of future success.
Failure is the best teacher – Failure is only valuable if you use it to identify what worked and what didn’t work and to use that information to minimize future failures. In the corporate and engineering worlds, learning from failure starts with failure analysis. This is a process that helps you identify specifically what failed and then to understand the “root causes” of that failure (i.e. critical failure factors). But since failure and success factors are often closely related, the identification of the failure factors will likely aid you in identifying the critical success factors that cause an approach to succeed. The famous auto innovator Henry Ford revealed his understanding of learning from failure in this quote: “The only real mistake is the one from which we learn nothing.”
A failure factor in one area may apply to another area – Failure analysis tells you what failed and why. But the best corporations develop processes that “spread the word” and warn others in your organization about what clearly doesn’t work so that others don’t need to learn the hard way. On the positive side, lessons learned from both successes and failures in one discipline may be able to be applied to another discipline or functional area.
Experience builds your capability to handle future major failures – When a major failure does occur, your “rusty” employees and your out of date processes simply won’t be able to handle it. Both the military and healthcare managers have proven that the more often you train for and work through actual major failures, the better prepared you will be when an unplanned failure occurs in the future.
Conclusion
Many companies and organizations have been on the reliability journey for a number of years. There are many elements of a solid reliability program – establishing a reliability‐centered culture, tracking key metrics, bad actor elimination programs and establishing equipment reliability plans – to name a few. But, one key element to a solid reliability program, and one that is very important to improving unit reliability metrics, is root cause failure analysis (RCFA). One of the interesting benefits of organizations that have fully embraced the RCFA work process across the entire organization is that over time the RCFA methodology starts to impact how people approach everyday problems – it becomes how they think about even the smallest failure, problems, or defects. Now the organization starts to evolve into a culture that does not accept failure and provides a mindset to help eliminate failures across the organization.
2 What Is Root Cause Analysis
It is not uncommon to see industries caught in the vicious cycle of failure, repair, blame, failure, repair, blame, etc. When there is premature failure of equipment, people involved often asked the question, whose fault it is. Many a time you will get the answer “it is other guy’s fault.”
If one were to ask a operator why the equipment fail, the immediate answer will be it was the fault of maintenance mechanic who had not fixed it properly. In the same line, a maintenance mechanic likely answer to that question would be “operator error.” At times, there is some validity to both these answers, but the honest and complete answer is much more complex. This chapter briefly introduces the concepts of failure analysis, root cause analysis, and the role of failure analysis as a general engineering tool for enhancing failure prevention.
Failure analysis is a process that is performed in order to determine the causes that may have attributed to the loss of functionality. These defects may come from a deficient design, poor material, mistakes in manufacturing or wrong operation and maintenance. Many a time there is no single cause and no single train of events that lead to a failure. Rather, there are factors that combine at a particular time to allow a failure to occur. Failure analysis involves a logical sequence of steps that lead the investigator through identifying the root causes of faults or problems.
Look at any well‐studied major disaster and ask if there was only one cause. Was there only one cause for the TITANIC? Three Mile Island? The Exxon Valdez mess? Bhopal? Chernobyl? It would be nice if there were only one cause per failure, because correcting the problem would then be easy. However, in reality, there are multiple causes to every equipment failure. Let us take the case of TITANIC failure.
The Causes of TITANIC disaster
The TITANIC passengers included some of the wealthiest and most prestigious people at that time. Captain Edward John Smith, one of the most experienced shipmasters on the Atlantic, was navigating the TITANIC. On the night of 14 April, although the wireless operators had received several ice warnings from others ships in the area, the TITANIC continued to rush through the darkness at nearly full steam. Suddenly, the captain spotted a massive iceberg less than a quarter of a mile off the bow of the ship. Immediately, the engines were thrown into reverse and the rudder turned hard left. Because of the tremendous mass of the ship, slowing and turning took an incredible distance, more than that available. Without enough distance to alter her course, the TITANIC sideswiped the iceberg, damaging nearly 300 feet of the right side of the hull above and below the waterline.
The two official investigations back in 1912 started with a conclusion – the TITANIC hit an iceberg and sank. They made somewhat of an attempt to answer why that happened without attaching too much blame. The result was not so much as getting to the root cause but found out the immediate cause.
Richard Corfield writes in a Physics World retrospective on the disaster that caused 1514 deaths on 14–15 April 1912. He described it was an event cascade followed by a perfect storm of circumstances conspired the TITANIC to fail. The iceberg that the TITANIC struck on its way from Southampton to New York is No. 1 on a top‐9 list of circumstances. Here are eight other suggested circumstances from Richard Corfield's article and other sources:
Climate caused more icebergs: Weather conditions in the North Atlantic were particularly conducive for corralling icebergs at the intersection of the Labrador Current and the Gulf Stream, due to warmer‐than‐usual waters in the Gulf Stream. As a result, there were icebergs and sea ice concentrated in the very position where the collision happened
The iron rivets were too weak: Metallurgists Tim Foecke and Jennifer Hooper McCarty looked into the materials used for the building of the TITANIC at its Belfast shipyard and found that the steel plates toward the bow and the stern were held together with low‐grade iron rivets. Those rivets may have been used because higher‐grade rivets were in short supply, or because the better rivets couldn’t be inserted in those areas using the shipyard's crane‐mounted hydraulic equipment. The metallurgists said those low‐grade rivets would have ripped apart more easily during the collision, causing the ship to sink more quickly that it would have if stronger rivets had been used.
The ship was going too fast: Many investigators have said that the ship’s captain, Edward J. Smith, was aiming to better the crossing time of the Olympic, the TITANIC’s older sibling in the White Star fleet. For some, the fact that the TITANIC was sailing full speed ahead despite concerns about icebergs was Smith’s biggest misstep. “Simply put, TITANIC was traveling way too fast in an area known to contain ice, which was one of the major reason of the TITANIC disaster.
Iceberg warnings went unheeded: The TITANIC received multiple warnings about icefields in the North Atlantic over the wireless, but Corfield notes that the last and most specific warning was not passed along by senior radio operator Jack Phillips to Captain Smith, apparently because it didn't carry the prefix “MSG” (Masters’ Service Gram). That would have required a personal acknowledgment from the captain. “Phillips interpreted it as non‐urgent and returned to sending passenger messages to the receiver on shore at Cape Race, Newfoundland, before it went out of range,” Corfield writes.
The
