6 0 obj The subcell ran so quietly that you could only hear the water flowing over the fill. Found inside – Page 38ROOT CAUSE ANALYSIS AND INCIDENT INVESTIGATION— CASE STUDY OF FORD MOTOR COMPANY ... Using 5-Why analysis for incident investigations involving safety will ... %PDF-1.7 Root Cause Analysis and Implementation: A Case Study. stream Words: 961 Length: 3 Pages Topic: Business - Management Paper #: 87878338. Business Problem-Solving: Root-Cause Analysis The Root Cause Approach Root cause analysis is a popular problem-solving technique that seeks to bring out, and respond to, the deeper causes of a problem as opposed to only those that are visible on the surface (Okes, 2009). Safety … Covering medical devices used in the home and those used in clinical environments, the book presents informative case studies about the use errors Root cause analysis (RCA) has been used widely as a means to understand factors contributing to medication errors and to move beyond blame of an individual to identify system factors that contribute to these errors. Root Cause Analysis Discussion. In December 2016, gearbox No. KEYWORDS root cause analysis, defect prevention, process improvement, quality assurance, modification management 1 Introduction 1.1 RCA project overview The product in our study is a network element (NE) that is a Case Study… In the following case, I’m going to follow a speech given by the U.S. Chemical Safety Board Investigations Manager Stephen Selk, P.E. A “root cause analysis” is a systematic, detailed process that is conducted in to h�b```� ��q� �����+f�9�� Sologic’s methodology, services and software are built on more than 20 years of field experience. Given the scheduled operating times, the bearings should last approximately 11.5 years, while the gear teeth should have an infinite design lifetime. In 2008, Lockheed Martin’s facilities maintenance and operations team had a counter-flow, mechanical draft cooling tower designed and installed onsite. 3 led to a condition assessment of the subcell. 1 had catastrophically failed, and although the original trouble cell was repaired, cooling capabilities dropped to 75 percent. 1, removed their red locks and turned the controller to “auto,” they became instant believers. What it is: The fishbone diagram Also referred to as “Ishikawa cause and effect” after Japanese founder and quality control expert Kaoru Ishikawa. The fan shaft could be rocked from side to side by hand. As a case study team, prepare a 10 slide power-point using tools provided in this case study to present your rationale and validation of the root causes your team has chosen. Describe the event. Found inside – Page 105Case study : Near miss event Consider a case from a large , Midwestern surgical center as an example . This case was a near missevent in wrong - patient ... %%EOF In 2008, Lockheed Martin’s facilities maintenance and operations team had a counter-flow, mechanical draft cooling tower designed and installed onsite. The unexpectant gearbox failure led to a nightmare scenario for both operations and maintenance. Found inside – Page 211In this case study, three separate and distinct examples of root cause ... However, it may be helpful to restate the steps in root cause analysis and ... Specific measurements and points have been clearly identified, and the maintenance plan frequencies have been developed to minimize equipment intrusion while painting a clear picture of current conditions. Using Exploratory Data Analysis To Improve The Fresh Foods Ordering Process In Retail Stores (PDF) This case study demonstrates how explorative data analysis, root cause analysis, and basic statistics helped reduce the inefficiencies in the retail inventory and ordering process of fresh foods within grocery chains. 0 But awareness of the underlying assumption means it can be questioned or changed. x��U�n�@}G��ю²w{�(Ri�V�Ҁ��� qi�4��������S�����3gό�ի�|��j����?�%�q΅�g9�a�-���`\.Uoz3�cJ;�� � This authoritative volume: Illustrates how failures are associated with part integrity, a complete system, or the execution of an engineering process Describes how proper design, operation, and maintenance of the equipment help to enhance ... In the sections on finding root causes, this second edition now includes: more examples on the use of multi-vari charts; how thought experiments can help guide data interpretation; how to enhance the value of the data collection process; ... The design and engineering team is currently in the process of developing a new breathing tube layout that will extend out the sides of the cooling tower with a heavy-duty desiccant that can last for several months under the extreme conditions. 