Root Cause Analysis Enhancement Jan 21, 2006 Presented by: Mohammed A. Al-Dossary Construction Engineering & Management Quality Management CEM 515 Term.

Root Cause Analysis

Enhancement

Jan 21, 2006

Presented by: Mohammed A. Al-Dossary

Construction Engineering & Management

Quality Management

CEM 515

Term Paper

Abqaiq Plants Today film

Outline

• Part I: Abqaiq Plants Overview

Plants Background

Plants Processes

Plants in Saudi Aramco Organizational Chart

• Part II: Root Cause Analysis Program

Initial investigation

Review Methodologies

• Summary

• Lessons Learned

Upset Definition

An unplanned shutdown of critical equipment during normal operation which may lead to production losses.

Problem Statement

Top Management Statement:

We would like a team to work on identifying the root causes of the nuisance and repetitive upsets!

We don’t want m

ore

upsets please!

Forming Investigation Committee

• Management appointed a leader from Maintenance

• Leader selected members from operations (customer), maintenance and engineering

• Committee members = 5Op Manager Maint. Manager

DCS Engineer Process EngineerElectrical EngineerMechanical Engineer

Team Leader

Investigation Methodology

Kickoff meeting was started by the team leader and a Weekly meeting was scheduled which lasted for 4 hours

Investigation Methodology

Initial Reviewof archived reports

Review of CurrentInvestigation system

ExternalBenchmarking

Personnel Interviews

Investigation Methodology

Initial Reviewof archived reports

Review of CurrentInvestigation system

ExternalBenchmarking

Personnel Interviews

5%56%

5% 5%

18%

11%

INSTRUMENTATION

HUMAN ERROR

ELECTRICAL

MECHANICAL

PROCESS RELATED

UNKNOWN

Investigation Methodology

Initial Reviewof archived reports

Review of CurrentInvestigation system

ExternalBenchmarking

Personnel Interviews

EquipmentTrip

EquipmentTrip

Report Workflow (Manual)

Collect Data(Supv Opr)

Collect Data(Supv Opr)

Ops. ForemanCalls for meetingOps. Foreman

Calls for meetingTrip Meeting

(All)Trip Meeting

(All)

Investigation Workflow

Enter Data(Supv Opr)Enter Data(Supv Opr)

Verify Data OpsForeman

Verify Data OpsForeman

Area EngineerReview

Area EngineerReview

EngineeringReview

EngineeringReview

Reliability UnitReview

Reliability UnitReviewEndEnd Division Heads

Review & RemarksDivision Heads

Review & Remarks

EndEnd

Recommendation& Action plan

Recommendation& Action plan

Investigation Methodology

Initial Reviewof archived reports

Review of CurrentInvestigation system

ExternalBenchmarking

Personnel Interviews

0

0.5

1

1.5

2

2.5

Trip Inex

Companies

Trip per equipment per year

1 2.2 1.4 0.2 0.5

Company A Company B Compay C Company D Company E

Investigation Methodology

Initial Reviewof archived reports

Review of CurrentInvestigation system

Externalbenchmarking

Personnel interviews

• Current quality of Investigation • Personnel satisfaction of current system• Hidden back breaks• Expectations

Implementation Roadmap

Start

Develop Team Name

Develop Team Mission

StudyMethodologies

Qualitative Quantitative

Quantitative Methodologies

• Identified the data boundaries

• Identified data population = 400

• Gathered all data for 4 years

• Designed Q&D Access Database

• Used Minitab to generate statistical analysis

Quantitative Methodologies

50%

24%

13%

5%5%

3%

Instrumentation

Mechanical

Electrical

Human Error

Process

Unknown

By Category

Quantitative Methodologies

By Plant

0

2

4

6

8

10

12

14

16

18

20

Percentage

Pla

nt

N

Pla

nt

A

Pla

nt

B

Pla

nt

C

Pla

nt

D

Pla

nt

E

Pla

nt

F

Pla

nt

G

Pla

nt

H

Pla

nt

I

Pla

nt

J

Pla

nt

K

Pla

nt

L

Pla

nt

M

(%)

Quantitative Methodologies

By Season

57%

43% Winter

Summer

Quantitative Methodologies

By Shift

48%

32%

20%

S1

S2

S3

Quantitative Methodologies

By Equipment

Gen

erat

or

St.

