Attributing root causes to "wear and tear" doesn't always tell the whole story.
By Ken Reed, Vice President, System Improvements, Inc. TapRooT®, an EHSQ Alliance Affiliate.
In 2016, the Bureau of Safety and Environmental Enforcement (BSEE) expanded the SafeOCS reporting system to require the submission of off-shore well control equipment failure reports. The first annual report has been released for 2017, which is the first full year of reporting.
A particularly significant finding in this report is that "wear and tear" was cited as the root cause of 53.6% of all reported incidents in 2017.
Is “wear and tear” an acceptable root cause? I don’t have the data for this particular set of reports, but I have found, in general, that this root cause is often selected at the maintenance technician level. It is in a drop-down box in the CMS system, and it is an easy selection to make. It doesn’t require much research, and management accepts this as a normal failure mode.
Unfortunately, having something as ambiguous as “wear and tear” makes it almost impossible to adequately analyze equipment failures for trends. The definition of this root cause is either too broad or not defined at all. It is an easy selection, requiring very little follow-up action by either the maintenance or the reliability departments. There is no way to understand why the part actually failed.
World class maintenance departments have put severe limitations on when “wear and tear” can be selected as a root cause. In fact, some organizations have removed this selection completely, forcing the maintenance department to determine the actual physical cause of the failure. For deep ocean leaks, this root cause could probably be broken up into multiple actual physical causes, including:
- Improper assembly of the component
- Inadequate pre-use testing
- Inadequate inspection prior to use
- Wrong component installed
- Infrequent inspections during use
- Improper design analysis
There are many possible causes that will give your company a much better understanding of the physical cause of a failure. If you find that a large percentage of your equipment failures are being categorized under a single failure mode, you have several possible problems:
- Your categorization is poor. That category is too broad.
- Your review of the results not able to catch the misuse of the CMS. If you are allowing everyone to pick a single category, you are missing the opportunity to catch problems.
- Your review of the results is not triggering adequate repairs. If you actually DO have a large percentage of failures in a particular failure mode, you should be performing a root cause analysis to understand and correct the causes of this frequent failure mode.
Take a look at your CMS input screens. Are you allowing the selection of a root cause that doesn't tell the entire story? Why is this category there in the first place? What management reviews are in place that will catch this type of problem?
Don’t make this section of your CMS a paperwork exercise. Make sure you are getting useful information that allows you to catch and correct the real physical causes of your equipment failures. Then, once the physical cause is determined, don’t forget to complete your investigation to find the human performance problems that lead to these failures.
(Republished with Permission. The original post can be found here).
TapRooT® Root Cause Analysis is used to improve performance by analyzing and fixing problems to prevent major accidents, quality issues, equipment failures, environmental damage, and production issues. Click HERE for more information.
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