root cause analysis · pdf fileroot cause analysis ... and coupling manufacturer's...

RCA Name Multiple leaks in new pipelineReport Number 2013-B105

Report Date 9/8/2013RCA Owner Marcus McCoy

Root Cause Analysis ReportProblem Statement

Focal Point Multiple leaks in new HDPE pipeline

WhenStart Date 6/3/2013 End Date 6/4/2013

Unique Timing Initial hydro testing of a new line during extremely hot weather

WhereWidget processing divisionPhoenix, AZProcess water treatment line

Actual I mpact CostDelayed startup-2 weeks $400,000.00Repair of leaks and replacement of coupling gaskets $125,000.00Customer upset due to delayed startup $0.00

Actual I mpact Total: $525,000.00

Frequency 1 times

Reportable spills $0.00Lost future contracts $5,000,000.00Clean up costs $100,000.00

Potential I mpact Total: $5,100,000.00

Business UnitLocationSystem

RevenueCost

Customer Service

overall

Potential I mpactEnvironmental

RevenueCost

\ 22

Report and chart generated by Sologic’s Causelink software. www.sologic.com

Report Summaries

Executive Summary

After over three miles of high-density polymer pipeline was installed with over 800 couplings, the initial 25 PSI hydro testing resulted in 50-60 percent of the couplings leaking. The couplings leaked because gaskets were damaged during installation and because the pipe sealing surfaces were improperly prepared. Gasket damage was caused by gasket misalignment because of improper lubrication being used to install the gaskets, among other problems.

This problem resulted in a $525,000 profit reduction due to delaying startup by two weeks ($400,000) and increasing out-of-pocket costs by $125,000 for repairs. Our customer was also unhappy with the delays. Additional, potential impacts include reportable spills due to the leaks, possible loss of a $5M contract and $100,000 in clean up costs.

Solutions include, but are not limited to, using a vegetable oil for gasket lubrication during installation; polishing the sealing areas of the pipe prior to installing gaskets; using a Sawzall with a fine tooth blade to cut pipe instead of a chainsaw; shading the installation surfaces on sunny, hot days; and incorporating the piping and coupling manufacturer's recommendations into the piping specifications.

Cause and Effect Summary

The multiple piping leaks in the piping was caused by multiple leaks at the couplings. The couplings leaked because gaskets were pinched/damaged during installation and because the pipe sealing surfaces were improperly prepared.

The pinched gaskets were caused by the gaskets not sliding into designated seating areas within the coupling. The gaskets did not slide adequately due to lack of lubrication which would have allowed the gaskets to seat properly when the coupling was tightened. The lubrication used during installation was a soapy water solution with an unknown ratio mix of water and soap. The ratio of soap and water is unknown because the installers did not track the amount of soap put in the water bottles, but it was stated that there was not much soap in the mixture. A soapy solution was recommended by the manufacturer, but considering this application in the hot, sunny desert climate, it was ineffective because the water evaporated too quickly.

Aside from the gasket pinch, additional causes related to imperfections in the pipe surface area did not allow gaskets to form a seal. These imperfections include scratches, gouges, and abnormalities in the pipe’s gasket surface area. Scratches were created mostly during pipe transfer from the storage/staging area to the installation area. The scratches came when the 50 foot pipe’s ends dragged on the ground during transportation. The pipe is lifted from the center with a forklift, but the high-density polymer pipe is malleable (especially when heated from warm ambient temperature) and the flexibility of the pipe allows the ends to bend and touch the ground. While not in constant contact with the ground, the transportation path is not smooth, level, and flat so the ends come in contact with ground surface and rocks when moving into installation position. Most of the smaller imperfections were not addressed during the original installation (only the dramatic gouges were prepped or eliminated).

