Thank you for sharing the link, svanels. According to investigators, it is believed that two bolts securing the rear axle of the lead car became loose during the train's 12th circuit, causing the wheel assembly to detach. Ride operators reported hearing a strange noise coming from the train but did not intervene. This emphasizes the importance of proper maintenance and operator vigilance in preventing accidents. The key question is whether the consultant included operator condition monitoring, such as listening for abnormal noises, in the maintenance strategy. Failure to address this issue could raise negligence concerns.
- 15-07-2024
- Gregory Hughes
Larry, there may be a strategic issue at play here, suggesting a potential flaw in the RCM study itself. Let me elaborate. Bolts do not suddenly loosen on the 12th circuit; it is likely that they gradually became loose over time due to lack of proper inspection. Eventually, the nuts may have come off, possibly on the 12th circuit. This is not an uncommon issue as bolts tend to loosen with wear and tear. Regular boltwork inspections, especially on vehicles, can prevent such incidents. Were bolts checked with the recommended frequency and torque specifications as part of the maintenance routine? If not, it indicates a deficiency in the RCM process. Furthermore, was the work completed on time and to the required standard? If not, it may be necessary to review the management procedures. Prior to making any decisions, it is crucial to gather all relevant information. V.Narayan.
Dear Larry,
I completely agree with your analysis in response to your initial question/post. It seems that the reporter lacked proper information, and if they based their conclusion on information from individuals in the park where the incident occurred, who were likely briefed by their consultant, then the consultant should be held accountable for their negligence and face legal consequences. The industry standard SAE JA1011 for RCM clearly defines what RCM is and what it is not. Cases like this highlight the importance of adopting a standardized approach to RCM. Statements implying that RCM relies on repair histories and failure rates rather than the expertise of experienced workers show a concerning lack of understanding of the methodology, its implementation, and its outcomes. It's disappointing.
Best regards,
Is RCM liable for inadequate maintenance? A recent inspection found a mechanic at fault for not properly securing bolts and safety wires on a wheel assembly that resulted in an accident. The inspection also criticized a manager for declaring the ride safe without conducting a proper inspection, as well as Disneyland's maintenance policies for allowing employees to sign off on work completed by others.
quote: If a consultant advises me to jump into a river infested with crocodiles and I follow their advice, then they are extremely negligent and should face legal consequences to the highest degree. Who should be held accountable in this scenario - the consultant or the person who ultimately follows their reckless instruction?
Were you aware that there are crocodiles lurking within the waters of the river?
I am not able to swim, which is why I decided to hire a professional consultant for guidance. However, it is important to remember that even with expert advice, one must still rely on their own critical thinking skills. Not all consultants are of the same caliber, so it is unfair to shift blame onto them when mistakes are made. It is essential to take responsibility for our actions and decisions.
I agree with Daryl's perspective on this issue. Upon conducting further research and submitting a letter to the editor, it became evident that Disney aimed to streamline their operations by reducing staff and eliminating redundancies. They enlisted a consultant to guide them through this process, utilizing unreliable historical data to make maintenance decisions. This approach neglected the key aspect of involving maintenance staff in the decision-making process. The core objective of Reliability-Centered Maintenance (RCM) is to improve maintenance practices by ensuring the right tasks are performed at the right time for the right reasons. Developed by United Airlines and the FAA in the 1960s, RCM has since become a standard practice in the military. As a certified NAVSEA RCM Level 2 Analyst, I understand the seven essential steps involved in evaluating maintenance procedures. It is crucial to identify potential failures, assess risks, and prioritize safety above all else. Unfortunately, the lack of a civilian certification program for RCM analysts has led to ineffective implementation of RCM principles in various industries. The occurrence of maintenance-related failures at Disney highlights the importance of proper RCM application. In conclusion, a thorough evaluation and proactive maintenance plan are essential to prevent such incidents. Howard W Penrose, Ph.D., CMRP, President of SUCCESS by DESIGN Reliability Services, emphasizes the significance of following RCM guidelines to avoid maintenance failures.
- 15-07-2024
- Victor Thompson
Is RCM a fail-proof system?
I wanted to share a quote from the front page of the RCM standard guide SAE JA1012. It mentions how some processes claiming to be RCM are not truly based on the principles defined by Nowlan and Heap. While some variations may partially achieve RCM goals, others can be counterproductive or even dangerous. This underscores the importance of having a standard, especially for organizations considering implementing an RCM-based maintenance process. In my opinion, RCM is not infallible, as very few systems are.
