Category: Equipment/Equifactor®

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

plane-crash-julie-click-kester1

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

Untitled

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:

NewImage

 

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

Screen Shot 2014 06 16 at 12 32 08 PM

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

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.

wd40-ducttape

 

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

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

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

photo_6958978_ver1.0_640_480

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

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: http://www.fnal.gov/directorate/OQBP/index/oqbp_misc/Final_LHC_Root_Cause_Analysis_Report_Rev2_19Sep07.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:

http://in.reuters.com/article/2012/07/16/refinery-operations-motiva-portarthur-idINL2E8IBEFL20120716

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:

http://www.taproot.com/products-services/about-taproot

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!)

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