Report No.

Root Cause Failure Analysis Report

A) What Are The Details Of The Event/Failure?

Failure Report Title

(May be based on the work order title)

Date Of Event/Failure _____________________________

Equipment Tag No _____________________________
Tag Description _____________________________
Equipment Type _____________________________
Equipment Vendor _____________________________
Equipment Serial No _____________________________
CMMS Work Order No _____________________________
Work Order Opened (date) _____________________________
Work Order Closed (date) ________________________________

NOTE: Complete only relevant sections. If certain sections are not considered relevant, you must
state why it is not relevant. Incomplete reporting is unacceptable.

What does ‘it’ do?

B) Function
Very often there is a lack of clarity on, what the equipment should actually do, what the performance
standards are for the equipment (e.g. to pump 350cu meter/hour of crude at 40bar). This lack of clarity can
make the process of failure analysis very difficult. Consider what the normal operational performance
standard is for this equipment in its normal operating mode. It is necessary to know the normal parameters
first, as a reference/datum.

In this section record the entire key data regarding the equipment’s primary function.
1 What is the operating context for this equipment you have worked on?
(State the primary function and the performance, throughput, in a specified time, i.e. pressure,
temperature, etc?)

If relevant, please describe secondary functions.

2 State what the standard primary function performance standard is, i.e., it is the datum for
comparison, and who has set this performance standard?

• Work - What is expected? Cycles/Load Etc. __________________________________________________

• Time - How long for? Duration
• Throughput - At what rate?
• Output quantity & quality. At what quality?
• Safety & risk compliance
• Standard set by (whom)
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________

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 C) Functional Failure How has ‘it’ not done what it should?

In what way has this piece of equipment been deemed to have failed to fulfil its function?
3 Provide a brief statement of the ‘problem’ or failure that Maintenance was asked to
investigate/resolve. [This may be the key point from the maintenance work order.]

4
What change or deviation was observed from the normal operating condition?
Compared to the function details previously in Q1 & Q2, e.g. was deterioration, slow down,
increases noted, etc? State how? By how much? Over what time frame, etc?

Please describe what changed/deviated below, e.g. reduced by x% in time t.

What was the sequence of events that lead up to this failure?

5 Can this be supported with hardcopy documentation such as logs/trends/journals? (Via
SER/DCS/RMPIS/Other_________ ) Consider all aspects.
‰ Yes? ‰ No?
If Yes please attach the logs/trends/journals to this report.

The attached documentation demonstrates/proves that:

_______________ <caused/occurred> and then subsequently

D) Failure Effect What happened?

6
State in words briefly what happened when the failure occurred? Consider the effect on
the equipment, system, and plant.

7 How serious was the failure in terms of downtime, secondary damage?

(More detailed consequences analysis, see Section H)

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 E) Action to Restore Function
State clearly what exactly has been done physically to overcome this functional failure?
8
Explain beneath:-

3 Action Code Description

Cleaned
Repaired
Reset
Refurbished in situ
Overhauled
Recalibrated
Adjustment
Other, specify

9 If the item was replaced please state the condition of the fitted item:

3 Action Code
Replaced with new item
Replaced with refurbished item
Refurbished and then replaced
Replaced with modified item
Other

10 Where are the primary failed components now?

Lost/Discarded ‰
Available for review (tagged and stored) ‰
Refurbished and reinstalled
A) Good as new ‰
B) Better than old ‰
Refurbished and returned to store ‰
Returned to vendor ‰
Other, explain ________________________ ‰

11 Has this equipment been returned to as good as new condition and function?
‰ Yes? ‰ No?
If Yes how did you verify, test and confirm that the equipment meets the required performance
standards following the response?

Note: Attach test sheets, start-up/ acceptance logs to validate.

If you have indicated No: By how much was it degraded? _____________%

Is this considered a temporary repair? or ‰ Yes? ‰ No?
Is this considered a modification temporary or otherwise? ‰ Yes? ‰ No?

