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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