Reliability Goals Achieved!

Weyerhaeuser Company: Valliant, Oklahoma

Event Summary:The Thermo Compressor Cone on Paper Machine Number 3 was experiencing repeated failures due to cracking along a longitudinal weld. Replacement Thermo Compressor Cones lasted two months and two days, respectively, before new cracking appeared.

Bottom-Line Results:

• Corrective action time frame was approximately four months.

• Base metal of Thermo Compressor Cone changed to Chrome Moly from 516 Carbon Steel Radiographic.

• Examination of all welds made and welding specifications provided

• Stress Relief of assembly performed after fabrication.

• Vibration analysis of piping conducted as well as improvements to their support system.

• Estimated Cost to Conduct RCA: $41,476

• Experienced a 25% increase in production capacity.

Download PDF
Play Movie

Paper Mill: Due to client company policy, their name could not be disclosed.

Event Summary: This paper mill was experiencing unusually high maintenance costs due to extensive maintenance repairs taking place across the mill. They were consistently dealing with feed stock problems as well as a high number of changeovers that caused rate reductions for long periods of time. The management wanted a reliability study performed to identify and correct the reasons causing the extensive maintenance and process issues.

Bottom-Line Results:

• Provided the mill with a means to manage the raw material feed stock so it would be more consistent when delivered to production.

• Provided a strategy to consolidate product changeovers to reduce the total number of changeovers in a given period of time.

• Added tankage to minimize process interruptions in the chemical area.

• Estimated ROI: 3500%

• Provided training to middle management on precision maintenance.

• Involved all employees in the process of suggesting ideas to solve mill problems.

• Provided a means for the operating areas and the support groups to function together to satisfy instead of functioning as pockets of process uniqueness.

• Converted the maintenance rebuild shop from an appalling condition to a clean room that no other operation than rebuilds takes place in.

• Created shift turnover procedures to insure proper understanding of current work status at shift change

• Added 24/7 vibration monitoring on several critical assets so component damage could be detected and maintenance scheduled.

• Increased uptime from 96% to 98% ~ $8,279,313 yr

• Rate reductions reduced 20% ~ $720,000 yr

MeadWestvaco: Covington VA.

Event Summary: During the years of 2007 and 2008, there were 19 failures on thick stock pumps on A and B unit in the Bleach Room. Several attempts had been made to implement corrective actions for the pumps but ultimately failures were still occurring. Thick stock pumps are a big ticket item ranging from $60,000 to $120,000 per rebuild due to the tight clearances and amount of material it takes to machine the pumps. It was determined by maintenance that the pumps could be rebuilt in-house in the bleach room maintenance shop. This has been very successful and has cut the cost of maintenance dramatically and has proven to have had greater reliability. Performing the rebuild by MWV millwrights has brought ownership and pride of the repairs and operations of the thick stock pumps. Although production loss was not used in the Opportunity Analysis for these failures, it would have been a significant factor in the loss equation for these events.

Bottom-Line Results:

There are substantially less failures on these critical pumps and defects are caught before they cause catastrophic problems. In-house rebuild of pumps has resulted in greater ownership and pride on the performance of the pumps. Maintenance cost in 2010 YTD (July) are approximately $25,000 compared to roughly $500,000 in 2006 and 2007 in the same time frame.

• Estimated Cost of Performing the Analysis: $20,000

• Approximate Savings:$700,000 per year

• Reduced account receivables and improved organizational effectiveness .

• Estimated ROI: 3500%

PSEG: Jersey City, N

Event Summary: In a power plant Pulverizer operations are designed to feed the boiler by grinding and conveying pulverized coal with air at desired ratios in order to maintain efficient boiler combustion during steam production. Due to the highly combustible atmosphere of the system it is possible to have an explosive environment or for a fire to develop from the accumulation of these combustibles in the air chamber, grinding zone, classifier, burning lines, air inlet-duct and/or the feeder whether the Pulverizer is in operations or in an idle state. After extinguishing three pyrites hopper fires earlier in the day, there was an explosion in the Pulverizer that resulted in the tripping of the unit and activation of the inert gas and fogging safeguards of the Pulverizer system. The plant was put into a safe operating environment and it was determined that a formal Root Cause Analysis, be conducted on this important incident at this time.

Bottom-Line Results:

• Elimination of all future Pulverizer explosions.

• Safe and effective response to pyrites fires in Pulverizer(s).

• Findings of the analysis leveraged throughout entire corporation.

