Unscheduled Deferment

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Shell Exploration & Production

Unscheduled

Deferment,ORIP and RCAProcess Guide

Operational ExcellenceDelivering Continuous Performance Improvement

EP 2007-9014

Restricted


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Restricted EP 2007-9014

Unscheduled Deferment, ORIP and RCA Process Guide

Reviewed by: EPT - Surface Production Discipline Leadership Team

Approved by: Global Discipline Head Surface Production (EPT-O-TFPL)

Date of issue: November 2007

ECCN number: Not subject to EAR - No US content

This document is classified as Restricted. Access is allowed to Shell personnel, designated Associate Companies and Contractors

working on Shell projects who have signed a confidentiality agreement with a Shell Group Company. 'Shell Personnel' includes allstaff with a personal contract with a Shell Group Company. Issuance of this document is restricted to staff employed by a Shell

Group Company. Neither the whole nor any part of this document may be disclosed to Non-Shell Personnel without the prior written

consent of the copyright owners.

Copyright 2007 SIEP B.V.

SHELL INTERNATIONAL EXPLORATION AND PRODUCTION B.V., RIJSWIJK

Further electronic copies can be obtained from the Global EP Library, Rijswijk.


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EP 20079014 Restricted

1

Contents

Foreword ...................................................................................................................................................................3

Business Context .........................................................................................................................................................4

Introduction..............................................................................................................................................................4

Overview of ORIP.....................................................................................................................................................6

ORIP meeting structure ...............................................................................................................................................8

Roles and responsibilities..........................................................................................................................................10

Critical success factors.............................................................................................................................................11

Unscheduled Deferment, ORIP and RCA Process...........................................................................................................13

The Unscheduled Deferment, ORIP and RCA Process map...........................................................................................14

1. Identify.............................................................................................................................................................16

1.1 Identify opportunities ......................................................................................................................................18

2. Assess and Rank ...............................................................................................................................................20

2.1 Carry out 5 Whys on an incident.....................................................................................................................21

2.2 Categorise and risk assess ..............................................................................................................................22

2.3 Decide what action to take and allocate resources ..............................................................................................24

3. Select and Analyse............................................................................................................................................25

3.1 Establish RCA Team .......................................................................................................................................26

3.2 Conduct preparation meeting ..........................................................................................................................26

3.3 Analyse the incident.......................................................................................................................................28

3.4 Record root causes and communicate ...............................................................................................................28


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2

4. Decide and Act.................................................................................................................................................31

4.1 Develop corrective actions ..............................................................................................................................324.2 Endorse corrective actions at ORIP....................................................................................................................32

4.3 Implement the actions .....................................................................................................................................32

4.4 Review status of actions at ORIP .......................................................................................................................33

5. Analyse and Improve.........................................................................................................................................34

5.1 Monitor effectiveness......................................................................................................................................35

5.2 Identify and implement improvements ................................................................................................................35

5.3 Track and calculate benefits.............................................................................................................................36

Review of the Unscheduled Deferment, ORIP and RCA Operational Excellence Element ....................................................38

Appendices..............................................................................................................................................................39

Appendix 1 - Typical terms of reference for an ORIP meeting........................................................................................40

Appendix 2 - Roles and responsibilities RCA Facilitator/Team Leader.............................................................................43

Appendix 3 - Competence matrix for RCA ................................................................................................................45

Appendix 4 - 5 Whys RCA guidance.......................................................................................................................46

Appendix 5 - The Apollo process.............................................................................................................................49

Appendix 6 - Generic SAP Z8 Work Process Flow .....................................................................................................52

Glossary of terms......................................................................................................................................................54

Glossary of abbreviations/acronyms...........................................................................................................................55


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3

Foreword

Shell EP benchmarks indicate that unscheduled deferment is at

unacceptably high levels across the Group. There is, therefore,

a requirement to address this problem from the Corporate leveldown. Carrying out the activities of the UnscheduledDeferment, Operational Reliability/Integrity improvement Process

(ORIP) and Root Cause Analysis (RCA) elements of Operational

Excellence have been identified as one way of addressing theproblem.

The purpose of this guide is to explain how to manageunwanted incidents, with the aim of reducing unscheduled

deferment and improving and sustaining operational reliability.

This is a wide-ranging process that crosses the disciplines ofMaintenance and Integrity and Surface Production and

interfaces with the HSSE community. It is important to ensure

that all site-specific knowledge is brought to the problem solving

process to ensure its success.

As a result of using the guide, staff will be able to:

explain how the process works

describe which employees will be involved in the process

explain the role each employee has in the process

explain where to get training in how to use the process

explain what to do to implement the process

determine if implementation has been successful

outline some of the practices for conducting RCAs.

Analytical tasks, such as RCA, are often viewed as the

responsibility of qualified technical professionals, e.g.

engineers. However, any attempt to execute an RCA without

the participation of site staff is a missed opportunity and puts atrisk the quality and credibility of the results. Consequently,

given the broad range of disciplines involved in managing

unscheduled deferment and the assurance of operational

reliability, this guide is intended for staff involved in thefollowing activities.

Production Engineering staff involved in first line maintenance

and production operations.

Asset management involved with increasing technical and

operational integrity and reducing the level of risk

Maintenance and operations support staff involved with

Reliability Assessment, Production System Optimisation and

Production Programming.

Whilst the process could be used to address HSSE issues, it is

not the intention of this guide to take precedence overHSSE-related incident investigation procedures. For the

reporting and investigation of all HSSE incidents, refer to

EP 2005-0170 Incident Reporting and Follow-up.

All HSSE and loss of containment incidents are HSSE

reportable. The requirements for notification, analysis andreporting of these types of incident are specified in the HSSE

Standard (Incident Management Process, HSE0002). The

procedures outlined in this standard should be followed for

HSSE and loss of containment incidents. Security incidents arealso excluded from this process guide.

It is also not the intention of this guide to provide detailedinformation about how to conduct facilitated RCA investigations.

This can be sourced through Group Learning and Development

or via the Functional Discipline organisations.

This guide has three parts.

The Business Context contains an introduction, overview of theprocess, ORIP meeting structure, roles and responsibilities and criticalsuccess factors.

The Unscheduled Deferment, ORIP and RCA Process givesdetailed guidance on how to establish, carry out and maintain theprocess. It should be used as a reference guide for those involvedwith the process whether as a member of the ORIP meeting or asa member of an RCA team. Both parts refer to more detailedappendices.

A CD Toolbox located inside the back cover contains tools andtemplates that can be tailored to the requirements of any Asset.They are shown in the introduction of sections 1-5 and arereferenced throughout the guide and shown as

T


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4

Business Context

The extent of unscheduled deferment throughout the Group is

large. Figure 1 illustrates its extent and main causes based on

2005 production data.

Deferment is referred to as unscheduled when it is caused byevents that cannot be scheduled, e.g. trips, breakdowns and

interruptions by third parties, poor performance of equipment or

sub-optimum settings.

Full guidance on the coding structure and the appropriate root

cause codes to assign to unscheduled deferment are describedin the Deferment Administration Manual EP 2007-9017.

Unscheduled deferment elimination is a corporate goal. Itrequires the use of a structured process that frequently

incorporates RCA and is fundamental to:

maintaining a safe workplace

minimising deferment

maximising equipment reliability and plant availability

minimising operating cost

ensuring Technical Integrity.

Many of the causes of unscheduled deferment are directly

related to equipment or process system failures. However,

industry experience indicates that in 60-70% of incidents,people-related issues play a significant role.

Improvements are being made through the use of theUnscheduled deferment, ORIP and RCA process as shown in

the examples from BSP in Figure 2. In BSP West, the level of

unscheduled deferment is being sustained below 6% with themonthly average currently below 4% and falling. The reduction

in monthly fluctuations has made off-take scheduling and otherproduct movement activities much easier. At Darat, significant

improvements in the level of unscheduled deferment have beenseen after the introduction of the process.

