Identifying Procedural Non-Compliance and Latent Causes of Repeated Machinery Failures

This presentation is about the experience of discovering procedural non-compliance as a root-cause of several critical equipment failures. These are often failures that many others had previously investigated but had not identified root-causes of the failures. By recognizing that there are 3 areas to consider when analyzing failure—physical, human, and latent—the mindset of the investigator broadens to consider more than the broken component. To illustrate the concepts, a basic summary of three major equipment failures will be used to show how the physical, human, and latent causes of failure can lead to procedural non-compliance. In basic terms, people do not always follow the outlined procedures, but they do not seem to realize it. Additionally, certain “red flags” will be presented in plain terms that can alert the investigator to the possible existence of procedural non-compliance as a root-cause. By recognizing the existence of these types of failure causes, the investigator can more easily determine root-causes of failure.