Root Cause Analysis Enhancement

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Root Cause Analysis Enhancement
Construction Engineering Management Quality
Management CEM 515
Term Paper

• Jan 21, 2006
• Presented by Mohammed A. Al-Dossary

Abqaiq Plants Today film
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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

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Upset Definition

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

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Problem Statement

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

We dont want more upsets please!
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Forming Investigation Committee

• Management appointed a leader from Maintenance
• Leader selected members from operations
  (customer), maintenance and engineering
• Committee members 5

Op Manager
Maint. Manager
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Investigation Methodology

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

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Investigation Methodology
Initial Review of archived reports
Review of Current Investigation system
External Benchmarking
Personnel Interviews
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Investigation Methodology
Initial Review of archived reports
Review of Current Investigation system
External Benchmarking
Personnel Interviews
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Investigation Methodology
Investigation Workflow
Initial Review of archived reports
End
Review of Current Investigation system
Report Workflow (Manual)
External Benchmarking
Personnel Interviews
End
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Investigation Methodology
Initial Review of archived reports
Review of Current Investigation system
External Benchmarking
Personnel Interviews
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Investigation Methodology
Initial Review of archived reports
Review of Current Investigation system

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

External benchmarking
Personnel interviews
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Implementation Roadmap
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Quantitative Methodologies

• Identified the data boundaries
• Identified data population 400
• Gathered all data for 4 years
• Designed QD Access Database
• Used Minitab to generate statistical analysis

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Quantitative Methodologies
By Category
3
5
5
13
50
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Quantitative Methodologies
By Plant
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18
16
14
12
()
Percentage
10
8
6
4
2
0
Plant N
Plant A
Plant B
Plant C
Plant D
Plant G
Plant H
Plant K
Plant M
Plant E
Plant F
Plant L
Plant J
Plant I
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Quantitative Methodologies
By Season
43
Winter
57
Summer
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Quantitative Methodologies
By Shift
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S1
S2
48
S3
32
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Quantitative Methodologies
By Equipment
2.5
2.0
1.5
1.0
0.5
0
Pump
Gearbox
Generator
Ind. Motor
St. Turbine
Sync. Motor
Gas Turbine
Compressor
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Quantitative Methodologies
PS Card
I/P Card
O/B Bearing
ESD System
O/P Card
Instrument Loop
Vibration
Controller
I/B Bearing
ESD System
Instrument Loop
Instrument
Governor
O/B Bearing
ESD System
Thrust Bearing
ESD System
Instrument Loop
P Switch
Lube Oil
PS Card
T. Switch
Instrument Loop
I/P Card
Hardware
Wiring
O/P Card
Mechanical
Steam Turbine
Controller
Software
ESD System
Temperature
O/B Bearing
Instrument Loop
PIB Cabinet
Instrument Cable
I/B Bearing
ESD System
Field JB
RTD
Installation
Instrument Loop
Process
Specification
Wiring
Thrust Bearing
ESD System
Instrument Loop
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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

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Implementation Roadmap
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Qualitative Methodology
Start
Upset occurs
Fill out DB (Oper. Supv. Maint. Crew)
Form Inv. Team
Initial Assessment With Action Plan
No
No
No
No
Rel. Supv. Approval
Eng. Supv. Approval
Maint. Supt. Approval
Oper. Supt. Approval
Yes
Fill DB Sections RCA, Recommendations
Yes
Yes
Yes
Generate Final Report
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RCA program Gant Chart
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Implementation Roadmap
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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

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Lessons learned

1. Top management commitment
2. Multidiscipline and homogenous team
3. Empowered team under the supervision of one
   leader
4. Unlimited resources

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Root Cause Analysis Program
Construction Engineering Management Quality
Management CEM 515
Term Paper

• Jan 21, 2006
• Presented by Mohammed A. Al-Dossary

Thank you!
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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
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Team Name Mission
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Team Name Mission
back
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Root Cause Analysis Section
Built-in Library of fault trees
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