Transportation Technology Center, Inc., a subsidiary of the Association of American Railroads Larry Strouse Railroad Safety Specialist (HM) Federal Railroad Administration Root Cause Analysis 3:00 to 3:30 p.m. 27th Annual 2015 Quality Auditors and Industry Conference TTCI/AAR, 1/10/2012. filename, p1
F E D E R A L R A I L R O A D A D M I N I S T R A T I O N Moving America Forward
F E D E R A L R A I L R O A D A D M I N I S T R A T I O N The Art (and Science) of Root Cause Analysis Moving America Forward
Overview Definitions Regulatory Requirements Root Cause Origins Root Cause Mistakes Made Root Cause What FRA Is Looking For Tools CSB Investigation Case Study Moving America Forward 4
Regulatory Requirements 49 CFR 179.7(a) Each tank car facility shall have an AAR approved quality assurance program (QAP) that (1) Ensures the finished product (tank car) conforms to the applicable specifications and regulations; (2) Has the means to detect any nonconformance in the manufacturing, repair, inspection, testing, and qualification / maintenance program of the product; (3) Prevents nonconformances from recurring. Moving America Forward 5
Regulatory Requirements 49 CFR 179.7(b) At a minimum, the quality assurance program must have the following elements... (b)(7) Procedures for correction of nonconformances. 49 CFR 180.509 The qualification and maintenance program must maintain the design level of reliability and safety. Moving America Forward 6
Regulatory Requirements Federal tank car quality assurance regulations apply to: Design Manufacture Fabrication Inspection Testing Repair Maintenance Marking Representation Management Engineering Procurement Construction Inspection Quality Control Qualification Maintenance Ownership Moving America Forward 7
Regulatory Requirements Federal tank car quality assurance regulations apply to: Incoming / Receiving Inspection (Verification) In-Process Inspection (Verification) Final Inspection (Verification) Post-Release / In-Service Activity We must identify True Root Causes to develop and implement Effective Corrective Actions!!! Moving America Forward 8
Definitions Root Cause "The most basic cause (or causes) that can reasonably be identified that management has control to fix and, when fixed, will prevent (or significantly reduce the likelihood of) the problem s recurrence. Paradies M-1003 Chapter 7.2.6.10 - The root cause is the cause that, if eliminated, will result in the non-conformance never recurring. There may be multiple Root Causes for one problem!!! Moving America Forward 9
Definitions Root Cause (Analysis) Chapter 7 - Nonconformance Elimination Process Step 3: Clear Nonconformance Description(s) Nonconformance Disposition(s) Root Cause Analysis Corrective Action(s) Taken to Eliminate Root Cause(s) and Identify Responsible Personnel Follow-Up Plan(s) to Ensure Corrective Action(s) Are Effective and Permanent. Moving America Forward 10
Root Cause Origins Most Problems Can Be Tracked Back To: Process / Procedure Deficiencies Process / Procedure Deviations Human Factors Moving America Forward 11
Root Cause Mistakes Made Unclear Nonconformance Description(s) Poor: Bottom outlet valve leaks Better: Bottom outlet valve to tank saddle connection leaks about 1 pint per minute. Spur of the Moment Nonconformance Disposition(s) Poor: Tightened valve mounting bolts. Better #1: Offloaded car, removed valve, checked for gasket, reapplied valve, sent car out. Better #2: Offloaded car, notified car & valve owner, filed OTMA-1, sent car to shop for analysis. Moving America Forward 12
Root Cause Mistakes Made Limited Root Cause Analysis Poor: Valve technician didn t reference valve drawing to rebuild valve so we fired him. Better #1: Different valve drawings in existence; revised procedure to reference correct drawing. Better #2: Leak test procedure doesn t apply to this valve arrangement; revised procedure. Better #3: Inexperienced manager approved procedures; experienced manager now approves. Better #4: Top management reviews manager job descriptions for qualifications and QAP responsibilities. Moving America Forward 13
Root Cause Mistakes Made Limited Corrective Action(s) Effectiveness Poor: Supervisor trained valve technician so no more problem. Better #1: SME trains and tests valve technician, management conducts regular process audits. Better #2: Valve Process Improvement Teams reporting to VP - Operations. Better #3: Sales involves customers to monitor nonconformance (7.1s / OTMAs / 5800s). Better #4: Engineering works with customers to improve their Qualification & Maintenance Program. Moving America Forward 14
Root Cause Mistakes Made Limited Corrective Action(s) - Schedule and Personnel Poor: Valve technician will be trained so no more problems. Better #1: Supervisor will train technician so no more problems. Better #2: SME will train valve technicians by (date). Better #3: SME will train and test valve technicians by (date) and audit performance quarterly or more frequently if problems continue. Moving America Forward 15
Root Cause Mistakes Made Short-Term Follow-Up Plans Poor: Supervisor performed process audit, no findings. No repeat audits. Better #1: QA manager develops audit schedule, SMEs perform process audits. Better #2: Regular management process audit reviews. Better #3: Top management monitors nonconformance (rework, complaints, 7.1s / OTMAs / 5800s). Better #4: Management compensation plans include nonconformance & continuous improvement metrics. Moving America Forward 16
Root Cause - What FRA is Looking For Deeper Dives Peel the Onion!!! First, look at the process, not the people! Not we fired the employee so it won t happen again Not the employee wasn t trained so we trained the employee Not if the employee doesn t remember how to do the job he can ask the supervisor for the procedure Moving America Forward 17
Tools 5 Whys May require more than 5 Multiple iterations for combined failure modes TapRoot Reactive - multiple interviews and linked events Discovers missing and broken barriers Failure Mode and Effects Analysis (FMEA) Multiple interviews and expertise Pre-release design & process activity plus revisions Moving America Forward 18
Tools Reliability Analysis Weibull Competing failure modes and mechanisms Ishikawa Diagram Cause and Effect Diagram (Fishbone) Requires knowing the ribs Fault-Tree Analysis Combines Fishbone and FMEA Pre-release activity with revision Moving America Forward 19
CSB Investigation Heat Exchanger Moving America Forward 20
Case Study Leaking Bottom Outlet Valve Moving America Forward 21
Case Study Considerations Valve Design Gaskets Fasteners Moving America Forward 22
Case Study Considerations Procedures Process Personnel Moving America Forward 23
Who Is This? Moving America Forward 24
Who Is Ms. Barra? Moving America Forward 25
Summary Federal regulations require that the finished product conforms to customer requirements, AAR specifications, and Federal regulations. Federal regulations require that the QAP detect any nonconformance in manufacturing, qualification, and maintenance of tank cars. Federal regulations require deep dive procedures for corrective actions that prevent recurrence. Moving America Forward 26
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