Rockwell Automation
Engineering Analysis Information Request
Tech Support Case #
Jira #
Product OVER 5 YEARS old must have approval of Quality prior to submitting for analysis. If there are more than 2 products involved, please complete page 5 of this document. If a product is sent for analysis it will not be returned without being remanufactured. If warranty is void or not valid, there will be a charge for repair.
PRODUCTS INVOLVED (more space available at end of form)
Rows
Catalog/Part Number (including Series Letters)
Part Description
Serial Number
Date Code
Time in Service
1
2
THE PROBLEM
Problem is
Constant
Intermittent
Temperature Related
Yes
No
When Power is Applied
Yes
No
DESCRIBE PROBLEM, APPLICATION & ENVIRONMENT
Include as much detail as possible so that the receiving Quality Engineer can understand and try to replicate the failure scenario. Please ensure at a minimum to include the following: Type of application. Environmental conditions. What the product was doing. Details on any wiring, mechanical, loading, or any other recent changes. Details on the troubleshooting that was performed. Diagnostic or fault code data from the product.
REPEATABILITY OF THE ISSUE AND THE OPERATING DUTY CYCLE
Rows
System Installation Date
System Commissioning Date
Date of Problem Occurrence
Typical Operations (Hours/Day)
Frequency of Problem Occurrence
1
Customer Product Info
CUSTOMER FACILITY & INSTALLATION MANDATORY INFORMATION (DRIVES, MOTORS, ARMORSTARTS AND DYSCS ONLY)
Distribution Transformer VA Rating
Winding Configuration
Delta-Delta
Wye-Wye
Delta-Wye
Secondary Voltage (v)
Secondary Current (amps)
Grounding (Secondary)
B — Phase Delta
Ungrounded
High Impedance Neutral
Solidly Grounded Neutral
Power Factor Correction Capacitors
Yes
No
KVARS
Additional Line Impedance (In Front of Drive)
Yes
No
Mhy
Input Protection
Fuses
Circuit Breaker
Fuses (amps)
Circuit Breaker (amps)
Motor Ground is Directly Connected to PE Terminal of Drive
Yes
No
Input Contactors Installed in Front of Drive
Yes
No
Output Contactors Installed Between Drive and Motor
Yes
No
Does the Drive use a Dynamic Brake
Yes
No
Ohms
Watts
Communication Type
HIM Only
DeviceNet
Controlnet
ENet
Other
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Return Order Number & Creation Date
IC # / ESOTC # (International only)
Select the return option that applies:
Analysis then economy repair
Analysis with advanced exchange
Analysis with consumable warranty
Analysis with NPSR
Analysis ONLY (scrap after analysis)
Is this an ETO Project? If so, please select BU
SSB/LSC
LVMCC
Project #
Distributor SAP ID
Distributor PO #
End Customer ID and Name
Ship to Address (If required)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Company & Plant
City, State/Province, Country
Industry
CONTACT INFORMATION
Rows
Name
E-mail
Phone or Cell
Company
Rockwell Automation Requestor - (RA Account Manager)
Customer Contact
Other Technical Contact (RA FSE, Area Manager)
Distributor Contact
RA Quality Contact
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STOP Fill out this section ONLY IF you need additional space to list products involved in the case.
PRODUCTS INVOLVED
Rows
Catalog/Part Number (including Series Letters)
Part Description
Serial Number
Date Code
Time in Service
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Page 5 of 5
Form 20-24A Engineering Analysis Information Request Rev. 09/2019
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