Using TapRooT® RCA to Improve Incident Investigation and Identify Fixable Causes

Challenge
Before implementing TapRooT® RCA in 1993, we performed incident investigations, but we often stopped at a level above the root cause; we missed root causes that were important; we placed blame rather than finding fixable system problems; and we didn’t have consistent, convincing means to present our information to management. Therefore, our challenge was to improve our investigation system to better prevent repeat incidents (that can be dangerous and expensive) by implementing effective corrective actions that management would approve and implement in the field.

Action
In 1993, we trained six people in a 5-Day TapRooT® Course. The training helped us to decide to go forward with implementing TapRooT® RCA, rewriting our investigation procedure, and training a large number of people to use TapRooT® Root Cause Analysis to investigate problems.

We decided to license our site to use TapRooT® RCA to conduct our own courses based on the System Improvements copyrighted training material. One of the initial trainees became a certified instructor, and over an 18-month period, he trained about 200 people to investigate problems using the TapRooT® System.

Specific Example of How TapRooT Helped
How did TapRooT help us? The best way I can explain the impact of TapRooT® RCA is to describe some specific incidents that the TapRooT System helped us investigate and prevent (by identifying root causes that we could fix by implementing practical fixes).

One example was the investigation of a large fire in a process unit. The fire resulted in a complete unit shutdown. The systematic TapRooT® investigation helped us identify the misapplication of steel in the process as one of the causes.

But TapRooT didn’t let us stop there. We continued to look for the system causes that led to why the wrong metal was used. This allowed us to prove that we needed to perform a complete material verification (PMI or Positive Material Identification) to make sure that there were no other misapplications of steel in other similar parts of the process.

This verification was expensive. Without the detailed proof and logical presentation tools that are built into the TapRooT® System, management might not have perceived the need to spend the money needed (and commit to the plant down time needed) to complete this verification.

What did we find? The inspections identified three additional areas that needed repair. Any one of these could have resulted in an additional fire and unexpected shutdown. Worse yet, a large fire could cause injuries or fatalities. By using TapRooT® RCA, we avoided these future problems that would have eventually occurred.

As part of the TapRooT® process, we institutionalized our corrective actions by updating the PMI Policy. We also looked beyond the specific problem of this metallurgy application to the generic problem of pipe wall and pipe joint thinning. (Having a database helps you develop a convincing argument that this isn’t just a one-time problem but rather a repetitive problem that needs a refinery-wide system fix.)

Longer Term Results
In January 1997, when performing the inspections implemented due to our previous TapRooT® investigation, we found thinning of a piping joint on a process unit furnace. We shut down the furnace to make repairs that cost about $270,000. If the inspection (implemented after the incident investigation described above) had not been performed, the pipe would have failed. The cost of repairing a catastrophic failure would have been much higher (possibly ten times as much) and could have led to personnel injuries.

The total impact has been so broad and pervasive that it’s hard to measure in dollars. Why? Because people in the field make some improvements and aren’t “documented” as being attributed to implementing TapRooT® RCA. Also, it would be unfair to say that the only improvement initiative is TapRooT® RCA. Therefore, in any large facility, progress is not the result of a single initiative but rather the cumulative impact of all improvement initiatives. Therefore, we can’t just look at our improved performance and attribute it all to TapRooT® RCA. However, I can point to specific incidents (like the one I described here) in which TapRooT® RCA helped us develop effective corrective actions that would not have been developed before we started using TapRooT® RCA.

Lessons Learned
Here at the Torrance Refinery, we firmly believe that the TapRooT® System provides us with the necessary tools to determine the true root cause of an incident. This saves us investigation time and saves us the pain of having repeat incidents that we know would cost millions of dollars and cause personnel injuries.

We have also learned that we need to apply TapRooT® RCA “across the board.” If we try to apply TapRooT® RCA only occasionally, we will lose proficiency and miss opportunities to catch problems when they are small (before big accidents happen).

We also learned that we needed to trend root cause data from the incidents so that we could identify problem areas (generic causes). This would allow us to eliminate whole classes of incidents by implementing generic system fixes. The database also helps us make a convincing argument that helps management see the need to implement fixes that we previously would have failed to convince them of their desirability.

We are expanding the use of TapRooT® RCA beyond safety and production issues to problems with project planning and implementation. This leads us to new ways to improve our project initiation and approval processes and save even more money by stopping problems before they are “set in concrete.”