1 until a precision state was achieved. With this information, we pulled the cooling towers’ operation log and found that our variable-frequency drives (VFDs) ran the gearboxes in the natural frequency band regularly and for long periods of time. The oil was sent for analysis and returned with a high particle count. They are based on the root cause analysis template for sentinel events developed by the Joint Commission on Accreditation of Healthcare Organizations. Quality Press Inc, New Jersey (2010) Google Scholar. This equipment is the heat sink for a chiller plant that provides cooling to 90 percent of the site’s buildings, including top-priority production equipment and comfort cooling for a majority of employees. Although resources were limited, there was enough evidence to paint a picture of the failure. In this case, the way the parent was raised is not something that the parent can change. endobj Effective root cause analysis for Causal Factor to find fixable root causes. Root Cause Analysis Case Study: Missing the Indicators - Fatal Parking Garage Collapse. Found inside – Page 67... root cause analysis in system level products. Two case studies will be presented to show the importance of a well-adjusted failure analysis workflow. 4 0 obj Percarpio, K.B., & Watts, B.V. (2013). In this week's root cause analysis case study, let's take a look at how and why eggs could remain in your yard and what can be done to prevent that awful rotten egg odor. Unfortunately, its 10th flight marked another first—NASA’s first space shuttle disaster. An apparent cause analysis (ACA) is a process used to investigate the cause or causes of a medium or low-risk safety event. Designed as a quality improvement measure, ACAs are used to explain in detail why an issue or near miss occurs and then to correct the issue... She was found on the floor with a bleeding skin tear to her left hand and an abrasion to her left knee; her wheelchair was tipped forward. 4 failed. Root cause analysis (RCA) of accidents Lessons learned from 6 case studies Karin Hoelzer, DVM, Ph.D. October 2016 Regardless, enough was enough, and we all wanted to get to the bottom of the situation. Found inside – Page 93Root. cause. analysis ... Even though action research (AR) was not seriously considered for this study, the Supplier C case shows the potential of AR in ... Over a span of three days, the component was taken apart piece by piece, cleaned and closely inspected. About This Quiz & Worksheet. During the analysis and training phase of the cooling tower improvements, there were confusion and resistance toward the additional and more challenging steps. Reducing Quality & Waste Losses by 70%. Found inside – Page 74The third responsibility is the service delivery, including the root cause analysis. As a general observation, the client organizations of the historic case ... Case Study - Root cause analysis. This meant the gearboxes were exposed to excessive vibration due to operations. The primary case study is a comparison of information security risk assessment and root cause analysis results from an analysis of a complex issue regarding access control violations. It was at that moment our entire culture shifted from “that’s how we’ve always done it” to “let’s get to precision maintenance.”. Not only did the technicians discover how to perform laser alignments, but they learned how to read and balance all the rotating equipment, including the tower fans. The activities underlined above (emphasis added) are those focused on estimating the potential market demand of an innovation. This new layout will keep the desiccant away from the moisture being blown out by the fans and minimize the presence of water in the gearbox. During this inspection, it was discovered that the motor to the gearbox coupling had completely sheared, leaving behind a pile of rubber dust. Analysis – Determine Causes Evaluate Possible Root Causes of Vibration zPeak Pulsation Frequency = Peak Piping Vibration Frequency (17X run speed) zImpeller Blade Pass = 17X run speed •Thermowell Vortex Shedding and Natural Frequencies ≠ Problem 15 C) Case Study. The new gearbox in subcell No. This was a question that seemingly had never been asked before. We conclude with lessons learned from the case study and resulting ongoing improvement activities. Found inside – Page 182Surveillance-attentiveness breakdown case (Continued) case study, 68–70 TERCAP ... Task framework factors, 16t Taxonomy of Error, Root Cause Analysis, ... A bout 3 weeks before launch of a major system upgrade on a product called ‘Saluki’ with 4 years in the market, a show-stopper problem was discovered in the pre-launch stock of finished ‘Saluki-II’ product. How it works: Teams work together to brainstorm and identify potential causes and group them into … This will help avert any damage caused by excessive vibration. Found insideThis book presents the outcomes of the 16th International Conference on Software Engineering, Artificial Intelligence Research, Management and Applications (SERA 2018), which was held in Kunming, China on June 13–15, 2018. Found inside – Page viConduct.Root.Cause.Analysis.to.Redesign.Workflows. and.Processes. ... 