BakerRisk’s easy-to-use root cause analysis software.
Root Cause Analysis (RCA) Software
CATree is an easy-to-use software that provides a systematic, consistent, repeatable process to identify a wide range of potential causes. CATree is unique in that these causes cover not only the regulated elements of process safety and occupational safety health and environment, but also the additional elements in risk-based process safety (RBPS) including safety culture, tools and equipment, the life cycle of engineering projects, human factors, and more.
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CCPS undertook a project to update the Guidelines for Investigating Chemical Process Incidents book. The second edition of the book was published in 2003, fourteen years before this project was started. The book’s focus is investigating process-related incidents. Whilst the book was written for chemical process safety incidents, the basic concepts and provided examples are equally applicable to other industries with hazardous situations like mining and manufacturing. A major revision in the book is an increased emphasis on investigating near-miss and minor incidents. Another goal for the book project was to make it globally applicable. The book was extensively reorganised and consolidated.
Failure analysts have an opportunity to prevent "repeat" failures by performing good investigations and then passing on those findings to interested individuals and clients. Failure analyses are often performed for major failures. But what about near misses and precursors to major failures? Are they getting investigated?
Determining what happened is the first critical step in establishing why an incident occurred and the wider learning that can be gained from a more thorough investigation of the cause. A common mistake in incident investigation is trying to determine the “root cause” before determining the immediate causes of an incident.
Twenty five years ago, a major disaster in the North Sea took the lives of 165 persons on board the Piper Alpha oil production platform as well as 2 people from the rescue crew. To this day, the incident represents the worst offshore oil industry disaster ever and has become an industry- changing watershed event.
Learning from experience is one of the four pillars of Risk-Based Process Safety. Incidents that occur at one facility often provide opportunities to strengthen management systems at other facilities. Sharing the technical lessons learned from incidents is morally right and vital to improving process safety performance across the process and related industries. Most incidents also involve human factors, often as a key causal factor. Understanding these performance-shaping factors can also be essential to minimizing future failures.
NFPA 921 “Guide for Fire and Explosion Investigation” provides an excellent analytical framework for individuals having the responsibility of investigating fire and explosion incidents. Further, if the investigative results have the potential of being subjected to litigation, the investigative methodology must meet legal tests for admissibility in court. Both federal and state courts require experts to employ scientific methodologies in formulating their expert opinions. NFPA 921 establishes systematic investigative and analytical techniques around the core principle of scientific methodology. NFPA 1033 “Standard for Professional Qualifications for Fire Investigators” requires the investigator to “employ all elements of the scientific method as the operating analytical process throughout the investigation and for the drawing of conclusions”. This presentation provides case study examples of forensic scientific methodology as applied to industrial petrochemical onshore and offshore incidents.
Learning from experience is one of the four pillars of Risk-Based Process Safety [1]. Incidents that occur at one facility often provide opportunities to strengthen management systems at other facilities. Sharing the technical lessons learned from incidents is morally right and vital to improving process safety performance across the process and related industries. Most incidents also involve human factors, often as a key causal factor. Understanding these performance shaping factors can also be essential to minimizing future failures.
People have inherent strengths and weaknesses which can affect their performance. Issues such as fatigue, emotional stress, and motivation can adversely affect performance. Their performance is also influenced by factors external to the individual, such as poor equipment design, inadequate training, excessive workload, and the work environment.
A natural gas fired industrial oven exploded during an attempted restart a few hours after a cold start. The explosion was caused by accumulation of natural gas during the hours preceding the restart. The oven had a fully-automated control system, and the start, shutdown, and restart were controlled by process controls and a flame safeguard system. A malfunction of the flame detector allowed the automated controls to complete the start sequence and establish normal operating status without a flame present in the burner. The UV flame sensor gave a false positive signal, which allowed unburned natural gas to enter the oven. The investigation explored the cause of the incident and the failure modes of the flame detector.