• Consulting plus labor costs of company employees: approx. $100,000.

Alabama Power Company: Parrish, Alabama

Event Summary: A process interruption on Unit 10 Electric Fire Pump happened apparently due to an out board bearing failure. When investigated further, they found that the pump had actually failed five times in a six month period and each time it was the outboard bearing that had failed. Before the pump was repaired and put back in service they put together a Root Cause Analysis (RCA) team to utilize the PROACT® Approach. The RCA Team was comprised of; Paul Cooner – the mechanic on the pump, Chris Curow – the Maintenance team leader, Harold Dobbins – CBM specialist and Ronnie Johnston as the facilitator of the PROACT^® process.

Bottom-Line Results:

• The wrong bearing was found to be used as a replacement for the original bearing.

• The impeller shaft run out was found not centered and in need of a spacer.

• The correct bearing was installed and CMMS data was upgraded to reflect it.

• A spacer was installed and training was given to mechanics to help with proper alignment in the future.

Lyondell-Citgo

Event Summary: Recurrent failures of vacuum column bottom pumps. Both pumps came on-line in December 1996. The Mean Time Between Failure (MTBF) was very poor at three (3) months. Failures of mechanical seals, thrust bearings, impellers and case wear rings were very common. Most of the failures occurred at start-up. The system operates with one pump as a primary pump and the other as a spare pump. Different attempts to correct the above problems failed. There was not a good understanding of the causes of these failures and most important how they correlated to each other. At times, both pumps would not be available. The impact on production and the excessive maintenance costs resulted in management appointing a Root Cause Analysis (RCA) team to find and implement final solutions to these problems.

Bottom-Line Results:

• Estimated Cost to Conduct RCA: $40,000

• Estimated Returns from RCA: $7,150,000

• Return On Total Investment: ~17,900%

ISPAT Inland Steel

Event Summary: During a routine slag wash, the operator in the pulpit (control room) was raising the 11-ton lance carriage. While raising the lance to its idle position approximately 80′ above the fourth floor, a coupling on the drive platform failed, sending the lance carriage into a free fall. The carriage broke through the stop bolts and crashed into the 4th floor.

Bottom-Line Results:

• Estimated Cost to Conduct RCA: $30,000

• Estimated Returns from RCA: $1,150,000

• Return On Investment: ~4000%

AMTRAK

Event Summary: Root Cause Analysis Increases Locomotive Reliability: Amtrak instituted a program that coupled Reliability Centered Maintenance(RCM) with Root Cause Analysis (RCA) to increase rolling stock reliability. The RCM-RCA program at Amtrak combined features of RCM and RCA into a unique methodology to achieve success. A case study of the High Horsepower electric locomotive (HHP-8) power module failure RCA project is described in this paper. The initial focus of the RCA was a persistently high failure rate of power modules. Power modules are expensive to purchase and labor intensive to replace. Additionally, power module failures take locomotives out of revenue service.

Bottom-Line Results:

• The availability of the HHP-8 fleet has been increased by approximately 80%.

• Changes were made to the maintenance, condition monitoring, and troubleshooting procedures for HHP-8.

• The physical, human, and latent roots causing the high failure rate of HHP-8 Power Modules were determined. The use and analysis of the locomotive’s condition monitoring system has been made a daily requirement. The 92-Day and Annual procedures for cleaning power systems equipment have been modified.

PEMMAX Consultants [RCI Representative for Canada]

Company: Mining and Metallurgical – Waterloo, ON, CN

Event Summary: In a leaching operation, titanium shell-and-tube heat exchangers are used to cool from 250oC to 130oC a water based slurry with 30% mineral solids and a pH = 1; The plant uses 10 of these coolers and their average life was 20 days for annual production and maintenance losses of approx. $11,500,000. When leaching became the production bottleneck, a cross-functional team (6 employees led by Tony Rodriguez of Pemmax Consultants using the PROACT® RCA methodology) was given the challenge of increasing the average operating life of these units from 20 to 40 days.

Bottom-Line Results:

• MTBF increased from 20 to over 60 days.

• Savings are 2/3 of the initial losses; remember we tripled the MTBF of the coolers.

• Consulting plus labor costs of company employees: approx. $300,000.

• Payback at current savings less than 2 weeks.

