Citation

Cherolis NE, Benac DJ, Shaffer DM, Redman J. J. Fail. Anal. Prev. 2018; 18(5): 1143-1153.

Copyright

(Copyright © 2018, ASM International, Publisher Holtzbrinck Springer Nature Publishing Group)

DOI

10.1007/s11668-018-0504-7

PMID

unavailable

Abstract

Catastrophic or major incidents are typically investigated immediately, but what about the near misses or minor failures that might be precursors to major incidents? Are they investigated? Major failures often do not occur as one isolated issue or event; there are often less severe precursors to a major event. This paper presents a best practice and reasons for reviewing minor equipment failures in order to avoid major events as demonstrated through the judicious analysis of minor failures. Several case histories and the lessons learned from these minor equipment failure investigations are presented to encourage investigation of what may initially appear as insignificant failures, for their value in prevention of major incidents.

Language: en

Keywords

Lessons learned; Major incidents; Minor failures