- 15-07-2024
- Vanessa Carter
A case study similar to those featured in the new book on Reliability Centered Maintenance by Neil Bloom was recently reported. Neil will be sharing insights from this case study at RCM-2006, scheduled for March 8-10 in Las Vegas. Having recently acquired the book, I have found Neil's approach to RCM intriguing and look forward to delving deeper into it. Stay tuned for a detailed review of the book next week. If you have already read it, your feedback would be greatly appreciated. Terry O.
In a recent investigation, it was found that the train accident was caused by two main factors: improper maintenance and operator inaction. The investigation revealed that two bolts securing the rear axle of the lead car came loose during the 12th circuit, causing the wheel assembly to detach. Despite strange noises coming from the train, ride operators failed to address the issue. The question arises as to whether the consultant included operator condition monitoring as part of the preventive maintenance strategy. If not, negligence may be a factor. It is crucial to have experts familiar with the equipment involved in risk management assessments, supported by knowledge of maintenance technologies. Effective risk management relies on a thorough understanding of operational and maintenance history.
JimC, you are absolutely right! The issue that needed to be addressed was the loosening of bolts on a vehicle exposed to high levels of vibration and significant potential consequences. One possible solution could have been implementing a regular inspection program to detect loose bolts and tighten them, or making a design change to prevent the nuts from becoming loose.
I have a slight concern regarding the suggestion that operators should monitor for abnormal noise. Relying on operators with varying skill levels to identify loose bolts can lead to human errors and inconsistencies in detecting when bolts are becoming loose. The time frame between potential failure (P-F interval) for bolt-loosening can also vary greatly. It is generally more reliable for a skilled mechanic to address this issue based on a maintenance work order rather than solely relying on operators to notice the problem.
In my opinion, depending solely on operator vigilance is a risky strategy that may result in failure when safety is at stake. If this was the main recommendation from the RCM study, then the consultant may have overlooked a crucial aspect. V.Narayan.
It is evident that there are valuable responses to the issue at hand. One lingering question remains - when did the reported changes take place in relation to the RCM analysis? The lack of complete insight hinders our understanding of the situation. While blame may lie with various parties, if changes were implemented without a reevaluation post-analysis, the risk of preventable failures looms large. There may be deeper-rooted issues that all consultants should consider, including forthcoming changes impacting maintenance programs, the presence (or absence) of a sustainment process, and the company's priority between safety and cost. Before passing judgement, it is crucial to have all facts in hand, as the situation could affect anyone. Notably, a consultant's projection of cost-savings at Disneyland led to staffing and maintenance procedure cuts, potentially compromising safety measures. This resulted in the departure of experienced employees, raising concerns over operational safety.
It seems to me that the accident and RCM are not directly connected. The main cause of the accident can be attributed to two flawed practices: 1. The person performing maintenance procedures is not required to sign off on their own work. Instead, someone else is allowed to sign it, leading to a lack of direct responsibility for confirming that the work is completed. (The worker doesn't sign off, and the signer can claim they didn't have time to thoroughly check the work - absolving both of responsibility.) 2. Operators who observed unusual behavior were not trained on a general maintenance policy that would prompt them to take action (such as halting work) when they notice any abnormality in potentially hazardous equipment. These issues stem from inadequate maintenance organization, rather than RCM. It is not reasonable to expect an RCM consultant to address such basic matters. As svanels mentioned, RCM should only be considered after mastering simpler systems. This responsibility falls on the company's maintenance management, who should understand that RCM is only effective after initial steps are completed. If they realize that basic procedures need improvement, they should seek a consultant for a comprehensive maintenance overhaul, not just for RCM. If they are unaware of the dysfunction in their basic maintenance procedures, they are facing serious trouble.
Regardless of whether the Resource Consuming Monster (RCM) was involved, it is essential that the mechanic, their supervisor, and the higher-ups should be held accountable for their actions. RCM is not a new concept and has been a standard practice in maintenance for many years. When individuals like Mike Isanore demand exorbitant salaries, it is crucial that profits are shared with the hardworking employees who make the business successful. It is important to recognize the efforts of the people on the front lines who are crucial to the company's success.
In a previous comment, Howard mentioned a situation where a consultant was brought in to conduct an "RCM study" without involving the client's maintenance staff. This oversight is a serious issue, as the active participation of maintenance personnel is crucial for a successful RCM study. Both the client and the consultant share responsibility in this regard.