• Estimated savings as a result of the RCA were calculated at $7.6 MM/yr

• Estimated ROI: Greater Than 2,500%

LEAP® Failure Modes Effects Analysis [FMEA]
SYSTEM ANALYZED: OB Ultrasound – BAC Healthcare System

Event Summary: The following Basic FMEA was conducted to help determine the most significant events in that would require a thorough Root Cause Analysis (RCA). This analysis was intended to look at probabilistic events. The analysis delineated which events were most critical to the system in an effort to justify a detailed RCA. A number of challenges and systems failures were identified in the proposed redesign of perinatal interpretation of ultrasounds. Dr. Welper’s proposal was intended to stream line the current system.

Bottom-Line Results:

• As reflected in this Basic FMEA the proposed redesign generated additional steps in the process with identified risk for delay in diagnosis, misdiagnosis, compliance issues and quality of care considerations.
Download PDF

LEAP® Opportunity Analysis [OA]
SYSTEM ANALYZED: OB Ultrasound, BAC Healthcare System
Event Summary: The following Opportunity Analysis (OA) was conducted to help us determine the most significant events in our facility that would require a thorough and credible Root Cause Analysis (RCA). This technique was modified from its traditional format to accommodate other processes and systems. The analysis was intended to look at either probabilistic and/or historical events. The analysis delineated which events were most critical to the system, or the most costly, in an effort to justify a detailed RCA.

Bottom-Line Results:

• As a result of this perspective Opportunity Analysis a number of quality and risk issues were identified in the proposal put forward by Dr. Welper for process re-design in the interpretation of perinatal ultrasounds.
• Significant costs were pinpointed with the proposed changes.
• It is recommended that the team focus on the high cost and high risk issues identified in this perspective Opportunity Analysis.
• The proposed process should be made more efficient, less costly and better focused on quality outcomes for patients.
Download PDF

Specimen Integrity Opportunity Analysis [OA]
SYSTEM ANALYZED: Blood Drawing System Process

Event Summary: A 225-bed acute care facility observed an increase in the costs associated with their blood drawing systems in their ED. In an effort to quantify the severity and magnitude of the potential problem they commissioned a team to conduct an Opportunity Analysis (OA) to review their Blood Drawing Process and determine the scope of the problem.

CONCLUSIONS:
This analysis demonstrated that 4.8% of the occurrences (480/10,013) are causing 82% of the annual dollar losses ($2,400,000/$2,896,560). At the time of this analysis there were approximately 10,013 redraws per year (extrapolated from the period of 9/03 to 9/04) resulting in a consumption of man-hours, material and lost profit opportunities of $2,896,560. The following graphs demonstrate the distribution of losses for each type of event experienced. Clearly “Blood Contamination” was the single, most significant mode contributing to the need for redraws.

RECOMMENDATIONS:
A literature search reveals that the use of a well-trained phlebotomist staff will result in 98% successful draws on the first attempt. Given that statistic, this would indicate that a savings of $2,838, 629 ($2,896,560 x .98) would be realized under the current conditions. The cost of a phlebotomist staff of 25 (full-time equivalents) is estimated at $697,400 per year.

Bottom-Line Results:

• Total Potential Returns $2,838,629 per year
• Total Initial Investment $697,400 per year
• Potential Return on Investment (ROI) 407%
• Est. Payback Period ~ 3 months
Download PDF
Play Movie

Memorial Regional Medial Center: Interim Triage FMEA
SYSTEM ANALYZED: Emergency Department – Risk Analysis

Event Summary: The purpose of this study is to perform a prospective risk analysis for the interim Emergency Department (ED) walk-in entrance at Memorial Regional Medical Center (MRMC) using Healthcare Failure Mode and Effect Analysis (HFMEA). Through the application of HFMEA, the team will be able to identify potential failures and subsequent solutions for the interim process. The solutions will be translated into detailed action plans that will be applied prior to opening the entrance.

CONCLUSION:
The interim triage process at Memorial Regional Medical Center (MRMC) began on 2/9/04 and was operational for approximately eleven months thereafter during construction. The work team identified 28 potential events that may result in an adverse patient event or outcome. Upon calculation, it was demonstrated that 17, or just fewer than 50% of the events were within the “significant few”. This prospective analysis of the Interim Triage Process was a great exercise for staff and physicians to participate in. It seemed to enlighten many of them and force them to analyze a process and its potential failures before an adverse event occurs. Through identification of the potential failures and potential harmful patient events, the team was able to develop specific action plans before the walk-in entrance became operational.