12 If a temporary repair has been made, what is required and when?

• Requirement _________________
• Due date: _______________________
• Consequence if due date missed ______________________________________________________________
• Follow on MWO Number _______________________________________

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 13 How long will the equipment run now ? ______________________________.
Until what next datum? _________________________________________.
When? ____________________________.

F) Change Control

14 If you have performed a modification that alters the original fit, form or function, (this includes the
substitution of components, different manufacturers, in house made) then this may significantly
change its life.

These changes must be tracked.

Please explain technically the reason, purpose and who authorised this modification, -
• Reason [s] _____________________________________________________
• Purpose _____________________________________________________
• Authority To Modify Is _____________________________________________________
(Letter No., Engineering Package No, etc)

15 Detail what effect this modification will have on the function and performance of the
equipment/component?

Please indicate what updates are needed as a result of this repair?

16
When permanent changes are made it is very important that all the records, documentation and
support are also updated so that the maintenance support remains valid. Remember that
Maintenance is mandated to maintain and not modify – without review/approval and disciplined
change management.

The following must be re-validated:

• Equipment Master Record in CMMS ‰ Yes? ‰ No?
• Material Spare Parts details, stocking, specifications ‰ Yes? ‰ No?
• Drawings & documentation (to be red lined and returned to design
agencies to formally update corporate documentation records) ‰ Yes? ‰ No?
ƒ Support equipment and tools, updated, provisioned ‰ Yes? ‰ No?
ƒ Standard Job Plan (PM or corrective) ‰ Yes? ‰ No?
ƒ Standard Operating Procedure’s ‰ Yes? ‰ No?
ƒ Start-Up/Acceptance Forms Modified ‰ Yes? ‰ No?

Provide details as necessary in the box below

Any items with No – State Why!

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 G Failure Mode/Cause

17 What are the initial recorded CMMS Failure Codes for the work that was conducted?

ƒ Failure _________________
ƒ Failure Code _________________
ƒ Problem _________________
ƒ Problem Code _________________
ƒ Cause Description _________________
ƒ Cause Code _________________

What do you think happened?

18
What can you prove, support and how? Consider also your comments in section C.

State clearly in words in the box below

-Initially _______________________________________________________________________________________
-Subsequently _________________________________________________________________________________

Please expand and support your conclusion(s): -

19 What was the failed component(s) and its mode of failure, e.g., Oil Filter Blocked?

Has this failure occurred on similar equipment or a group of equipment?

20
‰ Yes? ‰ No?

If YES, – how often? _______________ in _________________duration.

21 Have you conducted a five-why or other technique to arrive at the Root Cause?
‰ Yes? ‰ No?

Be aware that the initial reported cause is rarely the root cause codes and a further level of detailed,
analysis and comparison is necessary to arrive at the real root cause.

If YES - What were the findings from this kind of techniques?

Please list the possible Root Cause of failure into the table below.

NOTE if further investigation is ongoing or required do not complete this section until the investigation is
complete.

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 Root Cause Yes No
Maintenance Related
Skills (Competency Deficiency Of Craftsmen)
Incorrect Tooling or Equipment Utilised
Improper Previous Repair (Rework Issue)
Improper Alignment or Field Installation
None Standard or Original Materials, Parts Used
Original Design or Selection In Question
Operational Related
Mal-operation. (Improper Operation/Sequence/Etc)
Improper Start-up or Shutdown
Equipment Overloaded, Operated Too Hard or Too Slow
Operating Context/Condition has Changed Since Design
Lubrication Issue (Insufficient/Incorrect/Contaminated)
Other, explain
E.g., design related
E.g., purchasing related

You must say what it may be and what it is not; i.e. a Y or N is required for each. No omissions allowed.

22 State what you consider are the real Root Causes.

23
Evaluate the Reliability of this failure?

Based upon the initially reported fault codes, the historical data that has been gathered, the evidence of this
event/failure and the basic causes of failure from the table above, from a maintenance perspective would
you say this failure is:-

a) Considered ‘normal’ due to appropriate wear & tear. ‰ Yes? ‰ No?

b) Considered abnormal & unusual. ‰ Yes? ‰ No?
c) Considered chronic or repetitive. ‰ Yes? ‰ No?

