(68b) Next Generation Root Cause Investigation and Analysis - Elimination of Repetitive Incidents through Strengthening Management Systems

Next Generation Root Cause Investigation and Analysis

As with all process safety incidents in industry, there are
lessons to learn from systemic failures that have the potential to end  in the
tragic loss of life, insult to the environment, and equipment loss. 

Dow has had a long and successful history of reducing
Process Safety and less severe Loss of Containment events.  This started with
the establishment of formal generational goals in 1995 to reduce incidents by
90% over a 10 year time frame.  These goals and progress metrics were and are externally
published. In 2005 another 10 year goal was established to further reduce
Process Safety incidents and their severity by 75% and 90% respectively.

By 2008 it was clear that our performance had plateaued and
we were not making progress in reducing incidents. As the incidents were
analyzed, the data showed that the vast majority of the incidents were
repetitive, while the incident may not have happened on the same piece of equipment
or in the same plant, it was clear that the same failure modes and management
systems were involved in subsequent incidents.

Analysis of the data also showed that there was an opportunity
to ensure  every required protection layer failure mode and its associated
management system failure were  identified and fixed and to improve how the
investigation results were leveraged across the company.

By 2009 we were back on track and actually surpassed our
2015 goal by 2011, and by 2013 achieved a 90% reduction. There were many
factors that helped achieve this level of performance, this paper will focus on
the following 4 items:

1.       The
companies Investigation process was modified  to ensure that the:

a.       Immediate
cause  for every required Protection Layer Failure was identified

                                                              
i.     
Company standard  required protection layer

                                                            
ii.     
Risk assessment validated protection layer

b.      Root
Cause for every protection Layer's Management System Failure was identified

c.       Involvement
of the function responsible for the local implementation each Management System
Failure

d.      Corrective
actions for Protection Layer and Management System Failures

e.      Appropriate
level of  functional Ownership of Management System Corrective actions

2.       Senior
Manufacturing and Process Safety Leadership Review of each Process Safety event
including a Repetitive Incident Analysis for the facility, site, technology and
corporation.

3.       Leveraging
the learnings through actions at the appropriate level consistent with the level
of management system failure.

4.       Broadly
communicating the learnings in formal Learning Event Reports across the company
to reinforce the importance of:

a.       the
proper definition , design and implementation of protection layers

b.      operating
within the constraints and maintaining all protection layers

The paper will also
contain two case studies of where Investigations were successful in leveraging
the Management System Opportunities at appropriate levels, one across the
entire company and one across a technology.