3rd

parties/customers

Wells

Pipelines/flowlines

Separation/

process

Com

pressors

Others

Safeguardingandcontrol

Pumps

Reservoir

Producedwatersys

tem

Powergeneration

Sub-sea

20

10

Separation/

process

Com

pressors

Wells

Safeguardingandcontrol

3rd

parties/customers

Pipelines/flowlines

Others

Powergeneration

Producedwatersys

tem

Sub-sea

Pumps

Reservoir

1200

800

400

Total gas = 4,500 mln m3Total oil = 94 mln bbls

Figure 1: Unscheduled Deferment 2005

Introduction


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Figure 2: Unscheduled Deferment story - BSP

May

-07Jan-0

4

Mar-04

May

-04Jul

-04

Nov-0

4

Jan-05

Mar-05

May

-05Jul

-05

Nov-0

5

Sep-0

4

Sep-0

5

Jan-0

6

Mar-06

May

-06Jul

-06

Sep-0

6

Nov-0

6

Jan-07

Mar-07

18.0%

16.0%

14.0%

12.0%

10.0%

8.0%

6.0%

4.0%

2.0%

0.0%

Unscheduleddeferment trend was

downward evenbefore formal ORIP

Unscheduleddeferment/ORIPimplementation

commenced Jan06

%

ofIPSC

BSP - West

Business Context


5

May

-07Jan-04

Mar-04

May

-04Jul

-04No

v-04Jan-0

5M

ar-05

May-05

Jul-05

Nov-05

Sep-0

4Se

p-05

Jan-0

6M

ar-06

May

-06Jul

-06

Sep-0

6No

v-06Jan

-07M

ar-07

25.0%

20.0%

15.0%

10.0%

5.0%

0.0%

Big story sofar is

TRENDREVERSAL

%

ofIPSC

Commencedimplementationof unscheduled

deferment/ORIP

BSP - Darat


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6

Overview of ORIP

ORIP is a formal, structured continuous improvement process.

Inputs to ORIP are the measurements made on plant

performance. These measurements may include defermentdata, KPIs, inspection, audit results and benchmarking results.

Outputs from ORIP are a list of ranked, appropriate, corrective

actions aimed at improving performance especially of plant.

ORIP has five clearly defined stages.

These are:

identify the unwanted incidents/conditions

assess and rank those incidents

select and analyse them to determine the problem decide the best course of action and act.

analyse and improve process effectiveness.

The relationship between the stages is shown in Figure 3 and

described below.

Identify

Unwanted events or conditions are those which have a

significant impact on the business in the areas of:

integrity and reliability

production loss, deferment and downtime

increased expenditure

damage to reputation.

The significance of the impact should be identified on the basisof pre-defined, location-specific thresholds or triggers for eachof these areas. Examples of trigger levels are shown in

Figure 5 on page 18.

Figure 3: The Operational Reliability/Integrity improvement Process (ORIP)

Analyseand improve

Select and analyseAnalysing and problem

solving tools(RCA, tripod B etc)

IdentifyUnwanted events/

conditions

Check thresholds

Assess andrank

Efficiency and

reliability

RAM/Bad actor register

Decide and acton appropriate measures

Comission plant changeMaintenance strategy;

RRM (S-RCM, S-RBI, SIFpro)

Do nothing PMR; SAP PM change

Procedural change Competence development

EIT


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Business Context


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If there are no location-specific thresholds, the initiator should

use the HSE RAM to carry out a preliminary assessment and log

the results in the ORIP register.

Assess and rank

All integrity and reliability issues and production loss, deferment

and downtime incidents should be subject to an initial RCA

using the 5 Whys technique. The results of 5 Whys should be

reviewed at the daily Operations meeting and a decision madeon the appropriate actions to take.

Along with expenditure and reputation opportunities, whichhave a significant impact on the business, they should be

assessed and ranked based on the severity of their impact by

the initiator and the ORIP focal point so that resources areaimed at the worst offenders.

The Group HSE RAM is used for this assessment. Medium and

high items are then taken to the weekly ORIP meeting forranking and further assessment if necessary. This meeting is

responsible for the final ranking and prioritisation of the

incidents and should approve any requirement for a detailedRCA and allocate appropriate resources.

Select and analyse

After assessing and ranking the events based on degree/

severity of impact, the worst offenders should be selected andanalysed using appropriate problem solving tools such as:

root cause analysis, e.g. 5 Whys, Apollo

lean

six sigma, etc.

Conducting formal RCAs will involve a team being chartered

with clear objectives and goals to carry out the RCA using a

suitable methodology. Subject matter experts (SMEs) will beidentified, consulted and participate as needed during the

analysis. On completion, the team must communicate the root

causes to relevant staff and identify solutions that will preventtheir re-occurrence.

Decide and act

Having analysed the event, the next step is to decide whatshould be done and act accordingly. Appropriate actions may

include the following.

Plant changes.

Procedural changes.

Competence development.

Changes to maintenance strategies.

Changes to SAP.

Mobilisation of equipment improvement teams (EIT).

Short interval controls.

The ORIP panel endorses the decision based on

recommendations from the analysis team, which for RCA, will

be the Reliability Engineer or RCA focal point. The endorsedrecommendations are then handed over for execution.

Approved actions should be put into a Corrective Action Plan(CAP). It is the responsibility of the implementation team leader

to produce the CAP. This may be the leader of the investigation

team or some other team assigned by line management.

Actions to eliminate the root cause of the analysed incident can

be tracked in the ORIP database or in SAP until closed out.

Analyse and improve

Success is not only about identifying root causes andimplementing solutions but what has improved as a result.

The Unscheduled Deferment, ORIP and RCA process and itscontribution to business improvements should be reviewed

periodically to ensure that they are meeting the best in class

standard and that benefits are being tracked. There should bepositive indicators that performance has improved as a result of

the actions that were implemented. If not, the RCA study, for

example, should be revisited.


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ORIP meeting structure

Please note that attendees at the ORIP meeting are sometimes

known as the ORIP panel.

Daily Operations meeting

This meeting will primarily deal with breakdown

opportunities. The Facility Operations and MaintenanceTeam, led by the Operations Supervisor, preferably the ORIP

Focal Point, should review incidents and the resultant 5 Whys

in detail as part of this meeting. It is also acceptable for aseparate daily meeting to be held for ORIP only.

At the start of the meeting, previous actions should be

reviewed for progress and, if the actions require additionalsupport/resources not available locally, the incident should

be elevated to the ORIP register.

The team should ask:

has all relevant information been collected and has the 5Whys been conducted in a rigorous manner and the true

root cause identified?

has the risk assessment been conducted and the severity

code been entered on the 5 Whys form correctly?

has the root cause Unscheduled Deferment Code been

correctly entered and has the reporting system beenupdated?

are the immediate actions taken suitable and are the short

and long-term solutions practical and achievable?

are any resources, external to the Facility, required to

implement the short-term solution?

The team should adjust the RAM assessment, deferment code,

etc. if they consider it to be incorrect. The decisions andreasons for this should be fed back to the technician for

learning purposes.

Some form of meeting minutes or action log should be keptand actions tracked.

Weekly ORIP meeting

This meeting will be chaired by the Operations Supervisor

and attended by relevant functional support staff. It will dealprimarily with opportunities arising from a threshold being

exceeded. Prior to the meeting, action parties assigned to

take specific actions should have updated their informationinto the tracking system so that the meeting may take

decisions based on up-to-date information.

At the weekly meeting, progress is reviewed and decisions

made on the priorities for action, resource requirements,

support activity, etc. Where there is more than one Facility

within the Asset, these priorities require optimising for thewhole Asset. New RCA reports should be briefly reviewed

and, where required, additional RCA investigations should be

initiated.

Should consequential issues arise from other activities/

investigations, the meeting should initiate additional RCAinvestigations.

