The plant mechanical engineer verified the cooling operations and allowed the maintenance team to shut down cooling tower cell No. This meant the gearboxes were exposed to excessive vibration due to operations. Quality Press Inc, New Jersey (2010) Google Scholar. The misalignment also caused the upper roller bearing to break apart. 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 ... Found inside – Page 340See registered nurse root cause analysis, unexpected postsurgical death, soft tissue sarcoma, 123–125 routine appendectomy, case studies, 15–26 routine ... 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. While the team replaced the coupling, one of the technicians noticed that the fan for cell No. 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. The root cause analysis done in this case, showed that one proximate cause could have been that the nurse did not place an identification band on the patient. stream
Effective root cause analysis for Causal Factor to find fixable root causes. Root Cause Analysis Reports Help Identify Common Factors In Delayed Diagnosis And Treatment Of Outpatients. 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.”. The readings also indicated severe bearing damage. ... Root cause analysis and improvement in the healthcare sector: A step-by-step guide. Case Study - Root cause analysis. The report revealed 2,984 parts per million of iron particles, while the Karl Fischer test indicated 19.6 parts per million of water. Cronenwett. With Automated Root Cause Analysis. Unfortunately, its 10th flight marked another first—NASA’s first space shuttle disaster. 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; ... Once the rush was over, the new coupling and gearbox were installed, and cooling returned to normal. Root Cause Analysis For Reliability: A Case Study Wikipedia defines Root Cause Analysis (RCA) as “a method of problem-solving used for identifying the root causes of faults or problems.” Essentially, root cause analysis means to dive deeper into an issue to find what caused a nonconformance. 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). Once the gearbox teardown was complete, a walkdown of the cooling tower was conducted. Found inside – Page 85... case study) was added to extend the level of granularity. For the root cause analysis, interested fields from an FMEA (e.g. failure mode, root causes, ... During this inspection, it was discovered that the motor to the gearbox coupling had completely sheared, leaving behind a pile of rubber dust. Root Cause Analysis Case Study: Missing the Indicators - Fatal Parking Garage Collapse. Root Cause Failure Analysis RCFA & an illustration case study. <>
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Objective. Prior to the catastrophic failure, the cooling tower was considered the worst actor and a money pit. %%EOF
This upgrade enables technicians to verify the oil level according to the preventive maintenance plans without shutting down the equipment unnecessarily. 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. 3 led to a condition assessment of the subcell. Vibration readings were as high as 0.2 inches per second at the misalignment frequency. 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. 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. 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. Found inside – Page 206See Root cause analysis Problem solving case study (Intranet Website Development), 154–156 explained, 153–154, 156 Process maps. See Flowcharts Projection ... It is important to When the gearbox was taken out of the cooling tower, an oil sample was sent for analysis. 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, ... 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. It was even difficult to see the oil condition up close. �jD�1�BsD/zK��E���⊊j��Y�[W��p1�Ȇ�����T.�4w˝���% -(��v�$������ִ{�K��Bp�C8��:�D���1���]TEGʏt͝Dܷ Undertaking root cause analysis remains a complex non-linear task which entails balancing a multiplicity of concerns and expectations. Found inside – Page 656We can again apply the formerly developed root cause analysis procedure to the current case study. In a manner similar to that in Case study 1, relating the ... 95 0 obj
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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. 131 0 obj
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The client was facing issues in their plant because of the energy consumption by their equipment’s. 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. Safety … 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 ”. These results raised a red flag for a potential failure like gearbox No. 1. The physician Mar. 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 ... Reducing Quality & Waste Losses by 70%. endstream
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You'll also answer multiple-choice questions about the steps of root cause analysis. The failed coupling on gearbox No. 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. 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. Found inside – Page 182Surveillance-attentiveness breakdown case (Continued) case study, 68–70 TERCAP ... Task framework factors, 16t Taxonomy of Error, Root Cause Analysis, ... 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. The cooling tower contains four subcells that consist of a motor, gearbox and fan assembly. 1 until a precision state was achieved. Visual inspection of the power supply identified broken ceramic bleeder resistors that had separated from their solder joints. Case Analysis Use the following outline to complete an in-depth case analysis. Most of these incidents are minor but a small proportion are more serious. The day they completed the first alignment on gearbox No. The rolling elements that fell to the bottom of the gearbox led to severe damage of the gear teeth. 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 ... Root Cause Analysis and Implementation: A Case Study. Instead of viewing root cause analysis as an opportunity for improvement, many see it only as an admission that things have gone wrong. ���(8o~�?�n˥#���_�� Lean Expert/University Lecturer/Trainer/Author. 0