The seemingly smaller surface area scratches and imperfections were not highlighted as an area of trouble during the onsite coupling training provided by the manufacturer, so installation technicians were not aware of which surface imperfections required attention and which imperfections were acceptable. The demonstration that the manufacturer's representatives provided during training included installation of a 3” coupling on 3” PVC pipe with no lubrication. Scratches, lubrication, and high-density polymer pipe were not addressed during this demonstration; however, it is noted that when asked if soapy water could provide sufficient lubrication for installation, the manufacturer's representatives confirmed that a soapy solution would be acceptable. It is important to note that the manufacturer was not part of this investigation, and evidence gathered is from the installer’s statements, photos, and supporting documentation. The manufacturer did provide field installation

\ 22

handbooks with additional installation instructions and recommendations, but these handbooks were not used during installation, as field personnel assumed the onsite training was sufficient enough to install the couplings.

Other surface area imperfections were created from chainsaw cuts used to adjust the pipe length in between couplings. Occasionally, the 50-foot standard pipe length was not appropriate when navigating the plant area, so the pipe would have to be cut shorter for specific applications. These cuts are not factory cuts and thus introduce a surface area that may contain imperfections such as uneven cuts (out of square), chain marks on the end of the pipe, and excess material left from rough cuts.

Lastly, the leaks were not detected until the pipeline construction was completed because no incremental hydro testing was performed during construction. Originally, the project manager assigned to this project had to leave shortly after bidding and project kick-off. Once construction began, a new highly-recommended project manager was assigned. While incremental pipe testing was discussed between the original project manager and the internal project engineer, the new project manager was not aware of the need and did not perform incremental testing. It is unknown why the new project manager did not perform in-construction hydro testing. The new project manager was unavailable for this investigation as he is no longer on this project.

\ 22

Label

Solution

Cause

Note

Assigned Criteria

Due Status

Term Cost

Solution

Cause

Note

Assigned Criteria

Due Status

Term Cost

Solution

Cause

Note

Assigned Criteria

Due Status

Term Cost

Solution

Cause

Note

Assigned Criteria

Due Status

Term Cost

Solutions

ID Description

1 Use vegetable oil (or equiv) for gasket lubricant

Soapy water used as gasket lubricant

Ken Anderson Pass

9/9/2013 Completed

Long $150.00

2 Develop task package (better documention)

Thought onsite training by manufacturer was sufficient

This will help determine how to perform the task and what QC will need to be done witheach task.

Rob Roy Pass

9/24/2013 Identified

Long

3 Implement installation training that includes tightening torque. Include a certificationand proficiency test.

Improper tightening of coupling

This solution will likely be addressed with the task package and formal training. Thissolution does not eliminate overtightening, but it does increase awareness. While thesolution does not pass all criteria, it is considered a value added solution and shouldhelp reduce improper tightening of the coupling.

Ken Anderson Pass


Medium

4 Use Sawzall with fine tooth blade to cut pipe

Chainsaw cuts aren't smooth

Ken Anderson Pass

9/23/2013 Approved

Short $400.00

\ 22

Solution

Cause

Note

Assigned Criteria

Due Status

Term Cost

Solution

Cause

Note

Assigned Criteria

Due Status

Term Cost

Solution

Cause

Note

Assigned Criteria

Due Status

Term Cost

Solution

Cause

Note

Assigned Criteria

Due Status

Term Cost

Solution

Cause

5 Design jig for moving pipe without pipe flexing (possibly using come-alongs and pipeends)

Pipe ends dragged on ground

All pipe is already laid - this solution not necessary for this particular job - but could beuseful for future. Further investigation is required to submit solution through criteria.

Rob Roy Not Checked

Identified

Medium

6 Polish out scratches on pipe to ensure a smooth gasket surface before installation ofgasket.

HDPE pipe has surface scratches

Cannot always eliminate scratching, but address scratches with surfacing process. Thissolution should be part of training and task package.

Larry Davis Pass

9/9/2013 Approved

Short

7 Use file on scratches


Using a file is an alternative to using a flapper wheel when necessary. Alternative toolfor smoothing out scratches and rough edges of pipe.

Ken Anderson Pass

9/9/2013 Identified

Short

8 Use die grinder to smooth out scratches


Die grinder is an additional tool used to smooth out scratches and gasket surfaceimperfections.