An explosion destroyed a small “Gas House” in which aerosol cans were being filled with ethylene oxide on June 24, 1997. At issue was whether the ignition occurred in the Gas House or from a remote catalytic converter. Our investigation of the pattern of blast damage supports ignition at the catalytic converter that generated a burn-back through the ducting. A strong jet ignition reached a flammable atmosphere in the Gas House and ignited an explosion that well exceeded the yield strength of the prefabricated metal Gas House in spite of the vent panels and access doors being released and discharging of the fire suppression system. One of the doors from the Gas House flew off of the building as hazardous debris, which impacted and catastrophically failed a second door located in an adjoining occupied building. This resulted in the only fatality associated with this event.
This paper addresses the potential for a loss of inerting to occur in a vessel with multiple exhaust vents due to air inleakage driven by natural convection. Air inleakage due to natural convection refers to flow induced by the density difference between the gas mixture inside the vessel and that in the exterior environment. Natural convection can result in the inleakage of air into an inerted vessel, despite the positive pressure induced by the purge gas flow. An air inleakage model was developed to predict the natural convection air inleakage rate and corresponding oxygen concentration as a function of the vessel configuration, operating conditions, exterior environment conditions, and purge gas flow rate. Examples are provided to illustrate the range of oxygen concentrations that can result from air inleakage due to natural convection. Demonstration tests were conducted to illustrate natural convective flow under relevant conditions and provide data for comparison with the model predictions. The results of this work demonstrate that the presence of multiple exhaust vents on an inerted vessel can lead to the development of a significant oxygen concentration. In some cases, the resulting oxygen concentration can exceed the minimum level required to support combustion. If the vessel is inerted to prevent the formation of a flammable gas mixture (i.e., rather than solely for product quality control), then an explosion may result if an ignition source is present.
An explosion occurred at the West Pharmaceutical Services plant in Kinston, NC, on January 29, 2003. The facility manufactured rubber parts for pharmaceutical delivery devices. The explosion occurred in the rubber compounding section of the plant, which suffered extensive damage. There were six fatalities and a number of injuries. The incident received national attention and was the subject of concurrent investigations by West Pharmaceutical Services, numerous federal and state government agencies, and dozens of third parties. In-depth investigation by West Pharmaceutical revealed that the explosion involved polyethylene dust. Unlike most dust explosions, no residual dust accumulations were found. The investigation posed major technical challenges in light of the extensive damage to the facility and injuries to key witnesses. Investigation challenges were also presented by the large number of parties conducting investigations, combined with initial concerns about a possible airplane crash or terrorist incident. The paper will focus on the investigation challenges including investigation methodology, interpretation of data, management of the investigation site, and management of information and evidence requests.
This case history illustrates an explosion at a plant powerhouse in which a number of large air compressors were operating. A fire was initiated in the demister for a set of these compressors. The demister element fire most likely resulted from the ignition of compressor exhaust valve deposits due to the formation of a hot spot on an exhaust valve. The demister element fire heated the demister vessel to the point that it failed at system pressure. The demister vessel rupture resulted in the catastrophic failure of a valve in the line to an air receiver tank holding a considerable inventory of lubricating oil. Oil entrained in the flow of air from the receiver tank through the broken line produced a flammable mixture of oil mist and air, which subsequently exploded. The oil mist explosion toppled a nearby masonry wall and caused damage to other portions of the powerhouse. The oil mist explosion (i.e., the secondary explosion) produced blast loads that were more severe than the demister vessel failure (i.e., the initial explosion). Fortunately, due primarily to the distribution of personnel in the area at the time of the event, there were no significant injuries.
In October 1988, one of the world’s largest combined loss storage tank fires occurred at a refinery located on the island of Pulau Merlimau, Singapore. At the height of the incident, the blaze involved three floating roof naphtha storage tanks, each approximately 134 feet in diameter and containing a total of 294,500 barrels of product. The resultant property loss was estimated at over U.S.$6.6 million in 1988 dollars. At several stages, the fire threatened to involve tankage in adjacent dikes containing kerosene, reformate, motor gasoline, and diesel product. Since the refinery was located on an island, equipment and manpower were ferried to the site. Despite the size of the fire and adverse logistics, firefighting efforts were successful in containing the incident to the primary dike tankage. This paper investigates the incidents leading up to the fire, operational and design engineering considerations, and analyzes the basic fire fighting strategy, pre-fire and emergency response plans, fire water management, and fixed / semi-fixed foam systems.
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