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Root Cause Analysis Discussion. The cooling tower contains four subcells that consist of a motor, gearbox and fan assembly. 1 criticality function, tied with electrical power to the site. 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 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 ... Covering medical devices used in the home and those used in clinical environments, the book presents informative case studies about the use errors 15 C) Case Study. This team asked, “Why is this happening?”. During the analysis and training phase of the cooling tower improvements, there were confusion and resistance toward the additional and more challenging steps. h�bbd```b``�"��H��H��L���U ��0Xv>�� LV �����@$��L���u��4�9Q �+�FD�M���Alu��?+��n{v#�$�;+� '�Y
(2017). How it works: Teams work together to brainstorm and identify potential causes and group them into … 22, 2015. h�b```�
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7�_~��US*:������}G 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. x��U�n�@}G��ю²w{�(Ri�V�Ҁ��� qi�4��������S�����3gό�ի�|��j����?�%�q΅�g9�a�-���`\.Uoz3�cJ;�� � Root Cause Analysis – A Mock Case Study Julie Miller INTRODUCTION Radiation Therapists constantly strive to deliver safe and accu-rate radiation therapy to their patients. 4 0 obj
The placement and lack of breathers indicated the gearbox was open to the fan’s humidity. 1, removed their red locks and turned the controller to “auto,” they became instant believers. The subcell ran so quietly that you could only hear the water flowing over the fill. Looking beyond superficial cause and effect, RCA can show where processes or systems failed or caused an issue in the first place. 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 ... When an issue, food safety or otherwise, occurs, it’s not uncommon that several things “went wrong” resulting in the issue. 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. ... 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 Vibration Corrective Action One of the most important questions in assessing the results of a HALT test is determining its relevancy. This is one practical example that I have faced when I was associated with that organization and I was a member of RCA team. <>
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 ... 120 0 obj
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A “root cause analysis” is a systematic, detailed process that is conducted in to A root cause analysis case study of the Valdez oil spill in Prince William Sound, Alaska on March 24, 1989. Case Study… 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 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. In October 2018, the maintenance team was called to cooling tower cell No. Our team has calculated tens of thousands of dollars in savings and reported them to both customers and management. 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 ... Technicians were not sure if the alignments would actually improve the tower operations. The chiller plant relied heavily on the previously cooled expansion tank while the weather temperatures reached more than 80 degrees F. This decrease in cooling operations created extra pressure and urgency for the completion of the project. 3 because the building management system software showed a demand for cooling but was receiving zero output. Follow. The next year, July 2017, gearbox No. <>
Found inside – Page xiRoot.Cause.Analysis:.Introducing. Chapter 14 The.Team.Critical.Success.Factors. ... Case.Study.No..1:.North.American.Paper. 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. Food Industry Case Study. 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, ... This case study was provided to the Romaine Task Force to illustrate how a root cause analysis can be conducted. In this case, the way the parent was raised is not something that the parent can change. 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. This article was previously published in the Reliable Plant 2019 Conference Proceedings. Found insideMost, if not all, causes of equipment failure can be determined through rigorous root-cause analysis. When followed by corrective actions, ... In December 2016, gearbox No. If the team did not act fast enough, the possibility existed for site-wide downtime. Found insideCASE STUDY: NORTH AMERICAN PAPER MILL Undesirable Event: Repetitive Thick Stock Pump Failures Undesirable Event Summary: Case Study: North American Paper ... Decorating and hiding Easter eggs is an exciting springtime tradition. In 2008, Lockheed Martin’s facilities maintenance and operations team had a counter-flow, mechanical draft cooling tower designed and installed onsite. ... an overview of the information from the report can be diagrammed in a Cause Map, or visual root cause analysis, allowing a one-page overview that clearly shows the cause-and-effect relationships. All the gearboxes have been placed on a vibration analysis route, allowing their behavior to be tracked. back. 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