202 Case Study 10.1: Causality of Noncompliance with BC-MAR System. The innovation failure case studies included in this analysis indicate lack of market demand as the single most common root cause of failure. Root Cause Analysis Reports Help Identify Common Factors In Delayed Diagnosis And Treatment Of Outpatients. Root Cause Analysis (RCA) is a method of problem solving that aims at identifying the root causes of problems or incidents. Root Cause Analysis is based on the principle that problems can best be solved by correcting their root causes as opposed to other methods that focus on addressing the symptoms of problems. 1. Explore the effectiveness of Root Cause Analysis training and software across a variety of sectors via these real-life success stories. Found inside – Page 373This case study presents an approach to monitoring the service quality of general elevators using root cause analysis. This example highlights the ... It was discovered that none of the breather tubes had desiccants and that the lines were either crushed or broken off completely. Vibration Root-Cause Analysis LCD was not available for root-cause analysis. Symptoms of misalignment were found in multiple locations, including the gearbox casing and shaft roller bearings. Industrial Engineer Who Help Businesses Reach Their Full Potential. With Automated Root Cause Analysis. �o �ʾ�_``�h`��``�h��#q(f`Teb��d�(Ƞ�����n�)�p2052��949(�:2�:LN``�)\#ޔа�b�G�)@G� iv�e�>��e\���!��Z !^ A secondary issue was also evident on the component parts – the black markings of water present in the oil and gearbox. Found inside – Page 252However , the fact that a root cause analysis is a case study is in fact its power . Nonetheless this criticism has led to shifting the focus of a root ... Vibration Corrective Action One of the most important questions in assessing the results of a HALT test is determining its relevancy. Found inside – Page 387... xix Root cause analysis of, using sequential error model, 81 case study, hydrocarbon leak, STEP, 297-299 defined, xix Root cause analysis system (RCAS). endstream endobj startxref These measurements fell well within the precision standards of 0.07 inches per second. Instead of viewing root cause analysis as an opportunity for improvement, many see it only as an admission that things have gone wrong. Found inside – Page 17This exploratory case study focuses on exploring human errors as root causes in IT service incidents. In the case study, we applied Human Factors Analysis ... Upon installation, an unidentified gearbox experienced infant mortality caused by an existing production defect. Found insideOne of the most frequent quantitative problems facedin the case studies wasthe lack ... In otherwords, ourinterest in root causes analysis is to uncover the ... 3 because the building management system software showed a demand for cooling but was receiving zero output. Follow. Due to the chill-water valve placement, half of the cooling tower had to be locked out, dropping cooling capabilities even further to 50 percent. The identification band is needed in order to utilize the bar- coding system to match the prescribed drug therapy to the medications brought into the room. All four of these failures were met with a quick and reactive response to replace the gearboxes immediately in order to return to 100 percent cooling capabilities. Finally, the preventive maintenance plan for the cooling tower has been rewritten to target and correct the appropriate equipment parameters and needs. ... WRONG MEDICATION ERROR CASE STUDY First Step: Investigate and establish a sequence of events based on evidence (SnapCharT®) Information came from CMS unannounced onsite survey resulting Undertaking root cause analysis remains a complex non-linear task which entails balancing a multiplicity of concerns and expectations. Throughout the entire maintenance task, the team was constantly asked for status updates by customers. Once the causes of the failures were identified, our team immediately decided to have the new gearbox aligned. About the company. <>/XObject<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 960 540] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> This team asked, “Why is this happening?”. The term “root cause” refers to the most primary reason for a production line’s drop in quality, or a decrease in the overall equipment effectiveness (OEE) of an asset. Common examples of root cause analysis in manufacturing include methodologies such as the “Fishbone” diagram and the “ 5 Whys ”. Annual Turnover: €1.2 billion. The present manual is also intended to provide guidance to all organizations establishing a new process for root cause analysis, especially in countries embarking upon a nuclear power programme."