Turb

ine

Ind.

Mot

or

Gea

rbox

Syn

c. M

otor

Pum

p

Com

pres

sor

Gas

Tur

bine

0

0.5

1.0

1.5

2.0

2.5St. Turbine

Ind. Motor

Gearbox

Sync. Motor

Pump

Compressor

Gas Turbine

Generator

Quantitative Methodologies

Mechanical

ESD System

Governor

Lube Oil

O/B Bearing

Instrument Loop

Instrument

Vibration

Process

Temperature O/B Bearing

Instrument Loop

I/B Bearing

Thrust Bearing

ESD System

Instrument Loop

ESD System

Instrument Loop

ESD System

O/B Bearing

Instrument Loop

I/B Bearing

Thrust Bearing

ESD System

Instrument Loop

ESD System

Instrument Loop

ESD System

PIB Cabinet

Instrument Cable

RTD

Field JB

….

Hardware

Software

PS Card

I/P Card

O/P Card

Controller

Specification

Installation

Wiring

PS Card

I/P Card

O/P Card

Controller

Probe

Field JB

Proximater

P Switch

T. Switch

Wiring

Steam TurbineSteam Turbine

RTD

Quantitative Methodologies

• Established fault tree for all instrumentation upsets = 200

• Involved all specialized people in the fault tree identifications

• Prepared an educational Root Cause Analysis Class

Implementation Roadmap

Start

Develop Team Name

Develop Team Mission

StudyMethodologies

Qualitative Quantitative

Qualitative Methodology

EquipmentTrip

EquipmentTrip

Report Workflow (Manual)

Collect Data(Supv Opr)

Collect Data(Supv Opr)

Ops. ForemanCalls for meetingOps. Foreman

Calls for meetingTrip Meeting

(All)Trip Meeting

(All)

Investigation Workflow

EquipmentTrip

EquipmentTrip

Collect Data(Supv Opr)

Collect Data(Supv Opr)

Verify Data OpsForeman

Verify Data OpsForeman

Area EngineerReview

Area EngineerReview

EngineeringReview

EngineeringReview

Reliability UnitReview

Reliability UnitReviewEndEnd Division Heads

Review & RemarksDivision Heads

Review & Remarks

EndEnd

Recommendation& Action plan

Recommendation& Action plan

Start

Fill out DB(Oper. Supv. & Maint. Crew)

Form Inv. Team

Initial Assessment

With Action Plan

Fill DB Sections RCA, Recommendations

Rel. Supv. Approval

Eng. Supv. Approval

Maint. Supt. Approval

Oper. Supt. Approval

Generate Final Report

Yes Yes Yes

Yes

No No No No

Upset occurs

RCA program Gant Chart

Implementation Roadmap

Start

Develop Team Name

Develop Team Mission

StudyMethodologies

Qualitative Quantitative

Conclusion

Managed to improve RCA program in the plants using qualitative & Quantitative techniques through an empowered project team under the supervision of the top management

Lessons learned

1. Top management commitment

2. Multidiscipline and homogenous team

3. Empowered team under the supervision of one leader

4. Unlimited resources

Root Cause Analysis Program

Jan 21, 2006

Presented by: Mohammed A. Al-Dossary

Construction Engineering & Management

Quality Management

CEM 515

Term Paper

Thank you!

ignificant ignificant

S P U R Trocess rocess

psets

eview

eameam SPURTback

Team Name & Mission

Mission:

To provide feasible short and long-term recommendations aimed at minimizing Plants nuisance and unnecessary upsets using qualitative & quantitative methods

back

Team Name & Mission

Team Name & Mission

back

Root Cause Analysis Section

back

Built-in Library of fault trees