Monthly ORIP meeting

The monthly meeting is chaired by the Operations Manager

and attended by senior functional support staff. It will deal

primarily with opportunities that are common to severalfacilities across the Asset and those concerned with reputation

and expenditure. The high priority issues should be reviewed

to ensure appropriate action is being taken to eliminate majoror repetitive trips/failures especially where thresholds have

been exceeded. At this meeting, the appropriate Reliability

Engineer may request an RCA as a result of analysis of

equipment performance. The meeting will then decidewhether the investigation is high priority and, if so, the RCA

Lead, facilitator (if required), team composition and time scale

for reporting and presentation should be decided.

See Appendix 1 for typical terms of reference for an ORIP

meeting.


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Business Context


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Figure 4: ORIP meeting structure

Monthly ORIP meeting

Assess and rankin ORIP database

Assess and rankin ORIP database

Asset weekly ORIP meeting

Platform1

Platform2

Platform3

ORIP information sources Daily production reports Field/control room logs Trip panel/RCA reports

Meeting goals: To review critical issues on the

ORIP register. To confirm/verify using RAM critical ORIP issues and action accordingly. To carry out process checks to ensure consistency across asset.

Meeting goals: To review critical issues on the ORIP register and report progress. To prioritise issues (using RAM) such

that resources are focused in the rightarea (one month look ahead).

To monitor the progress of the important issues.

Meeting goals: To review results of 5 Whys for trips

and unwanted events. To prioritise issues (using RAM) such

that resources are focused in the rightarea.

To monitor the progress of the important issues.

Daily Operations meeting Operations Supervisors (preferably ORIP focal point) Reliability Engineer

(where available) Maintenance Supervisor Discipline Maintenance Supervisors (E/I/M/P) (as required) Scheduler (if at location. If not, Maintenance Supervisor takes

this role) HSSE Advisor/Medic (as required) Selected Maintenance and

Operations Techs (as required)

Weekly ORIP meeting Senior Operation Supervisors Head Onshore Support Head of Maintenance Support Programmer (as required) Well Services (as required) Operations Supervisors (preferably ORIP focal point) Reliability Engineer

(where available) Maintenance Supervisor Scheduler (if at location. If not, Maintenance Supervisor takes

this role) HSSE Advisor (as required) Selected Maintenance and

Operations Techs (as required)

Monthly ORIP meeting Operations Manager Operations Supervisor Maintenance Supervisor Programmer Reliability Engineer Discipline Engineers (as required) Technical Authorities (as required) Wells and Reservoir Management Other disciplines (as required)


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Roles and responsibilities

Please note that these roles are generic and might differ from

Region to Region. However it is important that all theresponsibilities should be carried out.

Global Process Owner

Owner of this process guide.

Owner of the Global ORIP database.

Identifying, recommending and deploying improvements.

Regional ORIP Co-ordinator

Providing direct and indirect support to the Asset and theORIP Focal Point.

Giving guidance on effective meetings.

Providing training and coaching on ORIP.

Providing change management skills to facilitate smooth

implementation.

ORIP Focal Point

Ensuring that ORIP is implemented and sustained.

Be part of the Asset Team (and a reasonably senior person)both for credibility during implementation and for

sustainability.

Leading by example, and bringing achievements to the

attention of senior management.

Guiding and coaching staff on the process areas and beable to seek/give clarification on any issues that arise.

Ensuring that individuals and teams within the Asset are

performing their roles and that support functions are

contributing.

Ensuring that the meetings are running to the agreedschedule, RCAs being initiated at the required frequency,and that the ORIP register (database) is being maintained.

ORIP Panel

Please note: ORIP panel refers to staff who participate in thedifferent ORIP meetings.

Supporting unscheduled deferment elimination businessprocesses actively and visibly.

Approving/rejecting proposals to conduct formal RCAs and

other analysis activities on unscheduled deferment and/or

equipment reliability incidents (endorsement of initial riskassessment and managing the overall risk presented to the

business).

Providing sufficient resources (people, time, budget) to

conduct effective analysis.

Assigning ownership within the meeting for all approved

analysis events.

Approving/rejecting the root causes found and therecommended solutions.

Endorsing objectives for solution development, e.g. criteria,

boundary conditions, minimal capital investment.

Providing resources for implementation (with Asset approval).

Reviewing progress and effectiveness of action items.

Enabling timely follow-up and execution of corrective actionsby all and removing any barriers to the implementation ofcorrective actions.

Ownership of the quality of the implementation of approved

solutions.

Operations Support Staff

Developing a sense of ownership in the Asset and itsperformance levels. Prevention is better than cure but when

failures occur, these should be seen as unacceptable.

Registering unscheduled deferment and reliability incidents

for analysis.

Conducting basic RCA using techniques such as 5 Whys.


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Business Context


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Sharing learning from incidents with colleagues.

Utilising SAP to register and process equipment-relatedRCAs.

Reliability Engineers

Identifying equipment issues that impact on integrity,

production reliability and/or cost performance.

Escalating these to the ORIP meeting.

Facilitating formal RCA investigations.

Advising on composition of the RCA team.

Keeping the ORIP meeting informed of the status of RCAstudy and corrective actions execution.

Monitoring Asset performance for positive signs of business

improvement resulting from implementation of the actions

resulting from completed RCA events (KPIs).

Receiving, processing and sharing learning from other RCA

events outside their Asset Team.

The senior Asset Reliability Engineer should review the RCAreport for completeness and quality.

RCA Team

Conducting a preparation meeting.

Analysing the incident.

Recording root causes.

Communicating root causes.

Full details of the role of the RCA facilitator/team leader can be

found in Appendix 2.

Critical success factors for the process include:

management and staff sensitivities effective implementation

competence and skills.

A strong improvement culture can be developed if factors such

as these are embedded and sustained.

Management and staff sensitivities

Failure analysis often reveals inappropriate human intervention

and flawed (or absent) management systems. It is possible that

some managers may feel personally at fault and staff may bereluctant to reveal and address the real root causes of failures

for fear of exposing their manager.

In some cultures, this might be difficult to overcome but thebehaviour of middle and senior managers in embedding an

effective problem solving culture is important for sustained

success. Managers should not tolerate partial or incompletesolutions. Behaviours to be encouraged include:

supporting proactive behaviour

challenging fire-fighting repair priorities

ensuring that reward structures recognise managers and

teams who have few emergencies and who practise

long-term prevention and systematic problem solving.

Effective implementation

Characteristics of effective implementation include:

the ORIP meeting being accepted as the key management

process to enable the RCA process to become established

leadership commitment to the process providing resources

and clear decision making

Critical success factors


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the preferred RCA approach must:

reveal the physical, human, and latent (organisational/system) roots of the events investigated. Deductivelyrevealing physical causes and/or human interventions

alone does not reveal the root causes

be as simple as possible. Field staff should be able to

apply it as part of their daily activities without a

requirement to understand complex tools or software andit must be usable at locations with poor or no IT

leverage existing practices and well-known tools;

familiarity will lead to a wider acceptance

be applicable to small, chronic and major events

promote and support a change in mindset. Failures arenot inevitable but have causes; causes can be identified

and addressed. The methodology must stress that the key

question is to understand why things went wrong andwhy people behaved as they did, not who was to blame

use an established tool and supplier. A proven approach

to training and analysis is likely to yield the best results.

New or novel approaches should be avoided

include clear organisational roles and responsibilities with

reliability at the centre of the process.

ownership by the organisation implementing and embedding

the process in their normal ways of working effective performance measures in place to drive positive

behaviour and performance

a review process in place to validate quality and promote

continuous improvement

a means of communication for lessons learned and sharingof success, e.g. via Livelink or Global networks, newsletter

articles, awards and continuous striving for improvement.

Competence and skills

To ensure the success and sustainability of the process, thetraining and development of appropriate staff in the facilitationof RCA and participation in awareness training are essential.

Appendix 3 shows the competence requirements for different

job roles. Training is available via EP Learning andDevelopment.