--Publisher's description. Unfortunately, root cause analysis is an often maligned, misunderstood, and misapplied process. <>/Metadata 1482 0 R/ViewerPreferences 1483 0 R>> BC C NTES Root cause analysis in business case development 2 The nature of root causes A root cause is a fundamental reason for the occurrence of a problem – either now or in the future. Conditions assisting the failure were identified. �jD�1�BsD/zK��E���⊊j��Y�[W��p1�Ȇ�����T.�4w˝���% -(��v�$������ִ{�K��Bp�C8��:�D���1���]TEGʏt͝Dܷ The root cause, however, is how a parent manages themselves during the power struggle. 3 was aligned and balanced to a precision state and given a new oil sight glass. 2 failed. But it isn’t always easy - or safe - to bring large groups together for extended training sessions. Food Industry Case Study. Mar. Since then, all the technicians continue to drive the “why” and “how” questions until a maintenance project is completed with all the appropriate actions taken. The technicians were able to laser align the motor and gearboxes in all four subcells to within 0.002 inches, which resulted in vibration readings of 0.05 inches per second or less. Visual inspection of the power supply identified broken ceramic bleeder resistors that had separated from their solder joints. 22, 2015. An easy to use tool for conducting a root cause analysis. Found inside – Page 71example, a fishbone diagram is a type of root cause analysis that will be introduced in Part Two and can be used to analyze case studies throughout the ... Health Affairs, 32(8), 1-8. 4,512 views. So the route cause was low water level in source tank, hence we have concluded to fix alarm for low water level for avoiding the capturing of air by pump. The physician ���� JFIF H H ��XICC_PROFILE HLino mntrRGB XYZ � 1 acspMSFT IEC sRGB �� �-HP cprt P 3desc � lwtpt � bkpt rXYZ gXYZ , bXYZ @ dmnd T pdmdd � �vued L �view � $lumi � meas $tech 0 rTRC. Each of the gearboxes were installed with a breathing tube that extended from the top of the gearbox to the top of the cooling tower, near the fan outlet. Case Study Analysis (Final Milestone Project): Engstrom Auto Mirror Plant: Motivating in Good Times and Bad Root Cause Study Analysis Angela McVey Southern New Hampshire University Root Cause Study Analysis From our case study of Engstrom Auto Mirror Plant, we can be able to identify, depict and analyze the root causes of the various organizational issues that are evident … It is important to virtual instructor-led root cause analysis training In today’s complex and unpredictable workplace, effective Root Cause Analysis (RCA) skills have never been more important. Our team has since upgraded the oil sight glasses from flat windows to versions that extend outside the gearbox. The demographic and scientific phenomenology root cause analysis case study ppt of RBD are summarized in desk 2; samples of precise characteristics and samples of behaviors can be found in a lot of references. Found inside – Page 75126 US Airways Flight 1549 Root Cause Analysis for the Miracle on the Hudson Karunya Rajagopalan and Danny Kopec contents Case.Study.Elements. w��e�+^����@S�Ay�ba�S���_su}����j��2'���FA&O��?�Vж�c���[ Found insideCASE STUDY: NORTH AMERICAN PAPER MILL Undesirable Event: Repetitive Thick Stock Pump Failures Undesirable Event Summary: Case Study: North American Paper ... Found inside – Page 219... of Rework by Phase (DTCC case study), 206fig; Pareto Chart of Root Causes of Rework ... 59 Project scope (project charter), 69 Q Qualitative analysis, ... Prior to the catastrophic failure, the cooling tower was considered the worst actor and a money pit. This is one practical example that I have faced when I was associated with that organization and I was a member of RCA team. We also requested the gearbox’s natural frequency and were told that it had a band of 31 to 36 Hertz. The readings also indicated severe bearing damage. Found insideMost, if not all, causes of equipment failure can be determined through rigorous root-cause analysis. When followed by corrective actions, ... We contacted several companies for alignment pricing and concluded that we could purchase the alignment equipment and provide training to our technicians for the same price as one third-party alignment. Other Lockheed Martin sites are beginning to see the progress we’ve made and are following our example. The placement and lack of breathers indicated the gearbox was open to the fan’s humidity. Company size: 4,200 employees over 38 sites worldwide. Found inside – Page 28k k 3.1.3.1 Case Study: Improving the Reliability of Automotive Suspension Springs by Root Cause Analysis An example of improving reliability by root cause ... All the gearboxes have been placed on a vibration analysis route, allowing their behavior to be tracked. I thought you might be most interested in case studies which provide examples of how root cause analysis has been used. 2 0 obj Nursing schools respond to student medication errors seriously, and many choose to d … endobj Mohammed Hamed Ahmed Soliman. and do a root cause analysis based on it. I found more than 100 case studies which focus on root cause analysis and I’ve listed some case studies below which I thought would be helpful: “Eastman Chemical’s Success Story“, Quality Progress, June 2003 (open access) Found inside – Page 249See case study actual prices, 61-62 airline industry example (price leaks), ... 