Intelligence: Disturbance Problems & Identifying Root Causes

8/14/2019 Intelligence: Disturbance Problems & Identifying Root Causes

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:DisturbanceProblems &Identifying Root

3/11/2008 1

The Curious Incidentof the Dog in the Night

Kepner & Tregoe Methodology7-Step Process for Problem Analysis


1. Recognize a gap exists


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Kepner & Tregoe Methodology

7-Step Process for Problem Analysis

2. Determine seriousness /urgency of gap



3. Gather relevant details of gap

Who w as involved?

What deviation occurred?

When did the deviation occur?

Where did the deviation occur?

How much, how many, to whatextent did the deviation occur


4. Differentiate what is happeningfrom what is not happening


5. Identify potential causes &contributing factors


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6. Explain how each potential causecould result in observed gap



7. Test to confirm if it is the true & onlycause

4 Dimensions:Specifying Questions

PerformanceDeviation:

Closest Logical

Comparison:

COULDBEbutIS

WhatsDistinctive

Does theDistinctionSuggest a

Kepner & Tregoe Worksheet7-Step Process for Problem Analysis

NOT

ou eChange

IDENTITY What is the unit with the malfunction? What is the malfunction?LOCATION Where is the malfunction observed? Where on the unit is the malfunction observed?TIMING When was the malfunction first observed? When has the malfunction been observed since? When in the operation cycle was it first

observed?

MAGNITUDE What is the extent of the malfunction? How many units are affected? How much of any one unit is affected?WHO

Who was involved?

Tips

. .

2. Use wording that avoids double

meaning.

3. Put equal emphasis in developingen r es or e s no t co umn as orthe I scolumn.

4. Avoid working on columns 3 & 4before completing columns 1 & 2.


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The LeakingSoybean

Filter

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The Leaking Soybean Filter4 Dimensions: Specifying

Questions

Performance

Deviation IS

Closest Logical

Comparison: COULD

BE but IS NOT

What's Distinctive

About the IS

Does the Distinction suggest a change?

Square-cornered gasket is a new type, used

1st time 3 days ago at monthly

maintenance check

What is the malfunction? Leak ing oi l (no logi cal comparis on)

What is the unit with the

malfunction?

No. 1 filter No.s 2 thru 5 No. 1 has a square-

cornered gasket, the

other 4 have rounded

LOCATION

TIMING

Nothing. Location & level of vibration have

been the same for years

Where on the unit is the

malfunction obs erved?

Observed at the

cleanout hatch

Observed at valves,

pipes, locking

mechanisms

The cleanout hatch is

opened & refastened

daily at every shift

Nothing. Filt er has been cleaned, hatch

refastened on every shift for years

Where is the m alfunction

observed?

Observed at northeast

corner of filter house

Observed at other filter

locations

This location is

nearest to feedwater

pump, exposing No.

New type, square-cornered gasket installed

for 1st time 3 days ago as noted above

When has the malfunction been

observed since?

Observed continually,

all shifts

Observed when unit not

in use

Oil flows through the

unit under pressure

Nothing

When was the m alfunction first

observed?

Observed 3 days ago Observed before 3

days ago

There was a monthly

maintenance check

just prior to start of

MAGNITUDE

only when filter is in

Nothing

What is the extent of the

malfunction?

5 to 10 gallons of oil

leaked per shift

Less than 5 gallons,

more than 10 gallons

per shift

When in the operation cycle was it

first observed?

Observed as soon as

oil goes into the filter

at start of shift

First observed at a

time later on in shift

1st time oil comes

into filter under

pressure

N/A

How much of any one unit is

affected?

N/A N/A N/A N/A

How many units are affected? No. 1 filter only Filters 2 5 No information not

already noted above


3/11/2008 16The Burred Panels


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Deviation Statement: No. 1 Oil Filter Leaking Oil4 Dimensions:

Specifying Questions Performance Deviation:IS Closest Logical Comparison:COULD BE but IS NOT Whats DistinctiveAbout the IS Does the DistinctionSuggest a ChangeIDENTITYWhat is the unit with themalfunction?

No. 1 filter No.s 2 thru 5 No. 1 has a square-cornered

gasket, the other 4 haverounded gaskets

Square-cornered gasket is a

new type, used 1st time 3days ago at monthlymaintenance check

What is the malfunction? Leaking oil (no logical comparison)

LOCATIONWhere is the malfunctionobserved?

Observed at northeast cornerof filter house

Observed at other filterlocations

This location is nearest tofeedwater pump, exposingNo. 1filter to higher level of

vibration than other 4

Nothing. Location & level ofvibration have been the samefor years

Where on the unit is themalfunction observed?

Observed at the cleanouthatch

Observed at valves, pipes,locking mechanisms

The cleanout hatch is opened& refastened daily at everyshift

Nothing. Filter has beencleaned, hatch refastened onevery shift for years

TIMINGWhen was the malfunction firstobserved?

Observed 3 days ago Observed before 3 days ago There was a monthlymaintenance check just priorto start of shift 3 days ago

New type, square-corneredgasket installed for 1

sttime 3

days ago as noted above

When has the malfunction beenobserved since?

Observed continually, allshifts

Observed when unit not inuse

Oil flows through the unitunder pressure only whenfilter is in use

Nothing

When in the operation cycle wasit first observed?

Observed as soon as oil goesinto the filter at start of shift

First observed at a time lateron in shift

1st

time oil comes into filterunder pressure

Nothing

MAGNITUDEWhat is the extent of themalfunction?

5 to 10 gallons of oil leakedper shift

Less than 5 gallons, morethan 10 gallons per shift

How many units are affected? No. 1 filter only Filters 2 5 No information not alreadynoted above

N/A

How much of any one unit isaffected?

N/A N/A N/A N/A

Intelligence: Disturbance Problems & Identifying Root Causes

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