fracas - failure scene investigation
TRANSCRIPT
by Jim TaylorCRE, CPE, CPMM
Director of Operations, Machinery Management Solutions, Inc.
www.machineryhealthcare.comhttp://blog.machineryhealthcare.com
FRACAS
Failure Scene Investigation
Key Takeaway: Effective root cause elimination can be done by
the average maintenance professional
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You work in a facility or plant.
You’re a Maintenance professional: A Crafts Person, a Planner, a Supervisor, a
Maintenance Manager, or an Engineer.
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Low availability and repeat failures on your equipment is affecting your production and
customer service.
You want to find and eliminate these failures.
To keep track of it
all, you need a
system.
A
Failure Reporting,
Analysis, and
Corrective Action
System
(FRACAS).
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First, You must
capture as much
information about
the Event as you
can.
FSI
Failure
Scene
Investigation
You must capture the details of the Event in enough detail to do effective failure analysis.
As found condition
Failed components
Operating parameters
Sequence of events
Fluid levels
Signs of over temperature or pressure
You are the
designated
Failure Scene
Investigator.
by West Midlands Police
You are not the repair person.
You must capture the timeline of the Event in order to reconstruct the event.
T0 – time of event
T1 – time of trouble report
T2 – maintenance on scene
T3 – trouble shooting complete, parts ordered
T4 – parts on site
T5 – repairs complete
T6 – test complete
T7 – system back on line
The four basic
components of the
failure scene
investigation
process are:
The accident sequence
Physical Evidence collection
Digital evidence collection
Narrative evidence collection
The nature and complexity of the accident
determines the extent to which these
components are evaluated.
Arriving at the
scene:
Initial Response
1. Initial Response/Receipt of Information
2. Safety Procedures
3. Emergency Care
4. Secure and Control Persons at the
Scene
5. Boundaries: Identify, Establish, Protect,
and Secure
6. Turn over Control of the Scene and
Brief Investigator(s) in Charge
7. Document Actions and Observations
Preliminary
Documentation &
Evaluation
1. Conduct Scene Assessment
2. Conduct Scene ”Walk-Through“ and
Initial Documentation
Processing the
scene
1. Determine Team Composition
2. Contamination Control
3. Documentation
4. Prioritize Collection of Evidence
5. Collect, Preserve, Inventory, Package,
Transport, and Submit Evidence
Completing &
recording scene
investigation
1. Establish Failure Scene Debriefing
Team
2. Perform Final Survey of the Failure
Scene
3. Documentation of the Failure Scene
The key to an effective failure
analysis is having the right
information.
To do that, you must
systematically collect that
information.765-366-4285
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