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Unscheduled Deferment, ORIP and RCA Process


13

Unscheduled Deferment, ORIP and RCAProcess

This section of the guide gives a detailed explanation of theactivities of the main activity process. Each step of the process

has a section as follows.

1. Identify

2. Assess and Rank

3. Select and Analyse

4. Decide and Act

5. Analyse and Improve

Detailed activities

Each of these step has been broken down into its key activities.These activities form the sub-sections of the remainder of thisguide and are shown on the next two pages.


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The Unscheduled Deferment, ORIP and RCA Process Map

Identify

1

Assess and Rank

2

Carry out 5 Whyson an incident

2.1

Categorise andrisk assess

2.2

Select and Analyse

3

Establish RCA Team

3.1

Identify opportunities

1.1

Conduct preparationmeeting

3.2

Analyse the incident

3.3

Record root causesand communicate

3.4

Decide what action totake and allocate

resources

2.3


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Unscheduled Deferment, ORIP and RCA Process


15

Decide and Act

4

Develop correctiveactions

4.1

Analyse and Improve

5

Monitoreffectiveness

5.1

Endorse correctiveactions at ORIP

4.2

Implement theactions

4.3

Review status of actionsat ORIP

4.4

Identify and implementimprovements

5.2

Track and calculatebenefits

5.3


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Tool 1 - Top 10 Bad Actors

Tool 2 - Bad Actor Elimination Planning Guide

1. Identify

Unwanted events or conditions are those which have asignificant impact on the business in the areas of:

integrity and reliability

production loss, deferment and downtime

increased expenditure

damage to reputation.

There must be a threshold or trigger level against which anevent can be classified as significant. Production loss

thresholds should be defined at regional levels and othersthresholds at Asset level.

Measure Listing

Tools

Process Map

Identify1

Identify opportunities

1.1

Number Measure Shell EP Average Top Quartile

18.P.1 Unscheduled deferment 6.5%


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Identify


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Best in Class Standard

Properly defined and documented coding structure forcategorising unscheduled deferment incidents that areconsistently applied across all levels of the organisation.

Regular analysis of unscheduled deferment to identify topdeferrals. Frequency of analysis shall generally comply toweekly at Facility level, monthly at Asset level, quarterly atOU level, 6-monthly at Regional level and yearly atGlobal level.

Daily monitoring, reporting and investigation ofunscheduled deferment with properly defined trigger levels

to raise the level of attention within the organisation. Proactive management of unscheduled deferment by

providing a deferment improvement catalogue that is keptup-to-date showing the size of the opportunity, priority,action parties and target dates.

Operational controls and recovery plans in place fordifferent levels of unscheduled deferment scenarios tomitigate the business impact.

Unscheduled deferment improvement targets are setannually for the top deferrals for which remediation actionsare to be generated and performance monitored against

targets quarterly. Annual benchmarking of unscheduled deferment.

A process for accurately quantifying the size of thedeferment, which takes into consideration the transients infacilities and wells during shutdown and start-upoperations and other such related issues.

All data related to unscheduled deferment are held in thecompanys hydrocarbon allocation (HCA) system. Thisimplies that all data either from production historian (e.g.PI) or manually obtained data is entered into such asystem.

Business rules for RCA in place with trends showingimprovement over time. RCA thresholds established by theAsset Team in line with deferment reduction goals and anRCA compliance measure that is established and regularlyreviewed by management/supervisors. Any backlog ofRCA candidates will be tracked and will be readilyavailable and maintained. Targets will be set to ensurethe backlog is reduced to


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1.1 Identify opportunities

Unwanted events or conditions are those which have asignificant impact on the business. There must, therefore, be a

threshold or trigger level by which an event can be classifiedas significant. Examples of thresholds for the major areaswhere unwanted events or conditions occur are shown below inFigure 5. Thresholds for production losses will be determinedregionally whilst the others can be determined at Asset level.

In order to improve, it is important to continually lower thesethresholds, but not so far as the organisation becomesswamped with minor events. When considering the impact ofan event, recurring events must be identified so that theircumulative loss can be quantified.

Opportunities are likely to arise from three sources:

incidents

bad actors

analysis driven investigation.

Incidents

These are typically unexpected and must be dealt withimmediately, e.g. the failure of an oil export pump.

Bad actors

A bad actor is an item of equipment or particular equipmenttype, which poses significant risk of failure.

It is equipment that has, through failure history, demonstratedthat it has a high risk of failure and it has experienced fourfailures in a 12-month period. This threshold is a starting pointfor all Assets and should be reviewed annually.

As reliability improves, it should be possible to reduce thisthreshold thus encouraging continuous improvement.

Equipment designated as a bad actor by the Asset ReliabilityEngineer should be investigated in the same way as equipmentfailures or reliability incidents at an investigation level accordingto risk.

Figure 5: Trigger threshold

Reputation

Increased expenditure

Production loss, deferment and downtime

Input Focal Point

OIM/Asset Ops Team Leader

* Actions linked to Production loss above 25000m3 oil/>3 MM sm3 gas/>50000m3 water injection need to be closed out by the Asset Leader.

Plan overspend by 30%.Re-work with cost of loss >$100k[ie Significant on RAM].

OIM/Asset Ops Team Leader

Any event that impacts integrity.Any unplanned event/work/breakdowns andequipment reliability issue or threat with amedium/high risk on the RAM matrix.

Deferment/outage/capacity loss equivalent to>12,500m oil or gas equiv/>25,000m WI(*) [ie Significant on RAM].

Any potential event as a result ofnon-compliance with a medium/high risk

on the RAM matrix.

Production Programmer

Cost Planner/MaintenanceTeam Leader

Threshold

Integrity and reliability issues and threats


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It is recommended that a bad actor list is developed based onoverall business impact. In addition, both performance of

individual items of equipment and groups of equipment typesshould be considered.

Analysis driven investigation

At the monthly ORIP meeting, a request for an analysis drivenRCA may be requested.

Proactive application of RCA occurs when learning fromincidents takes place. In such cases, RCA would be used todetermine if any risks to the business exist that have actuallymaterialised on another Asset either inside the Shell Group or inthe industry thus allowing proactive steps to be taken to preventa recurrence of the incident. RCA can and should also be usedfollowing analysis of broader business performance. RCAshould, therefore, cover the following.

Learning from incidents and near misses.

Well or facilities production performance, e.g. scale build-upor internal fouling.

Corrective Maintenance - repetitive failures, highconsumption of materials or consumables and correctivemaintenance (CM) cost. An example would be equipmentidentified for work by an Equipment Improvement Team (EIT).

Reliability - overall low or declining reliability (platform, train,system, equipment or component).

Inspection - RBI, e.g. excessive rate of wall thinning,corrosion or erosion or other inspection findings. Thissituation should also include a review of the original RiskBased Inspection analysis.

Audit and Reviews - undesired findings from any audit.

Tool 1 - Top 10 Bad Actors - a template for listing keyinformation about bad actors.

T

Tool 2 - Bad Actor Elimination Planning Guide - sets outa process for eliminating bad actors.

T


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2. Assess and Rank

All integrity and reliability issues and production loss,deferment and downtime incidents should be subject to aninitial RCA using the 5 Whys technique. The results of 5Whys should be reviewed during the ORIP part of the dailyOperations meeting and a decision made on the appropriateactions to take.

Along with expenditure and reputation opportunities, whichhave a significant impact on the business, they should beassessed and ranked based on the severity of their impact so

that resources are aimed at the worst offenders. The GroupHSE RAM is used for this assessment.

The weekly ORIP meeting is responsible for the final rankingand prioritisation of the incidents and should approve anyrequirement for a detailed RCA and allocate appropriateresources.

Tool 3 - 5 Whys Template Tool 4 - Group HSE RAM

Tools


A root cause analysis process that is routinely performedby Operations staff. This will lead to root causeidentification and the generation of corrective actions thateliminate recurring problems. Support staff such asengineers, planners and supervisors will all have beentrained in a formal RCA process.

