TapRooT® Summit. If your creativity for solving problems is getting stale, this is the course you need to attend.

IDEA #3:: Attend the 2015 Global TapRooT® Summit in Las Vegas on June 3-5.

The Summit is a proven place to network and learn valuable best practices that can help you solve your toughest problems. Each Summit is unique, so you don’t want to miss one. And this year’s Summit is rapidly approaching. Register today at:

http://www.taproot.com/taproot-summit/register-for-summit

Hydrocarbon Processing: “True cost of poor quality”

April 2nd, 2015 by

See the article by Heinz Bloch at:

http://www.hydrocarbonprocessing.com/IssueArticle/3440210/Archive/The-true-cost-of-poor-quality.html

And then attend the Equipment Reliability and Troubleshooting Track at the 2015 Global TapRooT® Summit and hear Heinz speak about the business end of equipment reliability and the foundations of Equifactor®. See the complete Summit schedule at:

http://www.taproot.com/taproot-summit/summit-schedule

Pre-Summit Course: Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis

February 11th, 2015 by

Want to know how to save over half the price of attending the 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course PLUS save one day’s living expenses?

Go to the Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course!

We are offering a special 2-Day Equifactor®/TapRooT® course (only offered one time this year!) as a pre-Summit course June 1 and 2, 2015 in Las Vegas, Nevada. This pre-Summit course is only $1,295, but if you register for the TapRooT® Summit June 3 – 5, you can take an additional $200 off the price, making it only $1,095 — less than half of the normal price of the 3-day course!  Plus, since it is taught in just two days, you will save one day’s travel expenses!

This is a perfect opportunity for those who are planning to be part of the Equipment Reliability & Maintenance track at the Summit — where Heinz Bloch and our panel of experts will be offering innovative solutions to the biggest equipment reliability problems facing the industry today. Take this pre-Summit course, and then join the ranks of a select group of industry leaders at the Summit!

This course is taught by Equifactor® Program Manager, Ken Reed. Below, he gives us a brief overview of Equifactor® and talks about how to use this tool proactively.

In just two days learn the basics of the TapRooT® System for finding the root causes AND the Equifactor® Equipment Troubleshooting Technique for Root Cause Failure Analysis of Equipment Problems. Once you find the real root causes using this systematic process, learn to develop effective fixes that will keep problems from happening again. Check your corrective action effectiveness using the SMARTER technique. Also, learn to find and fix equipment problems proactively BEFORE an accident or incident occurs and to analyze the Safeguards that keep problems from happening or from getting worse once a single Safeguard fails.

LEARN MORE about this special course:  http://www.taproot.com/taproot-summit/pre-summit-courses#Equifactor

REGISTER TODAY on our website: http://www.taproot.com/taproot-summit/register-for-summit

FOR MORE INFORMATION about the 2015 TapRooT® Summit, download a brochure from the Summit Website: http://www.taproot.com/summit.php

Root Cause Analysis Video Tips: Equifactor®…Are you using it to prevent equipment failures?

November 5th, 2014 by

Tune in to this week’s TapRooT® Instructor Root Cause Analysis Tip with Ken Reed. He briefly discusses the importance of using Equifactor® proactively in order to prevent equipment failures from ever happening.  Among the many uses of TapRooT®, using it proactively is one of the most important. Keep the investigations to a minimum if you can help it!

For more information on Equifactor® and the courses we offer for it, click here.

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Was this tip helpful? Check out more short videos in our series:

Be Proactive with Dave Janney (Click here to view tip.)

Conduct Real-Time Peer Reviews with Mark Paradies (Click here to view tip.)

What Makes a World-Class Root Cause Analysis System with Ken Reed (Click here to view tip.)

 

Airplane Crashes: Pilot and People in a Simulator Die

November 4th, 2014 by

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Airplane loses power during take off at a Kansas Airport and plane strikes building. Pilot of the King Air Aircraft that crashed and 3 people working in a flight simulator inside that building are dead. Read more here at KAKE News in Wichita, KS.

I post this because of the debates and blame that are going to ensue. Was it just one thing, the plane crashing, that caused this issue to occur? Was it the location of all the flight buildings in the vicinity of an airport. Was this just a “freak accident”. So much more to learn… I hope they get it right so it does not happen again.

Root Cause Analysis Video Tips: What Makes a World Class Root Cause Analysis System?

October 6th, 2014 by

We hope you enjoy this new format of our Instructor Root Cause Tips. Today we have Ken Reed, TapRooT®/Equifactor® Instructor and Partner, discussing “What Makes a World Class Root Cause Analysis System?”. Be sure to pay attention to the 7 Strengths of TapRooT® that he discusses.

Click here to learn more about our courses where you can learn root cause analysis and implement in your own workplace.

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Was this tip helpful? Check out more short videos in our series:

TapRooT® & Healthcare: Getting the Most from Your Sentinel Event Investigation with Ed Skompski (Click here to view tip.)

