Читать книгу Root Cause Failure Analysis - Trinath Sahoo - Страница 68

Look over your list of potential causal factors and determine the real reason this problem or issue occurred in the first place. These data should have provided enough insight into the failure for the investigator to develop a list of potential or probable reasons for the failure. Dig deep to examine each level of cause and effect and the events that led to the unfavorable outcomes. The problem is that in the real world it is never possible to prove a single event that solely initiates a whole chain of other events. That is because there are always other events before the so‐called “root cause event.” This may seem like semantics, but for problem‐solvers, it is important to keep in mind that there never is a silver‐bullet answer.

Analyzing the short list of potential root causes is to verify each of the suspect causes is essential. In almost all cases, a relatively simple, inexpensive test series can be developed to confirm or eliminate the suspected cause of equipment failure.

Most equipment problems can be traced to misapplication, operating or maintenance practices and procedures. Some of the other causes that are discussed include training, supervision, communications, human engineering, management systems, and quality control. These causes are the most common reasons for poor plant performance and equipment reliability. However, human error may contribute to, or be the sole reason for, the problem.