ORIP meetings are planned, held regularly, are wellattended by key players (Asset Leader, Ops Manager,Maintenance Manager, Reliability Eng, Maint/OpsSupport Eng, Daily Delivery Coordinator, Facility Staff).

Incidents are tracked and the incident thresholds, areadopted and communicated to Asset staff and applied.

CMMS Notification breakdown flags and breakdownstart/end times are accurately recorded on every failure.CMMS Notifications will be used on corrective workorders and all Object/Damage/Cause and Activitycodes will be populated. All CMMS notifications will be

reviewed for completeness and accurate use of theObject/Damage/Cause and Activity codes.

Process Map

Assess and Rank2

Carry out 5 Whyson an incident

2.1

Categorise andrisk assess

2.2

Decide what action totake and allocate resources

2.3

Measure Listing


18.S.1 RCA completed against threshold 60% >90%

18.P.1 Percentage of Unscheduled Deferment Covered by RCA 80% 90%

(as a percentage of IPSC)


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Assess and Rank


21

2.1 Carry out 5 Whys on an incident

When an incident occurs, it is critical that key information aboutthe circumstances and process conditions are captured

immediately. Information recorded should include:

time and date

incident type

system affected

status of the operation at the time the event occurred

duration of event where applicable

description of the incident

SAP functional location for equipment

business impact.

This information should be captured in the ORIP Register (seebox below) and in SAP for equipment failures via theappropriate notification.

A fit for purpose RCA should be conducted on as manytrips/failures as possible. This might initially be a the 5 Whys

followed by a more formal RCA such as Apollo if the 5 Whysdoes not reveal the root cause.

When an event/failure occurs, an Operator or MaintenanceTechnician is sent to restore the situation and performdiagnostics to trace the fault and restore the plant to anoperating condition. At the same time, s/he should conduct aninitial RCA using the 5 Whys technique.

However, even though this is a very simple and quick process,it is recognised that Asset and Operations staff need to prioritisetheir resources and focus on the tasks adding most value.

If the 5 Whys does not reveal the root cause or a multiplefailure pattern is identified, an Apollo investigation or equivalentshould be started which should:

be driven by the local equipment owner and/or maintainerin conjunction with the Reliability Engineer or RCA FocalPoint

be attended by representatives from both Operations andMaintenance

result in actions that are clearly defined.

A more detailed description of the 5 Whys is given inAppendix 4 and an overview of the Apollo process is given inAppendix 5.

The ORIP register

A web-based register for Global use is under development.Currently, this register can be in any appropriate format, e.g.paper-based, spreadsheet or database. Ideally, there shouldbe one register for each Facility rolled up to Asset level.Typically, it should track opportunities through the following

four stages.

IN - to register an opportunity.

OPEN - to track an opportunity through theanalysis.

COMPLETED - when all corrective actions have beenclosed out.

CLOSED - when an analysis has been completedand accepted.

It should also contain performance indicators.

Maintenance staff shall use SAP through Z8 notifications andassociated work orders for equipment defects. Informationheld in SAP should be transferred to the ORIP register asappropriate.

Tools 3 - 5 Whys template - can be used to write up a 5Whys analysis.

T

Note

Object Damage Codes should be used to support theRCA effort. They should be captured in the initial Z1

notifications. If additional information results from a 5Whys analysis or a Z8 initiated formal RCAinvestigation for equipment failures, the data entered inthe object damage codes can be updated.


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2.2 Categorise and risk assess

Trips/failures that do not cause a deferment should also beinvestigated because:

there may be valuable lessons to be learned that are ofbenefit to the Operations or Maintenance and Integrityfunctions

similar equipment that is part of the direct production systemmay be at risk of the same failure

it is possible to draw a parallel with world class HSSEwhere every near miss is investigated in order tounderstand the circumstances. This leads to a provenreduction in serious incidents.

It is essential to prioritise each opportunity correctly to ensurethat all issues impacting on the business can be compared on

an equal basis and that the most important unwanted events areanalysed first. This includes all incidents, bad actors andanalysis driven investigations.

The Shell Group HSE Risk Assessment Matrix (RAM), shown inFigure 6, shall be used to quantify and prioritise identifiedopportunities. In general, the severity of ORIP opportunitiesshould be based on the severity levels of the RAM Assetsconsequence category. The exceptions to this are opportunitiesfrom the ORIP reputation category, which should be directlymapped to the severities in the reputation consequencecategory.

Figure 6: Group HSE RAM

No injury orhealth effect

Slight injuryor health

effect

Minor injuryor health

effect

Major injuryor health

effect

PTD or up to3 fatalities

More than3 fatalities

Nodamage

Slightdamage

Minordamage

Majordamage

Massivedamage

Noeffect

Slighteffect

Minoreffect

Majoreffect

Massiveeffect

Noimpact

Slightimpact

Minorimpact

Majorimpact

Massiveimpact

0

Severity

Poeple

Assets

Environment

Reputation

CONSEQUENCES

Has happenedat the Location ormore than onceper year in theOrganisation

Has happened inthe Organisation

or more thanonce per year in

the industry

Never heardof in theindustry

Heard of inthe industry

Has happenedmore than onceper year at the

Location

A B C D E

INCREASING LIKELIHOOD

Moderateimpact

Moderateeffect

Moderatedamage

1

2

3

4

5

ORIP Category

Integrity and Reliability Production loss, deferment and downtime Increased expenditure

ORIP Category

Reputation

Low Risk - manage for continuousimprovement

Medium Risk - Incorporate Risk ReductionMeasuresandDemonstrate ALARP

High risk - investigate alternatives


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Figure 7: Opportunity ranking

Action Example

High

Medium

Low

Mitigation mandatory and shall be applied immediately theopportunity is identified

Escalate to monthly ORIP meeting or deal with immediately.

Operations Supervisor to endorse rating.

Line break leading to loss of containment will requireimmediate isolation of broken section.

Action necessary where the ORIP meeting structure is in placeand incidents could be closed out at either weekly or dailymeetings.

Operations supervisor refers to person-in-charge at location.

Mitigation necessary but shall be applied after endorsementof Operations Supervisor.

Escalate to weekly ORIP meeting

Endorsement by ORIP Focal Point

Sudden degradation in efficiency leading to a situation wheretwo duty pumps out of three are unable to maintain the levelin a vessel. The third pump (standby) needs to be put intooperation to control the level thereby avoiding a trip of theentire process train. To operate in this mode, the logic needsto be overridden to allow simultaneous operation of all thepumps.

Action is applicable where the ORIP meeting structure is inplace and incidents could be closed out at the daily meeting

Mitigation not mandatory

No escalation required

No endorsement required

Figure 7 shows how in the Assess and Rank phase of the ORIPprocess, opportunities from the Identify stage are rankedaccording to their perceived risk levels, high, medium and low.This ranking determines how the opportunity will be actioned

The cost impact of the incident can be calculated fromdeferment and/or Opex either as a single cost for a singleevent or annually when a recurring incident is ranked andprioritised.

The decision about which problem-solving methodology to usefor the investigation is based on the complexity and priority of

the problem. The final decision will be taken by the ORIPmeeting.

During the investigation of a seemingly minor incident, it maybecome apparent that the risk to the business is higher or lowerthan was at first thought. The incident should be re-routed andre-prioritised for escalation and appropriate action.

Tool 4 - Group Risk Assessment Matrix - gives a more

detailed description of the consequence categories andseverity.

T


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2.3 Decide what action to take andallocate resources

The results of 5 Whys and subsequent risk assessments should bereviewed in the ORIP section of the daily Operations meeting and

a decision made on the appropriate actions to take. Operationscan then decide whether the original incident should be proposedfor the formal RCA process at the weekly ORIP meeting. Seepages 8 and 9 for a description of the ORIP meeting structure andAppendix 1 for typical agendas.