Ken Anderson Pass

9/9/2013 Identified

Short

9 Cut off section with scratch


\ 22

Note

Assigned Criteria

Due Status

Term Cost

Solution

Cause

Note

Assigned Criteria

Due Status

Term Cost

Solution

Cause

Note

Assigned Criteria

Due Status

Term Cost

Solution

Cause

Note

Assigned Criteria

Due Status

Term Cost

Solution

Cause

Note

Assigned Criteria

If gasket surface cannot be smoothed, it is recommended that the damaged area of thepipe be cut with a chainsaw and the new end prepped for gasket installation.

Ken Anderson Pass


Medium

11 Develop and implement standard operating procedures (SOP) for installation.

Excess material not removed

Develop SOP. These procedures should be included in formal training. Formal trainingwill allow for employee record tracking.

Jim Jones Pass

9/15/2013 Approved

Long

12 New policy to enforce document read and signed-off. Incorprate into employee trainingrecords.

Manufacturer's document not referenced by all installers

Create new policy. Further investigation into how the policy will be communicated andgoverned is required to submit solution through criteria.

Jim Jones Not Checked


Long

13 Document training records on mechanical coupling installations.


Implement formal training records to ensure that personnel working on pipe installationhas been formally trained for task.

John Smith Pass


Choose

14 Incorporate manfuacturer's document into piping specs and issue with all jobs

Manufacturer's installation document not used

John Smith Pass

\ 22

Due Status

Term Cost

Solution

Cause

Note

Assigned Criteria

Due Status

Term Cost

Solution

Cause

Note

Assigned Criteria

Due Status

Term Cost

Solution

Cause

Note

Assigned Criteria

Due Status

Term Cost

Solution

Cause

Note

Assigned Criteria

Due Status

Term Cost

9/29/2013 Approved

Medium

15 Fuse the pipes

Leaks at mechanical joint (couplings)

Not valid....customer wanted to use couplings to eliminate inside (ID) bead created fromfusion.

Ken Anderson Fail

Identified

Long

16 Pipe caps during transportation


Implement a piece of equipment to protect the pipe ends from dragging on the ground.Further investigation required to determine feasibility of solution.

Rob Roy Not Checked


Medium

17 Work in evening or night shift hours

Hot ambient temperature

Solution may not be possible considering scheduling conflicts, but could be evaluated.Night time installation may increase unwanted safety and installation hazards.Investigate further.

Rob Roy Not Checked


Medium

18 Use water hose to cool HDPE pipe temperature

Surface temperature of pipe was hot at install

Solution may cause other unwanted obstacles with work area. Further investigationneeded.

Rob Roy Not Checked


Short

\ 22

Solution

Cause

Note

Assigned Criteria

Due Status

Term Cost

Solution

Cause

Note

Assigned Criteria

Due Status

Term Cost

Solution

Cause

Note

Assigned Criteria

Due Status

Term Cost

19 Cover couplings until needed for installation

Surface temperature of the coupling was hot at install

Keep couplings covered to reduce direct sunlight that increases coupling surfacetemperature.

Ken Anderson Pass

9/29/2013 Approved

Short $300.00

20 Include QA/QC in testing procedure. Separate installation and testing into two separateresponsible parties.

No incremental hydro testing performed on HDPE pipeline

Quality Control would assist in developing necessary testing procedures with installationteam to incrementally test pipeline.

John Smith Pass


Long

21 Implement low pressure (air) and soap suds snoop test after every 1000' of line installed

Hyrdo test is the only process to check for leaks

Marcus McCoy Pass

9/26/2013 Approved

Medium $50.00

\ 22

Team

ID Label Description Label Description

1 First Name John Last Name Smith

Phone (1) Phone (2)

Role District Quality Manager Group

Email [email protected]

2 First Name Jim Last Name Jones

Phone (1) Phone (2)

Role District Continuous Improvement ManagerGroup


3 First Name Larry Last Name Davis

Phone (1) Phone (2)

Role MPC - Project Engineer Group


4 First Name Ken Last Name Anderson

Phone (1) Phone (2)

