The information collected in the Storm Packer (SP) failure (Information) will establish:
- The timeline of events – which activity(s) preceded each significant event?
- 3rd party impacts (process, products).
- Product readiness at the time of installation.
- Product suitability for the application.
- Crew competency.
Simple failures often do not require a formal Root Cause Analysis (RCA). But in the case of the SP failure, there are many factors to consider, so an RCA must be used to narrow the list of probable causes or pinpoint the true root cause. Regardless of the RCA method used, these recommendations will help ensure a successful RCA:
- Use a trained facilitator to lead the RCA.
- Use a recognized RCA method such as a Fishbone Diagram or the 5 Whys.
- Use an RCA team size of between 4 and 8 SMEs to maintain focus and progress.
- SME team expertise must include product, process, application, and environment.
- For complicated failures, multiple RCAs may be needed.
Some final thoughts.
- Do not substitute brain-storming sessions for a rigorous RCA. These sessions are useful early in the FA process for idea generation, but not for identifying root cause(s).
- RCA team members must approach the RCA with an open and objective mind.
- The RCA may take nontraditional paths of inquiry, but it will yield the true root cause(s).
- RCA participants must think in terms of what immediately precedes each event. Jumping to a conclusion on any path of inquiry will miss significant events on the path.
- Correlated events do not automatically mean that one caused the other.
An FA interrupts the organization and is an opportunity cost that adds to the already high cost of the failure (Failure Analysis or Failure to Analyze?). But a rigorous RCA will minimize FA cost.
TRUTH: A recognized RCA method led by a trained facilitator will identify the true root cause(s).
This is the 4th of six articles in the Failure Analysis series for downhole tools.