If you indicated Yes to either of the last two questions above. Please compare
I.e. [abnormal/unusual or chronic/repetitive] these to Nos.1&2
(on Page 1 to
define the
What is the historical frequency (number of occurrences)? ___________ deviation in
Attach the support through the relevant CMMS Reports. performance

d) Considered unacceptably costly. ‰ Yes? ‰ No?

Please support financially with the relevant CMMS report that considers lifetime maintenance costs
incurred for this asset.
What is the ‘normal’ unit cost per work/time/throughput for this equipment for a comparator?

<x> ____ $’s per

________ <of> _____

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H) Consequences of Failure Does it matter? How much?

24 State the consequences of this failure in terms of safety, environment, production, and
costs?

24a Safety: Was there an actual safety loss associated with this event /failure? (This refers to a
quantifiable safety loss that was sustained.) ‰ Yes? ‰ No?
If Yes - then how can this actual safety loss be quantified in financial terms? Indicate the value of this safety
loss in the box provided

<X $’s> for ___________________________

Environmental: Was there an actual environmental loss associated with this event/failure?
24b
(This refers to a quantifiable environmental loss that was sustained.) ‰ Yes? ‰ No?

If Yes – then how can this actual safety loss be quantified in financial terms? Indicate the value of this
environmental loss in the box provided.
<X $’s> for ___________________________

As this was an actual safety and/or environmental loss, has this been documented separately, accompanied
with the near miss or preliminary incident reportage and channelled through to population of, e.g., HAZOP
databases? ‰ Yes? ‰ No?

If Yes, - record the transmittal reference to Safety & Environmental Department ______________________
If No, - why not?

Production: - Was there an actual production loss associated with this failure/event?
24c
Note. This refers to a quantifiable loss that was sustained that was not recovered by increasing
throughput through the plant/unit/equipment once the failure/event was dealt with.
‰ Yes? ‰ No?

If Yes, - then how can this actual production loss be quantified in financial terms? Indicate the value of this
loss in the box provided. (You may need to discuss this with a performance-monitoring engineer.)

<X $’s> for ___________________________ <quantity> of <product> for <duration>

24d Maintenance: When maintenance responded to this event/failure. (It is important to understand if
this was a completely unbudgeted/unplanned response.)

Was this a breakdown response? ‰ Yes? ‰ No?

Did this occur out of hours and require call out/overtime? ‰ Yes? ‰ No?
Were all the costs directly apportioned to this failure/event? ‰ Yes? ‰ No?
If No, - then what other work (opportunistically) was conducted whilst the event/failure was being dealt with?

What were the total maintenance costs associated with the response to this event/failure?

Total _________________
Labour _________________
Materials _________________
Other _________________

What was the total downtime of the equipment? Hr’s

Hr’s

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What was the total maintenance time within this total downtime?

Where is the balance of the downtime to be attributed to if the maintenance downtime is less than 50% of
the total?

24e Non Operational/Other

Did this event/failure result in other non operational cost other than the direct costs of response/repair?
Perhaps taxes, penalties, logistics etc. ‰ Yes? ‰ No?
If Yes what were these costs by type and cost?
• _____$’s
• For _______<what>

25
Determine the Total Financial Cost Of This Event/Failure. (Add together numbers 24a –24e.)

______ $’s

I) Preventive Action

26 What should (could), be done to prevent this failure from re-occurring?

(Brief statement only)

<Why> -------------------------------------------------------------------------------------------------------------------------------------------------
<How>--------------------------------------------------------------------------------------------------------------------------------------------------
<By when>---------------------------------------------------------------------------------------------------------------------------------------------

27 Define the tasks or ideas that your work group should do to resolve this issue?

1. _______________________________________________________________________________________
2. _______________________________________________________________________________________
3. _______________________________________________________________________________________
4. ________________________________________________________________________________________
5. Approximate Cost?_______________ ROI v/s cost @ Number 25 = x:1 in y period

28
Have you any other suggestions that would prevent a re-occurrence? (Perhaps outside of
your control.)

My suggestion is to _____________ because _________________. This needs to be ________________,

By ____________________________________.