Role Hand Group


7 First Name Rob Last Name Roy

Phone (1) Phone (2)

Role Project Manager Group


9 First Name Marcus Last Name McCoy

Phone (1) 989-835-3402 Phone (2)

Role Facilitator Group Artemis


\ 22

Label

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Evidence

ID Description

1 Visual confirmation (pipe pressurized)

Water in pipe

Direct Observation

2 Pressure gauge

Pipe pressurized

Rob Roy

Instrumentation

3 Couplings leaking

Pipe pressurized


Coupling gasket not properly aligned

Direct Observation

4 Hyrdotesting procedure

Water necessary for hydro testing

\ 22

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Rob Roy

Direct Statement

5 Photos

Surface imperfections on pipe

Photo/Video

6 No other testing performed

Coupling leaks not caught before final hydro test

Original pipe superintendent did not do incremental testing on couplings

Direct Statement

7 Past pipe experience expressed during recommendation

Project personnel assumed that pipe super knew to incrementally test

Rob Roy

Direct Statement

8 Verbal witness statements (Hands)

Employees not aware of HDPE pipe surface prepping needs

Piping lifted from center wifth forklift

\ 22

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Direct Statement

17 Damaged gasket photos

Coupling gaskets did not seal

Coupling gaskets damaged

Coupling gasket pinched


Gasket area not adequately lubricated

Soapy water not sufficient

Rob Roy

Photo/Video

18 Investigation gasket demonstration of creased gasket


Gaskets rolled during installation

Rob Roy

Other...

19 Physical observation by technicians


Needed to change pipe length

Gaskets are soft

\ 22

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Direct Observation

20 Physical gouges in gasket

Coupling gasket creased


Rob Roy

Photo/Video

21 Installer statement

Clamp tightened

Close clamp



Mechanical coupling reps confirmed soapy water was sufficient

Does not always provide complete coverage of gasket area

Soapy water has thin consistency


Coupling in original shipping container (open top pallet)

Soapy water evaporated before installation completed

OD of HDPE pipe imperfect


Piping flexible

HDPE pipe flexes when hot (heated from ambient weather)

Pipe end dragged on rocks located in work area

Onsite training by manufacturer did not enforce necessity of surface prepping

Not mentioned by manufacturer reps

Manufacturer reps did not illustrate prepping HDPE pipe

Used 3" PVC pipe for demonstration

Manufacturer reps did not apply lubrication to gasket/pipe during demo/training

Not the same materials as being applied on site




Factory cuts aren't perfect


Soapy water solution deemed acceptable

\ 22

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Gaskets got stuck on parts of pipe during installation

Ease of sealing

Fast

Easy

Soapy water loses is lubricity as water evaporates

Soapy water (as lubricant) requires fast installation


Field clean-up on pipe ends not performed

Direct Statement

22 Mechanical coupling specs

Coupling designed to not have extra material in gasket area


Document

23 Newly installed gaskets not leaking


Ken Anderson

Direct Observation

24 Spray bottles used during lubrication


\ 22

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Direct Statement

25 Physical observation of soapy lubricant


Direct Observation

26 Installer Observation

Gravity causes soapy solution to drain to the bottom area of pipe






Installation requires gaskets to slide over pipe

Couplings sitting out in the sun prior to install

Direct Observation

27 Project Manager Statement

Only viable option for application

Piping flexible

Forklift most viable option

Use of forklifft more economical than crane

Work area not favorable for crane

35% grade (crane not able to work on that grade)


Standard procedure for cutting pipe length

\ 22

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence


Rob Roy

Direct Statement

28 Supervisor observation

Arid ambient conditions

Rob Roy

Direct Statement

29 No documentation

Original pipe superintendent did not do incremental testing on couplings

Rob Roy

Direct Observation

30 Manufacturer does not specify

Document

31 Lack of records (no formal records or history)

\ 22

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Rob Roy

Direct Observation

32 Project personnel statement


Couplings staged outside next to work area (about every 350 feet)

