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.