Friends,

Recently, while reviewing an on-line submission for a course, I saw the following simple RCA example.

A winch chain used for handling a (light weight) device in an offshore environment has snapped. At that time the workmen were at the winch for another activity. The broken chain began to reel out of the winch drum rapidly, flaying out and breaking the metal guard. The chain came out, narrowly missing a hydraulic hose. A hose rupture would have caused serious consequences.

The analysts found that the chain had not been lubricated for years; there was no maintenance routine in the CMMS! That routine had been REMOVED 4 years earlier to save maintenance costs!

I was reminded of the story of the lost shoenail for a horse - A horse, a horse, a kingdom for a horse!

For four years the bookkeepers were celebrating achievements in cost reductions.

Vee and all,

Because of a missing nail a kingdom was lost. Here is the story

The story is told that before an important battle a king sent his horse with a groomsman to the blacksmith for shoeing. But the blacksmith had used all the nails shoeing the knight's horses for battle and was one short. The groomsman tells the blacksmith to do as good a job as he can. But the blacksmith warns him that the missing nail may allow the shoe to come off. The king rides into battle not knowing of the missing horseshoe nail. In the midst of the battle he rides toward the enemy. As he approaches them the horseshoe comes off the horse's hoof causing it to stumble and the king falls to the ground. The enemy is quickly onto him and kills him. The king's troops see the death, give up the fight and retreat. The enemy surges onto the city and captures the kingdom. The kingdom is lost because of a missing horseshoe nail.

Moral of the story :

Ignoring little things can cause disasters.


My Warm Regards

Even when the PM was removed from CMMS, the user of the winch chain should do the pre-operational check as a safety measure first.

Thanks ,Rolly 12 , for rest of the story !
It is good to learn . .

This message has been edited. Last edited by: Panta,

Hi
Good RCA story.

Yes, a litte thing can make big impact if you
ignore.

Thanks,
Mugu