This step is designed to ensure that the right people in theorganisation are fully informed about the events within their Assets,which are having a negative impact on performance. The weeklyORIP meeting will decide whether a formal RCA should be carriedout. Its members are accountable for the decisions made aboutwhich incidents to investigate and which solutions to implement.

The Reliability Engineer needs to prepare for the ORIP meetingby quantifying the number and type of resources that will berequired for the Analysis phase.

A member of the ORIP meeting should sponsor an RCA teamwhich will be led by a facilitator. For more information, see step3.1 Establish RCA Team.

If it is decided that a formal approach should be used, a Z8notification should be raised in SAP for equipment-related incidentsto initiate the process. This should be done by the ReliabilityEngineer or equivalent position in Operations. A generic SAP Z8work flow process can be found in Appendix 6 and a user guideexplaining how to input data on the CD-ROM.

The maximum time allowed for completion of the RCA study isdependent on the outcome of the risk assessment as follows:

A report of all RCAs registered in SAP should be submitted tothe ORIP meeting by the Reliability Engineer or equivalent FocalPoint for ranking, approval and progress reporting.

This report is the register of proposed and ongoing RCAs andensures that the focus on current business needs is not lost byranking any new priority RCAs against other existing RCAs.

If it is decided that an RCA should not be carried out, the decisionand reasons should be communicated to the initiator.

If there is no requirement for further analysis, move to step 4.1Develop corrective actions.

RAM Category Complete study within

High 6 weeks

Medium 8 weeks

Low 12 weeks

Note

In the event of an incident, where an immediate response isrequired, key members of the Asset Leadership Team shouldbe consulted and an investigation instigated without waitingfor a submission through ORIP, i.e. they are fast-tracked.


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3. Select and Analyse

After assessing and ranking the events based on the degree/severity of impact, the worst offenders should be selected andanalysed using appropriate problem solving tools such as:

Root Cause Analysis, e.g. 5 Whys, Apollo, TapRoot

Tripod

Lean

Six Sigma, etc.

Conducting the more formal RCAs will involve a team beingchartered with clear objectives and goals to carry out theRCA using a suitable methodology. Subject matter experts(SMEs) will be identified, consulted and participate asneeded during the analysis.

The team must then communicate the root causes to relevantstaff and identify solutions that will prevent their re-occurrence.

Tool 5 - RCA report form Tool 6 - Generic investigation study

Tools

Process Map

Select and Analyse

3

Establish RCA Team

3.1

Conduct preparationmeeting

3.2

Analyse the incident

3.3

Record root causesand communicate

3.4


Operators and Reliability Specialists who areknowledgeable about RCA concepts and have eitherundergone RCA training or participated in several RCAs.There will also be RCA champions who have receivedtraining on the RCA Process and managers andsupervisors who demonstrate support and participate inRCAs.

An RCA Process Guide that has been communicated toAsset teams is well understood and is being activelyworked. The guide will include a recommended causalprocess, i.e. TapRoot, 5 Whys, and will be used tofacilitate completing an RCA analysis. A documentedmethod for identifying repeat failures and a thoroughReliability Review of all available data will be performedfor each required RCA.

Measure Listing


18.S.1 RCA completed against threshold 60% >90%


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3.1 Establish RCA Team

Once the ORIP meeting approves the need for a formal multi-discipline RCA, the resources identified by the Reliability

Engineer are assigned to a team after discussion with the AssetTeam and Functional Groups. For high risk events, a seniormanager is always involved plus a core team. The team ischartered by the Team Leader to agree deliverables and roles.Team composition will vary depending on the problem and itsseverity.

Factors that will ensure the success of the RCA team include:

a clear problem statement

the use of, and adherence to, a robust RCA methodology

cross-functional membership factual data used as the basis for all analysis activities (RCA

is part of a fact-based problem solving process)

commitment from the ORIP meeting to evaluate findings andrecommendations fairly

measurement of progress in implementing solutions

competent facilitation

participation of staff responsible for the analysed activity orequipment with the analysis preferably done at the worksite

a balanced team with enough subject matter experts toallow discussion.

The performance of the facilitator can make the differencebetween a successful or unsuccessful RCA even if there is aculture where RCAs are valued and their results acted upon.The successful RCA facilitator will meet the following criteria.

Impartial. The facilitator should have nothing to gain or loseby the results of the RCA. Specifically, they should extractinformation efficiently from the people who know the details(those who were there, experts, etc.) without being biased

by their own experience or interpretation. They do not listenonly to the loudest voice.

Organised. The facilitator should be skilled at organisinginformation and putting it into a clear format for presentationto others.

Persistent. The facilitator should not give up in the face ofproblems or difficulties but at the same time needs to

recognise when the team cannot progress without moredata.

Tactful. The facilitator will come across situations wherepeople are reluctant to participate or give information. Thisneeds to be handled diplomatically and assertively to getwhat is required to complete the RCA.

Strict in conducting meetings, e.g. stop arguments and makesure the investigation moves forward.

Thorough. The facilitator will ensure that all possiblecontributing factors to the incident are incorporated into the

analysis, corners are not cut and people factors missed.

For issues that are considered as high, a managementrepresentative shall be included in the RCA investigation team.

3.2 Conduct preparation meeting

A preparation meeting, teleconference or individual briefingsshould be held with the team members to develop the charterand the terms of reference for the analysis. The meeting shouldlast about an hour and, ideally, the ORIP sponsor should makean opening statement to set out:

the business impact of the issue being investigated

objectives for solution development, e.g. criteria, boundaryconditions, constraints such as HSSE and/or life cycle costand/or production and/or minimum capital investment

his/her expectations and, most importantly, give his/hercommitment to support the process through to full completionof the resulting recommendations.

The charter should be a brief, one paragraph problemstatement setting out why the team has been formed.

Prior to the meeting, the following activities should be carriedout where appropriate.

Identify and invite external observer(s) for lateral learningand/or an HSSE representative.


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Presentation by the Asset Team of the current maintenanceand operating strategy for the equipment under analysis.This should include performance indicators (MTBF),maintenance costs, PM programme, etc.

Provision of historical information such as drawings, SAPdata, warehouse data, operating information, interviews withkey staff, etc.

Provision by the Asset Team of spend data split byMaintenance/Projects associated with the failure beinganalysed to help quantify potential benefits fromimplementing the RCA recommendations.

Develop a failure/cost history in order to establish the baseline impact on business performance.

Arrange a site visit.

Activities such as these will not be discussed at the preparationmeeting other than to verify that they will be available at theappropriate point in the RCA.

The meeting should be chaired by the RCA facilitator or TeamLeader who will brief team members about:

individual roles and responsibilities (including data collection)

the role of the facilitator

objectives and deliverables (including acceptance criteria)

time-line (including next meeting)

post-RCA process.

Before getting started, it will be useful for the team to be awareof any criteria that will be used to judge whether or not the

recommendations that they make will be accepted by the ORIPmeeting. Acceptance criteria could include the following.

Eliminate or mitigate the consequences of the cause in caseswhere it is not technically or economically possible ordesirable to eliminate causes. It might not always bepossible to eliminate a cause. For example, if scheduledshutdowns are too long, it would not be possible toeliminate them altogether but it might be possible to reducetheir duration and/or the time between them.

Provide a predicted percentage return on investment. This islikely to be the impact that correcting the problem has onproduction reliability and/or unit operating cost.

No conflict with scheduled projects. Before starting an RCA,it is good practice to check that plans are not in place tomake changes to the equipment or area in which it operateswithin a reasonable time frame, i.e. before a next potentialrepeat incident could occur.

Clear resource and cost justifications. The recommendationsshould include clear cost justification and resourcerequirements.

Positive effects on the whole system. Recommendationsshould not be accepted if they deal with a root cause butmight cause problems in other parts of the system. This oftenarises with partial solutions. There will be a number ofpossible recommendations. These need to be rankedagainst acceptance criteria, e.g. the solution must, shouldand must not criteria.

