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'Sources of Failure' at VISY Pulp and Paper (Human Failure (Poor…
'Sources of Failure' at VISY Pulp and Paper
Hardware Failure
Maintenance
One of the most important tasks
Monthly Mill shutdown for Maintenance
Only given 24 hours (one day a month) to complete all required Maintenance
Maintenance tasks build up over the month
May not have time to complete all Maintenance within 24 hours
Tasks not completed carry over to next month shutdown
Usually less important tasks
These can build up and cause serious issues especially if a multitude of new tasks build up in the new month
Entire Mill must be shutdown
Complete cease of production
Profit loss
Unacceptable to fail to fix serious issues within timeline
Heavy burden on workers
Hundreds of contractors bought in all at the same time
Dozens of tasks happening all at the same time = chaos
Employees work may impact another worker causing delays, complete halt of other work or even injuries
Fixing over replacing
Replacing with salvaged/repaired parts rather tan new
Testing
Very limited time to carry out tests to determine Maintenance effectiveness
Often if test results were inconclusive or there was some type of inaccuracy, there is no time to repeat test
Decision often made to monitor this over the next month after Mill start up
Often the cause of Breakdown causing an impromptu Mill shutdown to fix, which is not desirable
Profit loss when Mill not running
Standards
Due to nature of work, these are set very high
Placed large burden on workers
Caused a lot of delays
Several hours to change one roller due to shear weight and danger of removing
Several mechanics and foreman standing around doing nothing for long periods of time while Crane lifts roller - Policy that all staff required for this task
Due to number of employees very strict policies
Software Failure
Administration
Poor communication
Between divisions
In same division
Several divisions
Messy hard to tell who is the boss of who
Hard to figure out who to report to
Workers pass blame around if something goes wrong
Policies
Huge number of employees so Policies enforced were overkill
School of thought being it is easier to just remove any chance of errors completely even if this is extremely inconvenient or inefficient
Lockout: If major task undertaken all qualified technicians apply padlock to safety device, cannot switch back on until all padlocks are taken off
Some technician called away for emergency, cannot restart until he gets back, can not override
Policies also somewhat streamlined due to shear scope of work
Employees work around Policies while still adhering to guidelines
Completion of Risk Assessment according to Policy but actually very ineffective
Leads to accidents causing Injury/Death
Human Failure
Human error
Deviation from operational procedures
Slips/Mistakes
Fatigue
Poor morale
Bullying
Lack of trust of other employees
Lack of respect of bosses
Leads to ineffective workforce
Stress
Long hours of hard work
Negligence
Organisational Failure
Too many divisions
Different organisational structures within divisions
Hard to determine who was in the wrong
Employees
Managers without sufficient training
Impossible to be adequately prepared due to scope of work
Lack of confidence in leaders
Loss of respect of authority
Workers think they know more than their boss
Policies and regulations not adhered to
Accidents/Injuries
Technicians without sufficient training
Hard to be adequately trained due to scope of work
Employees unsure of own authority
Employees unsure of exact role
Culture
Excessive complaints seen as a weakness
Defects or issues not reported, especially if these have been brought up several times
Defects not fixed in time
Causes accidents
Major mechanical failure
Millions of dollars of damage
Extended delays
Injury/Death
Employees alienated
Hard job, inability to perform seen as weakness
Overworked employees
Injuries and Accidents
Poor workforce morale
Maintenance policy ineffective due to desire to minimize profit loss
Covering up mistakes
Lack of trust between emploees
Kill the messenger
Important information not reported