RECOMMENDATIONS:
In order to determine the efficacy of the action plans developed, the team proposed a few measurable results that were tracked as the new process got underway. The first indicator, as stated in the objectives, is the patient satisfaction scores on five key indicators: Overall quality of care, Quality of Nursing Care, Total Time Spent, Likelihood of Recommending Friends/Relatives and Overall Teamwork between Doctors, Nurses and Staff. The team looked for scores that were statistically significant from the previous quarter. The results were an indicator of the effectiveness of the action plan. The team also tracked patient complaints as well as the patient walkout rate from the ED.

• Relative to patient safety indicators, patient and visitor falls were also tracked.
• To ensure the measurable indicators mentioned above were regularly tracked and presented to management, the HFMEA work team routinely met to discuss the results and created a monthly report to Senior Leadership highlighting progress achieved relative to the action plan.

Bottom-Line Results:

• During the 11 month construction period there were no unanticipated incidents with the temporary relocation of the triage entrance, in large part, due to the proactive risk analysis and preventive measures put in place to reduce identified risks.

Download PDF
Play Movie

Intra-Hospital Transfer Medication Error: RCA Patient Management

Event Summary: A 71-year old was transferred from an acute care teaching hospital to a second acute care hospital for rehabilitation services post embolic stroke. Both hospitals were members of the same health care system. Six hours after admission to the second facility the patient suffered an unexpected brain hemorrhage. The event involved an intra-hospital transfer, which caused some serious concerns regarding patient management among both physicians and staff since the type of hand-offs experienced in this case were similar to those occurring on a daily basis in the health system. It was believed there were systematic flaws involved in the transfer of this patient and uncovering them would result in possible system-wide recommendations to prevent recurrence in the future, thus protecting patients from exposure to harm. Although there was no proven relationship to the occurring brain hemorrhage, there were many system failures identified in the transfer process that could have potentially contributed to the event.

Bottom-Line Results:

• In conclusion, both facilities assumed that their Coumadin dosing schedules were the same. This was found not to be the case and the patient who had received a 5 mg dosage of Coumadin prior to the transfer, received another 7.5 mg dosage within two and a half hours. A series of miscommunications and misinterpretations as to test results also contributed to this adverse outcome as evidenced in the Logic Tree and associated Verification Logs.
Download PDF

Allied Chemical Corporation – Nylon Plant

Conditions: Plant incapable of achieving design capacity of 334,000,000 lbs. annually. ® Highest demonstrated production was 319,000,000 lbs (The first year).  Plant structures and machinery severely deteriorated. Elements Introduced:

• Data control and analysis.
• Preventive/Predictive Maintenance (P/PM) program.
• Root Cause Analysis (RCA) System.
• Reliability in design and construction introduced.
• Electronic notebooks for data collection.
• Addition of needed personnel.

Bottom-Line Results:

• Plant produced at 369,000,000 lbs. The first year.
Download PDF

Open Pit Mining Case Study

Conditions:

• Reliability was not considered a priority by anyone.
• Production throughput was believed to have reached its maximum at 9.3 MM tons/month without the introduction of new technology.
• Root Cause Analysis (RCA) was done superficially.
• Data systems were fragmented, recording mainly the manifestations of failure.
• Teaming concepts were introduced, but were not accepted by the wage-roll and 1st line supervisors.

Elements Introduced:

• Reliability policy set by the executive management.
• Management focus sessions held in all of the key production areas.
• Reliability vocabulary established.
• Proaction accepted as the desirable way to conduct business.
• Root Cause Analysis (RCA) established as a culture.
• The concept of the “Significant Few” introduced as a necessary paradigm.
• Wage-roll and 1st line supervisors involved in the development of a training package to introduce the entire organization to reliability concepts.

Bottom-Line Results:

• 8% Reduction in maintenance costs.
• Cost/unit at all time low.
• More committed workforce whose ideas are being utilized.
• $17,000,000 Saving against budget.
• 20% Increase in throughput
Download PDF

Allied Chemical Corporation – Chemical Plant

Conditions:

• Extraordinary low process yields.
• High downtime probably exceeding 15%.
• High overtime averaging 17%.
• Poor safety record.
• Executives involved in major repair and shutdown planning.
• Extremely high stress atmosphere.

Elements Introduced:

• Preventive/Prediction Maintenance (P/PM) program.
• Root Cause Analysis system.
• Planning & scheduling of maintenance.
• Spare parts inventory record system.
• Reliability data collection system.
• Positioned decision making at lowest possible level.