It is concerning that the consultant did not verify the accuracy of the historical data by consulting with operators and maintainers. Instead of simply searching for someone to blame, it is important to address the underlying faults that may have contributed to the situation. While it is important for justice to be served and negligence punished, focusing solely on assigning blame does not solve the real problem. It is essential to learn from these mistakes and work towards preventing similar tragedies in the future.
What steps can be taken to prevent major issues from occurring in the first place? Discover key measures to avoid serious faults and ensure smooth operations.
Who is Mike Isanore? I couldn't find any information about him on Google. The reorganization of maintenance, referred to as RCM, has stirred some controversy as no maintenance staff were consulted. Employees are hesitant to halt operations for fear of financial repercussions, indicating a troubling prioritization of money over safety. This situation seems to be driven by bean counters rather than a genuine concern for the well-being of employees and customers.
It is crucial to consider that a miscommunication led to a misunderstanding of the RCM process, resulting in a tragic outcome. Whether the consultant lacked knowledge or if management set unrealistic goals, the fact remains that there was a lack of understanding across the board. To prevent such scenarios in the future, industry standards and a scorecard should be established to ensure the proper use of processes. Military and SAE standards offer valuable guidance, but a more comprehensive approach is needed. Rather than assigning blame, we should focus on conducting a thorough analysis before drawing conclusions about root causes. This incident serves as a lesson in the importance of proper understanding and implementation of processes in order to avoid similar tragedies. Thank you, Howard.
Howard, I completely concur with your perspective on this matter. It's crucial that we avoid rushing blindly ahead without fully understanding the complete picture of what happened. Doing so will only lead to speculation and unverified assumptions.
quote: As MotorDoc originally stated, having a standard in place is crucial to ensure that our industry is not hindered by situations like this. It is important to prioritize the benefits that come with using our processes. Let's avoid focusing on exceptions and instead strive for consistency. - Howard
Let's ensure that our industry is not obstructed by such scenarios by having a standard in place. Let's focus on the benefits of using our processes rather than managing for exceptions. - Jim C.
The importance of implementing Best Business Practices (BBP) and prioritizing customer satisfaction while upholding ethical standards cannot be overstated. Each decision made by the RCM Team must be well-documented to ensure accountability and transparency, in line with the key principles of RCM outlined in JA-1011.
While the idea of creating a standard may seem beneficial in theory, the practicality and feasibility of such an endeavor must be carefully considered. The process of developing a standard would require significant time and resources, as well as consensus on the best approach - a debate that would undoubtedly arise between different stakeholders.
Furthermore, questions about enforcement, ownership, licensing, and costs associated with maintaining the standard would need to be addressed. The challenge lies in balancing the need for standardization with the desire for flexibility and innovation within RCM practices.
In my current role within the NAVAIR 00-25-403 standards, I have observed a reluctance among professionals to fully embrace standardized practices. Many are focused on creating unique systems and processes, potentially losing sight of the original purpose of RCM in the pursuit of efficiency and cost-cutting measures.
It is crucial to reflect on whether adherence to a new standard is necessary to enhance the effectiveness and reliability of RCM practices. The path to improvement may require a shift in mindset and a willingness to adapt to new frameworks for the benefit of all stakeholders involved. Are you prepared to embrace a new standard in your RCM practices?
Michael Eisner, the former CEO of Disney, once acknowledged the importance of Reliability Centered Maintenance (RCM) by stating that he has been applying its principles in managing his household, just like his father did. Many successful businesses have also adopted RCM as a standard practice. However, some may misunderstand RCM as disregarding traditional maintenance practices. The mismanagement of RCM at Disney serves as a prime example of the consequences of inadequate education on the subject. RCM is a straightforward concept that focuses on preventive maintenance to avoid downtime. It is vital to address maintenance tasks before equipment failure occurs, without compromising operational efficiency. This principle can be likened to changing a timing belt in a car before it reaches its recommended mileage to prevent breakdowns. The key is to understand that RCM is not a new or complex idea; rather, it is a practical approach to ensuring equipment reliability and efficiency.
Robbie and DunRobin discussed the use of MIL-P with the Coast Guard and NAVSEA. DunRobin pointed out that many organizations often perform excessive and incorrect maintenance, especially when using traditional methods. For example, some companies rely on insulation to ground testing to assess their motor insulation system, but is this truly effective? Is it a reliable predictive maintenance tool? This raises the question of whether companies should approach RCM as a practical tool rather than a strict doctrine. Howard also chimed in on the conversation.