The team should make sure that they understand all the criteriathat decision makers at the ORIP meeting will consider beforegiving the go-ahead to implement recommendations.

A form, such as the completed example shown in Figure 8 onpage 29 and 30, should be used to record the key facts.

Tool 5 - Root Cause Analysis Report Form - template thatcan be used for the report.

T

Example problem statement

Compressor XYZ has failed three times in the last 12months. These failures have resulted in productiondeferment of xxx bbls and associated maintenance costsof $yyy. This team has been formed to identify the rootcauses of the failure of compressor XYZ and recommendcost-effective solutions that can be readily implemented.


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3.3 Analyse the incident

It is not the purpose of this guide to give a prescriptivemethodology for carrying out RCAs. Any recognised

methodology meeting the criteria listed in Critical Success Factorson page 11 can be used.

Apollo is frequently used and an overview of it can be found inAppendix 5.

It is important to remember that most RCA experts agree that60% to 70% of all RCA root causes are people related ratherthan equipment related. If the RCA and its recommendationsfocus only on technical or hardware issues, important peoplerelated issues may either be missed or not given sufficientattention.

After the analysis, the results should be used to summarise theresults of the review and record the actions from the RCA.

The root causes should be recorded in the ORIP Register andSAP via the Z8 notification if equipment-related.

Relevant staff should be made aware of the root causes of theincident. Typically, these will be Operators, Maintainers andEngineers. This should be done through appropriatecommunication channels such as meetings or by e-mail.

If the root causes have the potential to cause further damage,the facilitator should communicate this to the key personnel whoare likely to be affected as soon as it is identified rather thanwaiting until all the RCA work is complete.

3.4 Record root causes andcommunicate

Tool 6 - Generic investigation study - an example of aninvestigation study.

T


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Figure 8: Root Cause Analysis Report

Significance

Safety None

Environmental None

Production Loss 2 Million Nm3 (over 2006) @ 3 cts/ Nm3 = $ 60.000,- deferment costs.

Maintenance Costs $ 62.000,- since July 2004 (year average $ 57.000,-)P-0605 = $ 26.300, - P-0606= $ 21.800, - P-0607 = $13.800, -

Frequency To date September 2006: 20 times since start up in 2004

Total Cost $ 117.000, - per annum

Reputation As reliable supplier

Investigation Team Geveke Erik Nijman TechnicianAndre Westerlaken Regio Service ManagerRenee Ippel Project EngineerKees Laseur Project Engineer

Maybelle Henk Blaauw Offshore installation managerRieks Everts Operations SupportBas de Jong Process EngineerJoop Maat Rotating Discipline EngineerGeert Meursing Sr. Maintenance and Reliability Engineer

Problem Definition

Frequent failure of the ORINOCO-09 condensate pumps P-605/06/07 resulting in poor availability, high maintenance costs and deferment

when the second pump trips as well.

Occurrence The 3 pumps 20 times in about 2 years of operation2004 (newly installed) = 1 failure2005 = 5 failures2006 (until September) = 14 failures

Date Occurred Randomly over the year, unpredictable, no tendency recognised.Production deferment will show an increasing trend as decreasing reservoir pressure will require more compression andresult in increased utilisation of the condensate pumps.

Summary of investigation

Summary:The Condensate pumps P-0605/06/07 were analysed to address the randomly, unpredictable increasing failure rate. A variety of defectshave been reported in SAP since the start up of the new designed condensate system in 2004. These defects were analysed and discussed in

the RCA study.

Conclusion:Although a variety of defects were recorded a common direction could be identified towards the process conditions for the suction valves.Investigation on the platform showed a variable suction pressure and pulsation dampeners installed outside the design range. Verification on theline up and material investigation on the failing parts did not show deficiencies from the design documents. The start-up procedure is ratedeffective. Material investigation on the failed parts did conclude no material or chemical issues related to the failures.The design parameters are reviewed if they cover the operational envelope/parameters. The hydraulic dynamic processes conditions werechecked and verified against the design criteria and the suction piping sizing was recalculated. The results showed that the piping diameter wastoo small and the pulsation dampeners were not effective. Replacement of the 3 suction piping system with 10 is will make it effective.The Project Management Process was reviewed to verify if the process controls were well applied.The review observed some shortcomings in the control and hand over process.The investigation was completed and corrective actions were formulated to prevent failures of a similar type.Follow up of SAP and QWR initiated actions are tracked via these systems.


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Figure 8: Root Cause Analysis Report (continued)

Investigations

Possible Causes Investigation Actions Assigned to Due Done

No early warning mechanism installed todetect a membrane failure. The present 4mA signal gives the actual pressure betweenthe two membranes but no alarm.

Foreign materials such as loose bolts arereported on failures

Loose/broken parts of the "sluisventiel"

The start of the second and/or third pumpcauses additional vibrations

Limited capacity of the suction line

Restricted capacity of the suction line

Inadequate design/datasheets

Limited capacity of the suction line

Ineffective project controls

Check if the signal can be transferred into an alarm. Investigate iffailure types are reported/and known

Investigate if failure types are reported/and known

Report the metallurgical investigation, check the correctness andsuitability of the material for the process conditions, and correctsizing,

Review the start up procedure/sequence in relation to thecondensate flow.

1. Check the hydraulic dynamic processes conditions and verifythe design criteria.

2. Recalculate the discharge piping when suction piping needs tomodified

Verify if small diameter parts as reduced bore valves are fitted inthe suction lines and if suction filters/strainers are fully open

1. Check the datasheet as it's thought that it stated one pressureinstead of a pressure range

2. Investigate if the design parameters cover the operationalenvelope/parameters

Raise a SAP Z5 notification to start the PIR/modification process.Replace suction piping/system with increased diameter

Raise a QWR to start the process to close the controls gaps in theEngineering process.

Henk Blaauw

Joop Maat

Joop Maat/Geveke

Henk Blaauw

Bas de Jong

Henk Blaauw

Joop Maat

Henk Blaauw

Geert Meursing

01.06.06

01.06.06

01.08.06

15.06.06

01.08.06

15.06.06

15.06.06

01.09.06

01.09.06

01.06.06

01.06.06

01.08.06

15.06.06

01.08.06

15.06.06

15.06.06

01.09.06

01.09.06

Report Writer: Geert Meursing

Report Date: 17 September 2006

Approval:

Appendix 1 Cause and Effect Chart

Name: Function: Date:

For Lateral Learning, the report to be copied to: (tick the appropriate box)

Principal Discipline engineer:q Civil and abandonment q Control and automation q Corrosion engineeringq Electrical engineering q Reliability engineering q Rotating equipmentq Safety engineering q Static engineering q Structure equipmentq Inspection q Pipelines q ...

Possible Causes Investigation Actions Assigned to Due Done

Solutions


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4. Decide and Act

Having analysed the event, the next step is to decide whatshould be done and act accordingly. Appropriate actionsmay include the following.

Plant changes

Procedural changes

Competence development

Changes to maintenance strategies

Changes to SAP

Mobilisation of Equipment Improvement Teams (EIT)

Short interval controls.

The Reliability Engineer or RCA Focal Point should ask theORIP meeting to endorse the findings and recommendedsolutions.

Approved solutions should be put into a Corrective ActionPlan (CAP). It is the responsibility of the implementation teamleader to produce the CAP. This may be the leader of theinvestigation team or some other team assigned by linemanagement.

The RCA or other interventions are only considered closed

when all follow-up actions have been implemented.

Tool 7 - SIC Template

Measure Listing


18.P.2 Overdue action items >5


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4.1 Develop corrective actions

The solutions which result from the 5 Whys, the more formalRCA investigation or any other type of analysis activity will vary

in terms the amount of budget and resources required. Somewill require little and can be implemented as part of day-to-dayactivities. Others might be large and require a changeproposal.

However, whatever the scale, the solutions should:

eliminate the causes or mitigate the consequences of theproblem

be practical

be clear

be cost effective comply with any recommendation criteria set prior to the start

of any RCA study

be implementable in the short to medium-term whereverpossible.