Bottom-Line Results:

• 98% Uptime for 10 years (calculation includes scheduled turnarounds)
• 40% Reduction in maintenance costs
• 4% to 5% maintenance overtime for 10 years
• Won Corporation’s “President’s Safety Award”
• Net dollar benefits estimated at $96,000,000
Download PDF

Refinery – Unreliability Example

Conditions: Refinery unreliability was at a level where the unscheduled downtime of critical equipment was estimated to be 18.46 days in the first nine months of the year. This loss of availability in a sold out market is detrimental to the refineries bottom line and Reliability Center, Inc (RCI) was asked to investigate the high unreliability. Elements Introduced: Opportunity Analyses (OA) was performed in the areas that experienced the most unscheduled downtime. The most significant problems exposed by the OA’s were investigated using PROACT® Root Cause Analysis.

• All management was exposed to Reliability Concepts.
• Ten site employees were trained as Root Cause Analysis (RCA) Lead Investigators.
• RCI investigators facilitated the RCA’s derived from the OA along with the site Lead Analyst.

Bottom-Line Results:

• An additional line of high voltage supply was added.
• Added electrical testing capable of detecting faults from the motor control center through the motor.
• Added a steam trap leak elimination program.
• Reduced steam pressure in the boiler.
• Upgraded water softening equipment .
• Added availability measurements in conjunction with Mean Time Between Failure (MTBF) and Mean Time To Restore (MTTR) measurements.
• Hourly maintenance workers were trained in reading fractured material surfaces.
• The unscheduled downtime was reduced to an estimated 30% or 12.93 days along with overtime.

Allied Chemical Corporation – Chemical Plant

Conditions: 116 Days of downtime compared to an industry average of 49.5 Days (worst record in the world for this type of facility) Elements Introduced:

• Continuous monitoring of large, high-speed, high horsepower turbo-machinery.
• Preventive/Predictive Maintenance (P/PM) Program.
• Root Cause Analysis (RCA) System.
• Data collection and analysis of process variables.
• Parts inventory management system.
• Machinery and parts balancing program.

Bottom-Line Results:

• Net dollar savings in three years was $36,000,000
• 19.4 Days downtime after one year (best in the world in one year!)
• 10 Days downtime after 2 years
Download PDF

Refinery: Lack of Work Flow

Conditions: Refinery had a lack of work flow. It was as if the work was being completed in disconnected spurts of activity. The facility had a negative cash flow and alarmingly shrinking profit margins. The loss of availability was so staggering that Reliability Center, Inc (RCI) was asked to investigate the problem. The RCI assessment team concluded four major issues that must be overcome to restore confidence and financial health to the facility. The areas of concern were:

• Lack of accountability at all levels.
• Lack of system thinking.
• A need to focus on reliability and the opportunity it presents for cost reduction and limiting capital expenditures.
• Lack of implementation speed.
• Boilers were allowed to deteriorate in order to preserve a census in the operating unit.
• Predictive maintenance tasks were not routinely performed.
• High amount of corrosion problems.
• High parts usage.

Elements Introduced: Rigidly enforced all safety policies and procedures at all times. Had the site manager write the letter to all employees that this was taking place. Developed criteria for behavior that is recognized and rewarded like interactions between producing areas, Communication between shifts, and Proactive interaction between departments.

• Newly developed improvement systems tested.
• Process description.
• Inputs needed.
• Where inputs come from.
• List of what could go wrong.
• What are the outputs.
• Output destination.
• What adverse affects can occur.

• Implemented interval based predictive maintenance program with dedicated technicians.
• Dedicated oversight to insure recommendations are implemented in a timely manner.
• Established reliability as the focus of the site.
• Implemented in-house advertising program promoting Proaction and Focus.
• Educated refinery personnel on reliability concepts.
• Selected and trained 10 site Root Cause Analysis lead investigators.
• Operators a part of the development of operating procedure review and verification process.
• Created a steam trap program to reduce steam losses and maintain minimum leak status.

Bottom-Line Results:

• The unscheduled downtime was reduced 10%.
• Predictive maintenance on-time inspections increased 35%.
• Accidents down by 5% due the enforcement f safety policies.
• Unscheduled equipment downtime from corrosion problems were reduced dramatically due to no time preventive maintenance activities.
• Parts usage fell proportionately with the reduction of unscheduled downtime.
  Download PDF