Ease of installation

Lower travel distance between couplings and pipe end




Need to transport pipe to final location


Forklift used to transfer HD pipe



Thought manufacturer document was just for documentation purposes

Pipe superintendent came highly recommended




Pipe ends sagged when pipe raised by forklift

Soapy water solution convenient



Ends of the pipe contain imperfections

Using chainsaw to make field cuts

Direct Observation

33 Manufacturer field installation guide

Soapy water would not chemically attack piping

\ 22

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Document

34 Project calendar

Construction performed in summertime

Rob Roy

Document

35 Site located in mountains

Construction site in desert

Rob Roy

Direct Observation

36 HDPE pipe photos

HDPE pipe is black in color




Excess pipe material hung over and folded back onto pipe end

Excess material not removed


Photo/Video

\ 22

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

37 HDPE pipe spec


HDPE pipe is heavy

Rob Roy

Direct Observation

38 In-house engineer statement


Larry Davis

Direct Statement

39 Pipe location photos

Photo/Video

40 Water pipeline currently exposed throughout site

Rob Roy

Direct Statement

\ 22

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

41 Plant site temperature 90+ and surface temperature of pipe higher than 90+


Rob Roy

Direct Observation

42 ?

Not tightening each bolt evenly (together)?

Not tightening in a cross pattern?

Manufacturer reps not prepared?

Choose

43 ?

Overtightening one side?

Choose

44 weather data


\ 22

Contributor

Type

Quality

Evidence

Cause(s)

Location

Link

Contributor

Type

Quality

Choose

45 scientific data/studies

Black objects absorb maximum solar radiation

Water evaporates quickly in desert

Choose

\ 22

Label

Note

Cause

Note

Cause

Note

Cause

Notes

ID Description

1 No procedure for ratio used

2 Fusing pipes requires reaming - more time and less desirable


3 One person was originally scheduled to be superintendent and performed bidding andoriginal scope. That first person had to leave jobsite and second person was assigned tobe the new pipe superintendent. All pipe superintendent references are for the secondperson, not the first.


\ 22

Chart Type Legend

Transitory

Non-transitory

Omission - Transitory

Omission - Non-transitory

Focal Point

Solution Implemented

Multiple leaks in new HDPE pipeline

Evidence

Visual confirmation (pipe pressurized)

Water in pipe

Evidence

Hyrdotesting procedure

Water necessary for hydro testing

a

Terminated because:

Desired state END

Evidence

Pressure gauge

Couplings leaking

Pipe pressurized Connects to:

a Water necessary for hydro testing

Evidence

Couplings leaking

Solutions

Fuse the pipes

Criteria Fail Status IdentifiedNot valid....customer wanted to use couplings to eliminate inside (ID) bead created from fusion.


Evidence

Damaged gasket photos

Investigation gasket demonstration of creased gasket


and or

Evidence


Physical observation by technicians


Evidence


Coupling gasket pinched

c

Evidence

Installer statement

Clamp tightened

Evidence

Installer statement

Close clamp Terminated because:

Desired state END

Evidence

Couplings leaking

Coupling gasket not properly aligned

Evidence

Investigation gasket demonstration of creased gasket

Gaskets rolled during installation

Evidence

Installer statement

Gaskets got stuck on parts of pipe during installation

Evidence


Physical gouges in gasket

Newly installed gaskets not leaking

Gasket area not adequatelylubricated

Evidence


Installer statement


Evidence

Installer statement

Project personnel statement

Plant site temperature 90+ and surface temperature of pipe higher than 90+

Soapy water evaporated before installationcompleted

Evidence

Installer statement


Solutions

Work in evening or night shift hours

Criteria Status IdentifiedSolution may not be possible considering scheduling conflicts, but could be evaluated. Night time installation may increase unwanted safety and installation hazards. Investigate further.


f

g

Evidence

Project calendar

Constructionperformed in summertime

Terminated because:

Other causal paths more productive END

Evidence

Site located in mountains

Construction site in desert

e

Terminated because:


Evidence

Supervisor observation

weather data


Connects to:

e Construction site in desert

Evidence


Solutions

Use water hose to cool HDPE pipe temperatureCriteria Status IdentifiedSolution may cause other unwanted obstacles with work area. Further investigation needed.


