Root Cause Analysis Enhancement

1. Construction Engineering & Management Quality Management CEM 515 Root Cause Analysis Enhancement Term Paper Jan 21, 2006 Presented by: Mohammed A. Al-Dossary Abqaiq Plants Today film

2. 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

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

4. Problem Statement Top Management Statement: We would like a team to work on identifying the root causes of the nuisance and repetitive upsets! We don’t want more upsets please!

5. Team Leader DCS Engineer Process Engineer Electrical Engineer Mechanical Engineer Forming Investigation Committee • Management appointed a leader from Maintenance • Leader selected members from operations (customer), maintenance and engineering • Committee members = 5 Maint. Manager Op Manager

6. Investigation Methodology Kickoff meeting was started by the team leader and a Weekly meeting was scheduled which lasted for 4 hours

7. Investigation Methodology Initial Review of archived reports Review of Current Investigation system External Benchmarking Personnel Interviews

8. Investigation Methodology Initial Review of archived reports Review of Current Investigation system External Benchmarking Personnel Interviews

9. Collect Data (Supv Opr) Ops. Foreman Calls for meeting Equipment Trip Trip Meeting (All) Recommendation & Action plan Enter Data (Supv Opr) Verify Data Ops Foreman Area Engineer Review Engineering Review Division Heads Review & Remarks Reliability Unit Review Investigation Methodology Investigation Workflow Initial Review of archived reports End Review of Current Investigation system Report Workflow (Manual) External Benchmarking Personnel Interviews End

10. Investigation Methodology Initial Review of archived reports Review of Current Investigation system External Benchmarking Personnel Interviews

11. 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

12. Start Develop Team Mission Develop Team Name Study Methodologies Qualitative Quantitative Implementation Roadmap

13. Quantitative Methodologies • Identified the data boundaries • Identified data population = 400 • Gathered all data for 4 years • Designed Q&D Access Database • Used Minitab to generate statistical analysis

14. Instrumentation Mechanical Electrical Human Error Process Unknown Quantitative Methodologies By Category 3% 5% 5% 13% 50% 24%

15. Quantitative Methodologies By Plant 20 18 16 14 12 (%) Percentage 10 8 6 4 2 0 Plant M Plant G Plant A Plant B Plant C Plant D Plant H Plant K Plant N Plant E Plant F Plant L Plant J Plant I

16. Quantitative Methodologies By Season 43% Winter 57% Summer

17. Quantitative Methodologies By Shift 20% S1 S2 48% S3 32%

18. St. Turbine Ind. Motor Gearbox Sync. Motor Pump Compressor Gas Turbine Generator 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

19. Field JB Probe Proximater …. RTD SteamTurbine 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 Installation RTD Instrument Loop Specification Process Wiring Thrust Bearing ESD System Instrument Loop

20. 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

21. Start Develop Team Mission Develop Team Name Study Methodologies Qualitative Quantitative Implementation Roadmap

22. Investigation Workflow Online Database Built-in Root Cause Analysis Data Consolidation Collect Data (Supv Opr) Ops. Foreman Calls for meeting Equipment Trip Trip Meeting (All) Recommendation & Action plan End Report Workflow (Manual) Collect Data (Supv Opr) Verify Data Ops Foreman Equipment Trip Area Engineer Review Engineering Review Tracking System Division Heads Review & Remarks Reliability Unit Review End Qualitative Methodology Start Upset occurs Fill out DB (Oper. Supv. & Maint. Crew) Form Inv. Team Initial Assessment With Action Plan No No No No Oper. Supt. Approval Rel. Supv. Approval Eng. Supv. Approval Maint. Supt. Approval Yes Fill DB Sections RCA, Recommendations Yes Yes Yes Generate Final Report

23. RCA program Gant Chart

24. Start Develop Team Mission Develop Team Name Study Methodologies Qualitative Quantitative Implementation Roadmap

25. 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

26. Lessons learned • Top management commitment • Multidiscipline and homogenous team • Empowered team under the supervision of one leader • Unlimited resources

27. Construction Engineering & Management Quality Management CEM 515 Root Cause Analysis Program Term Paper Jan 21, 2006 Presented by: Mohammed A. Al-Dossary Thank you!

28. ignificant rocess S P U R T psets eview SPURT eam back

29. 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

30. Team Name & Mission

31. Team Name & Mission back

32. Root Cause Analysis Section Built-in Library of fault trees back