188-189 process analysis, 185-187 root-cause analysis, 187-188 tools for, ... Using these predictive measures gave our team the ability to plan for a gearbox replacement during a planned site outage over a weekend in December 2018. endstream endobj 96 0 obj <. endobj This article was previously published in the Reliable Plant 2019 Conference Proceedings. Guidelines for Root Cause Analysis. Knowing the gearboxes’ natural frequency has enabled us to create a prohibited operation band on the cooling tower VFDs, preventing the tower from running in the 31 to 36 Hertz frequency band. The failed coupling on gearbox No. endobj You'll also answer multiple-choice questions about the steps of root cause analysis. Found inside – Page 334... 307 root cause analysis (RCA) Analyze Phase, 113–117 applying poka yoke in Control Phase, 196 case study, 231 on control charts, 88, 93–94 defined, ... The next year, July 2017, gearbox No. Found inside – Page 199In only one case study was the Root Cause of the accident found to be with the ... CONCLUSION Root Cause Analysis , carried out in a structured fashion ... <> Angela Griffith Oct 9, 2017 . Found inside – Page 182.15.1 TELEPHONE CUTOVER DISASTER : A CASE STUDY A Level Two trauma center scheduled a conversion to a new telephone system on a Friday afternoon. People kept opening the side-access door to see if the fan was indeed running. 131 0 obj <>stream The customer could see the root cause of those high disk usage comes from those unusual data movement operations. These changes have also given us a larger window to prepare for failures and are preventing unexpected downtime scenarios, which continues to increase customer satisfaction. The day they completed the first alignment on gearbox No. Aspenden et al., 2007. The cooling tower issues that were resolved have highlighted the importance of a reliability engineer analyzing maintenance data, the purpose and need for root cause analysis, and the benefits of predictive and precision maintenance with condition monitoring. A Cross-Sectional Study on the Relationship Between Utilization of Root Cause Analysis and Patient Safety at 139 Department of Veterans Affairs Medical Centers. h�bbd```b``�"��H��H��L���U ��0Xv>�� LV �����@$��L���u��4�9Q �+�FD�M���Alu��?+��n{v#�$�;+� '�Y Found inside – Page 59The bugs have been classified in five dimensions, namely root cause, ... This case study has been conducted with the use of defect data gathered from 13 ... �UTlS�+���[��kgqD��- P"�qMpL���Hf�]�>�+Gj�h"Į/\ql˓/$�KJ�%|�a�[��A�;f��"��=�N�PRj-��{T�`6�E�{n���m�ﻓ���ukê S������9�bAmB���8������=���%�"I�C��������4h,b�j�ѼWL4"b!�;4�P`�k���.>�[c_jF��+ݍ �M����y�߱���懇;���Iտ0�sH��=� Essentially, a root cause represents a fundamental process, system or policy It was even difficult to see the oil condition up close. <> eO�>�3�a1~�͆RN[liE8N�< ����>Gh��,t#K(�XK�ge�D��u���H�¢�g�0��rHft1#{�!3GV3{�Ie�~�t�*v��Zq�_��b�n�x}�*�$l����M While the team replaced the coupling, one of the technicians noticed that the fan for cell No. Concept with case study 7-step problem solving processes with root cause analysis Found inside – Page 320... procedure and safe practices proper PPE Operating procedure and safe practices Table 1 Root cause analysis for case study 1 S. No Cause Bestpractice 1. <> 1 was sitting lopsided. The misalignment also caused the upper roller bearing to break apart. endstream ���(8o~�?�n˥#���_�� Found inside – Page 693.3 Root-Cause Analysis — Defects Caused by Ambiguity We performed a case study of one software development project and based the study's design on that of ... To learn about fishbone diagrams, see Patient Safety 104: Root Cause and Systems Analysis . Business. A replacement part and crane rental were on rush order. Technicians were not sure if the alignments would actually improve the tower operations. The plant mechanical engineer verified the cooling operations and allowed the maintenance team to shut down cooling tower cell No. In October 2018, the maintenance team was called to cooling tower cell No. Root cause analysis (hereafter known as RCA) is a project management methodology used to identify the source of any issues or problems experienced in any process or product. The core idea behind RCA is that ongoing problems are best solved by eliminating the root problem, instead of applying temporary solutions that fail to resolve recurring issues. Once the gearbox teardown was complete, a walkdown of the cooling tower was conducted. ... Root cause analysis and improvement in the healthcare sector: A step-by-step guide.

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