Prevent Equipment Failures with Ken Reed (Click here to view tip.)

Be Proactive with Dave Janney (Click here to view tip.)

Food Industry Related OSHA General Duty Clause Citations: Did you make the list? Now what?

August 13th, 2014 by

OSHA General Duty Clause Citations: 2009-2012: Food Industry Related Activities

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Doing a quick search of the OSHA Database for Food Industry related citations, it appears that Dust & Fumes along with Burns are the top driving hazard potentials.

Each citation fell under OSH Act of 1970 Section 5(a)(1): The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed……

Each company had to correct the potential hazard and respond using an Abatement Letter that includes words such as:

The hazard referenced in Inspection Number [insert 9-digit #]

for violation identified as:

 Citation [insert #] and item [insert #] was corrected on [insert

date] by:

 

Okay so you have a regulatory finding and listed above is one of the OSHA processes to correct it, sounds easy right? Not so fast…..

….are the findings correct?

….if a correct finding, are you correcting the finding or fixing the problems that allowed the issue?

….is the finding a generic/systemic issue?

As many of our TapRooT® Client’s have learned, if you want a finding to go away, you must perform a proper root cause analysis first. They use tools such as:

 

o   SnapCharT®: a simple, visual technique for collecting and organizing information quickly and efficiently.

o   Root Cause Tree®: an easy-to-use resource to determine root causes of problems.

o   Corrective Action Helper®: helps people develop corrective actions by seeing outside the box.

First you must define the Incident or Scope of the analysis. Critical in analysis of a finding is that the scope of your investigation is not that you received a finding. The scope of the investigation should be that you have a potential uncontrolled hazard or access to a potential hazard.

In thinking this way, this should also trigger the need to perform a Safeguard Analysis during the evidence collection and during the corrective action development. Here are a few blog articles that discuss this tool we teach in our TapRooT® Courses.

Monday Accident & Lesson NOT Learned: Why Do We Use the Weakest Corrective Actions From the Hierarchy of Safeguards?http://www.taproot.com/archives/28919#comments

Root Cause Analysis Tip: Analyze Things That Go Right … The After-Action Review

http://www.taproot.com/archives/43841

If you have not been taking OSHA Finding to the right level of action, you may want to benchmark your current action plan and root cause analysis process, see below:

BENCHMARKING ROOT CAUSE ANALYSIS

http://www.taproot.com/archives/45408

 

SmartGridNews.com reports “The U.S. grid is the worst in the industrialized world (outages are up 285%!)”

July 15th, 2014 by

The article starts with …

Power outages in the United States are up an astonishing 285% since 1984. The U.S. ranks last among the top nine Western industrialized nations in the average length of outages. That dismal performance costs American businesses as much as $150 billion every year according to the EIA.

It also has a map of power outage by state:

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CLICK HERE to see the whole article.

Monday Accident & Lessons Learned: UK RAIB Accident Report – Locomotive failure near Winchfield, 23 November 2013

July 14th, 2014 by

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The UK RAIB has issued an accident report about the failure of a locomotive near Winchfield, UK. This was a near-miss for a derailment. Here is the Summary:

At about 18:50 hrs on Saturday 23 November 2013, while a steam-hauled passenger train from London Waterloo to Weymouth was approaching Winchfield in Hampshire at about 40 mph (64 km/h), the right-hand connecting rod of the locomotive became detached at its leading end (referred to as the small end), which dropped down onto the track. The driver stopped the train immediately, about one mile (1.6 km) outside Winchfield station. There was some damage to the track, but no-one was hurt. The accident could, in slightly different circumstances, have led to derailment of the train.

Screen Shot 2014 06 16 at 12 34 19 PM

The immediate cause of the accident was that the small end assembly came apart, allowing one end of the connecting rod to drop to the ground. The reasons for this could not be established with certainty because some components could not be found after the accident. It is possible that the gudgeon pin securing nut unwound following breakage of the cotter and previous loosening of the nut. A possible factor is that the design of some components had been modified during the restoration of the locomotive some years earlier, without full consideration of the possible effect of these changes. There were deficiencies in the design and manufacture of the cotter. It is also possible, but less likely, that the securing nut split due to an inherent flaw or fatigue cracking.

RAIB has made four recommendations, directed variously to West Coast Railway Company, the Heritage Railway Association, and the Main Line Steam Locomotive Operators Association. They cover the maintenance arrangements for steam locomotives used on the national network, a review of the design of the small end assembly on the type of locomotive involved in the accident, guidance on the design and manufacture of cotters, and assessment of risk arising from changes to the details of the design of locomotives.

For the complete report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/140616_R132014_Winchfield.pdf

 

Maintenance Error Causes Fire at Power Plant in Colorado

June 10th, 2014 by

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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:

http://www.pennenergy.com/content/dam/Pennenergy/online-articles/2014/06/CSFD%2BDuty%2BReport%2Bfor%2BDrake%2BFire%2B052314.pdf

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

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