The reason why RCM implementation is costly is due to verbose explanations like the one provided. Just because a standard is new does not necessarily mean it is groundbreaking. Many new standards have existed before, but were overlooked by those in power. The individuals on the front lines often already understand what needs to be done. When politics and power struggles are eliminated, RCM becomes straightforward and effective. However, there is a need for better organization of paperwork. In my view, this is simply a means to create unnecessary positions. When it comes to changing a timing belt in your car, there is only one scenario - do it at the recommended time to save headaches, money, and service. Simplify the process.
Dear gentlemen, let's keep things simple. A mechanic didn't just "safety wire a bolt". In investigations, this is the main cause. This could have occurred regardless of whether RCM was done. An RCM analysis doesn't recommend firing all experienced mechanics and keeping incompetent ones. It could be argued that staff reductions led to others being overworked, becoming a management and cultural issue rather than a fault of RCM. From my experience with aircraft, I advise those doing RCM to beware of being blamed for things going wrong, even if unrelated. Terms like "cost cutting" and "contracted out" raise suspicions in the public, especially the media. Would you trust a carnival ride maintained by an average carnie or one with an RCM-developed maintenance program by knowledgeable consultants? Personally, I'd choose the consultants. Not all consultants are the same though. Cheers, JC.
Dear readers, I cannot help but agree completely with JC L. In the 'from the editor' section of my newsletter, I would like to share my recent experiences related to aircraft. As we approach the holiday season, for some of us, it is a time to relax and prepare for the New Year. Therefore, I would like to extend my warm wishes for Merry Christmas, Happy Holidays, and a Happy New Year to all. Personally, I will be grounded for a while as I fly an average of once per week for work. Recently, I have noticed significant changes in the reliability and maintenance issues of the aircraft I have been flying in. Over the course of four weeks, I encountered various maintenance problems on different aircraft, ranging from Auxiliary Power Units (APU's) to cracked windshields and computer resets.
During my travels to different destinations, such as Melbourne, Australia and the IMC-2005 conference, I experienced delays due to these maintenance issues. These incidents have led me to delve deeper into the topic of reliability and maintenance and how it communicates with management, as explored in my ongoing 'Maintenance is from Mercury, Management is from Pluto' series. This series delves into different philosophies, workforce changes, motivation, and the application of training and experience.
As we approach the New Year, with its uncertainties and opportunities, I urge you, dear readers, to make a difference in 2006. I will continue to provide you with tools and knowledge, but I also encourage you to share your knowledge and experiences with me for future newsletters, blogs, and articles. Together, we can work towards solutions to the challenges in reliability and maintenance. Remember, nothing is impossible.
Sincerely,
The Editor
While the article lacks clarity, the consultant and their interpretation of "RCM" may be the culprits. This is why John, an familiar acquaintance, strived to establish the SAE standard for defining RCM. Were a team of experts used to pinpoint functions, functional-failures, and failure modes? Was the specific failure mode that led to the accident identified in the RCM analysis? Was a formal decision diagram utilized to devise mitigating tasks? What tasks were recognized in relation to this failure? The notion that Disney chose to implement RCM to reduce maintenance costs is intriguing. For individuals in leadership roles, the decision to initiate RCM should prioritize enhancing reliability and EHS performance. The issue that arises with our profession as RCM Consultants/Providers is the tendency to showcase success stories of clients who transitioned to an RCM culture and made substantial savings on maintenance. This is particularly prevalent in manufacturing companies accustomed to a reactive firefighting approach. By replacing reactive work with proactive PM/PdM tasks, significant savings from secondary damages and prolonged downtime can be achieved. However, Disney does not operate under the same reactive culture; their involvement in RCM should focus on safety and reliability, with cost considerations only for failures impacting operations. If the assertion that "RCM was to blame" holds true, it indicates that they received subpar service from an inexperienced consultant who promoted RCM solely as a cost-cutting measure.
Doug, I appreciate you redirecting the conversation to its main point. I attempted to convey a similar message recently but may not have articulated it clearly. Thank you, V.Narayan.
Who is at fault for the failure in RCM? The answer is clear: it was not RCM, but rather the management. The organization of a business falls under the responsibility of management, including procedures, budgets, safety enforcement, work practices, and employee training. It is essential to encourage prompt action in unsafe situations, similar to the urgency displayed by a passenger on a plane with an engine on fire. Failure to do so will only lead to unjustly blaming RCM.