Investigation activities are not seen as part of the solution orcorrective action plan. All solutions should be endorsed by therelevant Subject Matter Expert/Technical Authority.

One solution that is recommended is the use of short interval

controls. These allow process owners to review and react tochanges in key production parameters over a short time period(generally two to four hours). Control limits are set for the keyparameters (usually slightly inside the alarm limits) andperformance against these limits monitored.

If a process or piece of equipment starts to perform outsidethese limits this will be identified at the next review interval andbefore the alarm limits are reached.

In many cases, ORIP participants will determine the course ofaction appropriate to the issues being discussed. However,

corrective actions (including budget and resource estimates) toissues that have been addressed via an RCA study should beforwarded to the monthly ORIP meeting by the ReliabilityEngineer or RCA Focal Point for discussion and if ORIP does nothave the authority, then forwarded to the relevant parties forapproval. The ORIP meeting should assign appropriate priorityto the implementation of the actions and recommend that therequired budget and resources required to complete them beapproved. If the recommended corrective actions are rejected,the RCA team should revise them and re-submit them to theORIP meeting.

4.3 Implement the actions

In most cases, the allocation and subsequent implementation ofactions from ORIP will be straightforward. Where correctiveactions have been proposed from an RCA, there may be aneed to engage with staff who were not part of the analysis tomake sure they understand the requirements and priority of theactions that have been approved by ORIP. It is essential thateffective communication between the two parties takes place tomake sure that ownership is transferred and that all parties areclear about the progress monitoring process at ORIP.

Approved corrective actions should be put into a CorrectiveAction Plan (CAP). It is the responsibility of the ImplementationFocal Point to produce the CAP. At one end of the scale, theCAP could and should be no more than the list of correctiveactions in the RCA investigation report. At the other end of thescale, it could be a detailed project plan requiring significantresources, chartered teams, etc.

The Corrective Action Plan should include:

incident record number

risk assessment of incident

causes of the defect

solutions/actions

name of responsible party for completing action

due date of action.

4.2 Endorse corrective actions atORIP

Tool 7 - SIC Template - explains how to use short intervalcontrols and gives several examples. A short interval control

process guide is also available on the Shell Wide Web.

T


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Where maintenance work must be executed, the Work theprocess specified in the Work Preparation, Scheduling and

Execution process guide (EP 2006-5445) should be followed.

Note that between 60% and 70% of root causes will be humanfactors related and will not require a formal work order to beraised. The solutions are likely to be process or proceduralchanges and associated communication and training.However, planners and schedulers will need to allow for staff tohave time off to attend appropriate events and this should beallowed for in any allocation of resources.

4.4 Review status of actions at

ORIPDuring all ORIP meetings, the progress of all actionimplementations, including RCAs, should be tracked using theORIP register, SAP-generated reports and information submittedby the Reliability Engineer(s) and/or implementation focalpoints. This is to identify any slippage and/or backlog that isbuilding up and to ensure that appropriate remedial action istaken.

An historical weakness of the RCA process was the potential forthose in charge of RCA management to lose focus during

implementation and to fail to identify that work resulting fromRCAs was not being completed. This step, involving the ORIPmeeting is, therefore, very important in ensuring that progress ismonitored effectively.

An RCA can only be considered closed when all action itemshave been completed. Furthermore, the RCA can only beconsidered effective when there are positive indicators that theimplementation of the RCA actions has lead to an improvementin performance.

The following indicators are useful for informing the ORIPmeeting where things are stuck or whether things are

progressing to plan.

RCA investigation study completed.

All actions ranked and work orders created.

Work orders listed in 90-day plan or Capex approved andexecution year allocated for Capex items.

Actions actually executed in field.

Full RCA actions closed out.


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5. Analyse and Improve

Success is not just about identifying root causes andimplementing solutions but what has improved as a result.

The unscheduled deferment, ORIP and RCA process and itscontribution to business improvements, should be reviewedperiodically to ensure that they meet the best in classstandard and that benefits are being tracked.

Process Map

A history of completed RCAs for each Asset for aperiod of five years. Subject Matter Experts (SMEs) willalso be identified, consulted, and participate, asneeded, while conducting RCA analysis.

A periodic review of completed RCAs and CorrectiveAction Plans. These will check for data quality,accuracy, completeness and thoroughness of the RCAprocess. They will be conducted by an SME orReliability Engineer and the findings will be reviewed

with the Asset Teams.

Analyse and Improve

5

Monitor

effectiveness5.1

Identify and implementimprovements

5.2

Track and calculatebenefits

5.3


Measure Listing


18.S.2 Number of RCAs Completed per Annum Total number Total number

18.S.3 Repeat failure listing by equipment Equipment Specific Equipment Specific

18.P.2 RCA Overdue Action item Compliance >5


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Asset leadership is responsible for the overall monitoring of allaspects of performance. An integral part of this process is the

follow-up and quantification of the success of solutions designedto reduce unscheduled deferment. Depending on results, theAsset Team should adjust the trigger thresholds.

The quantification of value as a result of successfulimplementation can be based on:

reduced production loss, deferment and downtime

improved reliability

reduction in loss of containment

reduction in corrective maintenance

reduction in labour, consumables or spares consumption

improved safety performance.

For equipment related events, this will be the responsibility ofthe Reliability Engineer.

Suitable KPIs will need to be determined when a solution isimplemented. An example is given below.

When it has been proven quantitatively (KPIs) that solutions haveworked, this information should be shared within the Asset Team

and cascaded within the work place (as a minimum). TheReliability Engineer should also consider what informationshould be shared with relevant Principal Technical Experts witha view to wider distribution.

Deferment Identification and Reporting

Ideally, all OUs should use the Global Deferment CodingStructure which has been implemented in Energy Components(EC) and which is the preferred tool for Hydrocarbon ProductionInformation Management in Shell EP. The process will be builtinto the role of the Surface Production Team in EPT as an annual

Global roll-up exercise, and thus facilitate the sharing oflearning and continuous adjustment of Global Support ResourcePool to address common and recurrent bad actors across theRegions. The annual top deferral analysis will complement thebenchmarking exercise, which currently does not cover allAssets and in most cases is not carried out annually.

5.2 Identify and implementimprovements

When improvement areas have been identified, the next stepwill be to implement them.

This will involve analysing the KPIs to ascertain areas forimprovement and, subsequently, analysing the reasons forinadequate performance. When the causes have beenidentified, and possible solutions developed, an action planshould be created to address some or all of the issuesidentified. The activities on the action plan should becommensurate with the business risk or opportunity.

An ORIP meeting should be used to agree appropriate actionsand implement them.

5.1 Monitor effectiveness

Note

It should be a matter of routine that measures such as MTBF

for critical equipment should be tracked and analysedregularly by the Reliability Engineer and Operations staff

Example

The mean time between failure for a centrifugal pump is 3months. An RCA shows that lubrication is ineffective and adifferent bearing is being used to the one recommended bythe pump manufacturer. The lubrication regime is improvedand the recommended bearings used. Improvements can bemeasured as follows.

Measure MTBF (increasing trend should be visible).

There should be no failures due to the causes identified inthe RCA.

Cost savings due to manpower not being used for

corrective maintenance and a reduction in replacementbearings can be quantified and extrapolated over theworking life of the pump.


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Implementing improvements requires significant effort and it isimportant to demonstrate that the effort is paying off.

Benefits from the process come through four main areas.

1. Reduced unscheduled deferment leading to more uptime andmore sales revenue.

2. Less time spent fixing failed equipment leading to reducedlabour costs (both direct and indirect).

3. Less materials consumed to re-instate equipment to its desiredstate leading to less material costs.

4. Fewer human errors.

Measuring the benefits is not as easy as it may seem. Mostmanagers usually ask for cumulative performance reports suchas year-to-date oper

Documents

Unscheduled Deferment