2: Equipment/Software Issue
Definition/Typical Issues
Was there a difference between the actual and desired performance of the equipment, software, or material/product? Did the equipment, software, or material/product fail to perform as desired?
Was there a variation or change in raw materials that led to the incident? Was there a difference between the anticipated raw materials and those actually used in the process?
This node includes problems with equipment/software design, fabrication, installation, and maintenance. Problems with the equipment/software reliability program are also coded under this node. In addition, issues with materials and products are coded under this node.
If the causal factor was an equipment performance gap, then coding under this node is appropriate.
Note 1: Equipment/software failures can also be thought of as performance gaps. The gap is the difference between the desired performance (the equipment/software operates) and the actual performance (the equipment/software failed). Thus, the definition is not failure to perform as designed, but failure to perform as desired. This means that items can perform as designed and still fail, because they fail to perform the desired task. This is shown in Example 4 where an air handling system performs as designed, but not as desired.
Examples
Example 1
- A spill to the environment occurred because a valve failed. The valve failed because it was not designed for the environment in which it operated.
Example 2
- The software control system failed to properly control a machining operation. This resulted in production of out-of-specification parts. The software did not consider an unusual sequence of steps that occurred when machining some parts.
Example 3
- An air handling system failed to provide adequate cooling to a computer room. When the computer system failed, all of the automatic controls became inoperable. The air handling unit was designed with an inadequate capacity for the heat load in the room.
Example 4
- An air handling system failed to provide adequate cooling to a computer room. When the computer system failed, all of the automatic controls became inoperable. The system was undersized due to recent upgrades to the computer systems that rejected more heat to the room. The impact of the increased heat loads on the air handling system was not considered during the computer system modifications.
Example 5
- The formulation for a lubricant used by the facility was changed by the manufacturer. This led to a number of bearing failures. The facility was unaware of the change and, therefore, did not consider the effect of this change on the process equipment.
Example 6
- A supplier changed the part number for a specialty wrench. Although the wrench was still available, it appeared that the wrench was no longer stocked. As a result, there were delays in repair of a pump.
Typical Recommendations
- Ensure that equipment is fit for its current use.
- Perform hazard assessments of equipment during its design and after the design is complete.
- Develop procedures for operation of equipment.
- Make the original equipment manufacturer's manuals readily available.
- Design equipment with the end use in mind.
- Lay out equipment in the order in which it is used.
- Provide appropriate specifications for raw materials.
- Verify that stock is current prior to its use.
- Establish a process to ensure a first-in/first-out (i.e., the first material placed in storage is the first material used [pulled out of storage]) usage pattern.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 2 | Equipment Difficulty |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 1 | Structural |
| 2 | Machinery/Equipment |
| 3 | Outfitting |