29
Do you consider your suggestions to be: -
An in-house maintenance activity(s) ‰ Yes? ‰ No?
A outsourced specialist maintenance activity ‰ Yes? ‰ No?
A redefined operations activity (s). ‰ Yes? ‰ No?
A modification or enhancement. ‰ Yes? ‰ No?

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J) Maintenance Strategy Review

30 Would checking the equipment at different intervals have been sufficient to detect the failure
before it occurred? How would it then become detectable and preventable? Please explain.

We should check ___________________ by _______________ <technique> at ____________ <interval>. This

would then make _______________________ <what> detectable & preventable because
______________________________________________________________________________________ <why>

31
Should we consider a scheduled overhaul / strip down for this equipment? Would the timely
replacement of a component have retained the original system resistance to failure as a whole?
Please expand/support below.

- Wear pattern ____________________________ - characteristic _____________________

32 Is this equipment currently in the preventative maintenance (PM) programme?

‰ Yes? ‰ No?

If NO - What are the reasons why it should be included in the PM program ? What specific individual
failure modes would be targeted and how, in the revised preventative maintenance checks?

It should be included in the preventative maintenance program because ____________________________. We

would target ________________________________ failure mode(s) with _________________________________
activities/tasks________________________________ using __________________________ techniques.

If YES - Why didn’t the current preventative measures avoid this current failure?

The equipment is in the PM program and the current PM activities did not prevent this current failure because
_____________________________________________________________________________________________
_____________________________________________________________________________________________
My support/evidence for this conclusion is ___________________________________________________________

If YES - What was the date of the last PM?__________ Type/Code Used ___________
Have the PM’s been conducted on time/schedule in the last year? ‰ Yes? ‰ No?
(Please attach the proof that the scheduled PM’s have been completed on schedule and completed.

Do you still believe a review of the preventative maintenance -content/frequency is warranted?

‰ Yes? ‰ No?
33
Is this equipment currently included in the predictive maintenance program?
‰ Yes? ‰ No?

If YES, should or could the failure have been predicted?

Explain _______________________________________________________________________________

If NO, should condition monitoring be considered?

Explain _______________________________________________________________________________

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 Do we need to change ‘it’?
K) Design out.
What should be done if no suitable preventative task can be found? Is there an inherent
34 systemic or equipment ‘problem’ that can only be resolved by a redesign action?

A design out initiative needs to be considered here because _____________________________________________.

This is supportable, as ________________ is unacceptable in accordance
with________________________________________________standard/regulation/required performance standard.
The consequences (in cost, danger terms) of not making this change are ________________________

What needs to be done, by whom & by when?

L) Status/Conclusion

35 What tangible & supportable actions are recommended?

Category Yes No Next Action To Due Date.

Inconclusive Need to Send Failed Components For
Analysis
Maintenance Costs Are Unacceptable – Consult
Vendor/TSD
Design Change Is Necessary
Review Materials Of Construction Change
Revise Preventative Maintenance Content/Frequency
Revise Predictive Maintenance Content/Frequency
Review/Revise Operating Procedures
Training Is Required
Improve, Prove Different Tools/Test Equipment
Corrosion/Erosion Issue. Refer To TSD Inspection
Other, specify

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Scratchpad - Anything To Add or Record?

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Team Leader/Title/Department

Name:_______________________

Title:_________________________

Department:___________________

Team Members/Discipline/Dept

Name Discipline Department

___________________________ ___________________________ ___________________________

___________________________ ___________________________ ___________________________

___________________________ ___________________________ ___________________________

___________________________ ___________________________ ___________________________

___________________________ ___________________________ ___________________________

Date Report Closed Out: _____/______/______

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