Evidence

HDPE pipe photos

HDPE pipe spec


Evidence

Project Manager Statement

In-house engineer statement


Terminated because:


Evidence

scientific data/studies

Black objects absorb maximum solar radiation

Terminated because:


Connects to:

f Hot ambient temperature

Evidence



Solutions

Cover couplings until needed for installation

Criteria Pass Status ApprovedKeep couplings covered to reduce direct sunlight that increases coupling surface temperature.


Evidence

Installer Observation

Couplings sitting out in the sun prior to install

Evidence


Couplings staged outside next to work area (about every 350 feet)

Evidence


Ease of installation Terminated because:

Desired state END

Evidence


Lower travel distance between couplings and pipe end

Terminated because:

Desired state END

Evidence

Installer statement



Terminated because:


Connects to:

g Hot ambient temperature

Evidence

Installer statement

Does not always provide complete coverage of gasket area

Evidence

Installer statement

Physical observation of soapy lubricant


Terminated because:


Evidence


Gravity causes soapy solution to drain to the bottom area of pipe

Terminated because:


Evidence

Installer statement

Soapy water (as lubricant) requires fast installation

Evidence

Installer statement

Soapy water loses is lubricity as water evaporates

Terminated because:


Evidence

scientific data/studies

Water evaporates quickly in desert

Terminated because:


Evidence

Installer statement

Spray bottles used during lubrication

Solutions

Use vegetable oil (or equiv) for gasket lubricant

Criteria Pass Status Completed


Evidence

Installer statement

Mechanical coupling specs


Evidence

Installer statement

Mechanical coupling reps confirmed soapy water was sufficient ?

Evidence

Manufacturer field installation guide

Soapy water would not chemically attack piping

Terminated because:


Evidence


Soapy water solution convenient

Terminated because:


Evidence


Installationrequires gaskets to slide over pipe

Terminated because:


Evidence


Solutions

Implement installation training that includes tightening torque. Include a certification and proficiency test.

Criteria Pass Status IdentifiedThis solution will likely be addressed with the task package and formal training. This solution does not eliminate overtightening, but it does increase awareness. While the solution does not pass all criteria, it is considered a value added solution and should help reduce improper tightening of the coupling.


and or

Evidence

?

Not tightening each bolt evenly (together)? ?

Evidence

?

Overtightening one side? ?

Evidence

?

Not tightening in a cross pattern? ?

Evidence

Mechanical coupling specs

Coupling designed to not have extra material in gasket area

Terminated because:


Evidence


Gaskets are soft

Evidence

Installer statement

Ease of sealing Terminated because:

Desired state END

Evidence

Physical gouges in gasket

Coupling gasket creased

Connects to:

c Coupling gasket pinched

Evidence

Photos

Surfaceimperfections on pipe

Evidence


Ends of the pipe containimperfections

Evidence


Using chainsaw to make field cuts

Evidence


Standard procedure for cutting pipe length

Evidence

Installer statement

FastTerminated because:

Desired state END

Evidence

Installer statement

EasyTerminated because:

Desired state END

Evidence




Terminated because:

Desired state END

Evidence

Installer statement


Solutions

Use Sawzall with fine tooth blade to cut pipe

Criteria Pass Status Approved


Terminated because:


Evidence

Installer statement

HDPE pipe photos


Terminated because:


Evidence

Installer statement


HDPE pipe photos


Evidence

Installer statement

HDPE pipe photos

Solutions

Polish out scratches on pipe to ensure a smooth gasket surface before installation of gasket.

Criteria Pass Status ApprovedCannot always eliminate scratching, but address scratches with surfacing process. This solution should be part of training and task package.

Use file on scratches

Criteria Pass Status IdentifiedUsing a file is an alternative to using a flapper wheel when necessary. Alternative tool for smoothing out scratches and rough edges of pipe.

Use die grinder to smooth out scratches

Criteria Pass Status IdentifiedDie grinder is an additional tool used to smooth out scratches and gasket surface imperfections.

Cut off section with scratch

Criteria Pass Status IdentifiedIf gasket surface cannot be smoothed, it is recommended that the damaged area of the pipe be cut with a chainsaw and the new end prepped for gasket installation.

Pipe caps during transportation

Criteria Status IdentifiedImplement a piece of equipment to protect the pipe ends from dragging on the ground. Further investigation required to determine feasibility of solution.


Evidence


HDPE pipe photos

Solutions

Design jig for moving pipe without pipe flexing (possibly using come-alongs and pipe ends)

Criteria Status IdentifiedAll pipe is already laid - this solution not necessary for this particular job - but could be useful for future. Further investigation is required to submit solution through criteria.


Evidence


Need to transport pipe to final location

d

Terminated because:

Desired state END

Evidence


Pipe ends sagged when pipe raised by forklift

Evidence

Installer statement


Piping flexible

Evidence

Installer statement



Terminated because:


Evidence

Verbal witness statements (Hands)

Piping lifted from center wifth forklift

Terminated because:


Evidence

Installer statement



Connects to:

d Need to transport pipe to final location

Evidence


Forklift used to transfer HD pipe

Evidence

HDPE pipe spec

HDPE pipe is heavy Terminated because:


Evidence


Forklift most viable option

Evidence


Use of forklifft more economical than crane

Terminated because:

Desired state END

Evidence




Evidence


35% grade (crane not able to work on that grade)

Terminated because:


Evidence

HDPE pipe photos

Excess pipe material hung over and folded back onto pipe end

Evidence

HDPE pipe photos

Solutions

Develop and implement standard operating procedures (SOP) for installation.

Criteria Pass Status ApprovedDevelop SOP. These procedures should be included in formal training. Formal training will allow for employee record tracking.

Excess material not removed ?

Evidence

Installer statement

Field clean-up on pipe ends not performed

Evidence

Verbal witness statements (Hands)

Employees not aware of HDPE pipe surface prepping needs

Evidence

Installer statement



Evidence

Installer statement

Not mentioned by manufacturer reps

Evidence

?

Manufacturer reps not prepared?

Evidence

Installer statement



Terminated because:


Evidence

Installer statement



Evidence

Installer statement

Used 3" PVC pipe for demonstration ?

Evidence

Installer statement

Manufacturer reps did not apply lubrication to gasket/pipe during demo/training

?

Evidence

Installer statement


Solutions

Incorporate manfuacturer's document into piping specs and issue with all jobs


Manufacturer'sinstallationdocument not used

Evidence

Installer statement

Solutions

Develop task package (better documention)

Criteria Pass Status IdentifiedThis will help determine how to perform the task and what QC will need to be done with each task.


Terminated because:


Evidence

Installer statement

Solutions

New policy to enforce document read and signed-off. Incorprate into employee training records.

Criteria Status IdentifiedCreate new policy. Further investigation into how the policy will be communicated and governed is required to submit solution through criteria.

Document training records on mechanical coupling installations.

Criteria Pass Status IdentifiedImplement formal training records to ensure that personnel working on pipe installation has been formally trained for task.

Manufacturer'sdocument not referenced by all installers

Evidence


Thought manufacturer document was just for documentation purposes ?

Evidence

No other testing performed

Coupling leaks not caught before final hydro test

Evidence

Installer statement

Solutions

Include QA/QC in testing procedure.Separate installation and testing into two separate responsible parties.

Criteria Pass Status IdentifiedQuality Control would assist in developing necessary testing procedures with installation team to incrementally test pipeline.


Evidence

No other testing performed

No documentation

Original pipe superintendent did not do incremental testing on couplings ?

Evidence

Past pipe experience expressed during recommendation


Evidence


Pipe superintendent came highly recommended

Terminated because:


Evidence



Solutions

Implement low pressure (air) and soap suds snoop test after every 1000' of line installed



Terminated because:

Desired state END

Report and chart generated by Sologic’s Causelink software.

www.sologic.com

root cause analysis · pdf fileroot cause analysis ... and coupling manufacturer's...

Documents