Smart Incident Investigations | RefinerLink
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Smart Incident Investigations

By Steve Pagani

Oct 26, 2015
 

Here are some tips on conducting smart investigations for oil refinery incidents.

 
 

Properly conducted incident investigations are extremely important to understand the vulnerabilities in your refinery. These investigations can catch issues before they achieve larger magnitudes.



 

Consider the Worst Case “What If”


Before determining if an investigation is needed or how detailed it needs to be,

 

make sure to consider the worst case scenario. Even if the incident didn’t result in a severe consequence, the worst case scenario may dictate that a very detailed investigation is needed.

 

For instance, if someone gets sprayed with cooling water during maintenance don’t ignore the incident. What if the same mistake was made in a different area of the plant and the material in the pipe was hot naphtha? Investigating smaller incidents will help prevent the catastrophic incidents.

 

The same applies for when luck is in your favor. If bucket full of tools falls from a vessel and no one is underneath should we be concerned? Of course! Because the only thing that prevented a major injury was luck. And if that’s the case, someone needs to investigate what happened and how to prevent it in the future.

 

 

Pick the Right People

 

Get the right people involved when conducting an investigation is extremely important. A high quality investigation usually involves a good mix of people. The team should generally be composed of people that are knowledgeable about the topic but have no vested interest in the outcome of the investigation.

 

Avoid picking people that are team members or supervisors of the people directly involved in the incident. It’s human nature to want to sway the team towards a conclusion that won’t direct blame towards people you know (or yourself for that matter).

 

At the same time, the team members have to be knowledgeable enough to ask good questions. If they have no relevant background the team may miss significant parts of the incident or not be able to dig deep enough into the details.

 

 

Arrive at the True Root Cause

 

Once the investigation team has been formed it is important to arrive at the true root cause, otherwise the time and effort is wasted. A vessel



overpressures during startup and relieves highly flammable material to the atmosphere. Why?

 

Because procedures weren’t followed. Is that the root cause? End of investigation? No. Why weren’t procedures followed?

It could be that procedures are never followed and it’s an acceptable practice at the site due to lack of leadership. Or that the person has performed this task hundreds of times before and felt he didn’t need to review the procedure. Or that the procedure is cumbersome and it’s easier to skip a few steps.

 

Whatever the reason is, it’s important to dig deep for the root cause. The more specific the root cause the better you can tailor the recommendation to ensure something similar doesn’t happen again.

 


Simplify the Recommendations


Let’s be honest. The simpler the task, the more likely it will get done. So when developing recommendations make sure to simplify. The recommended actions have to be effective, but they don’t have to be overly complex.



Suggestions for expensive projects and new equipment to resolve the specific issue that was discovered may sound effective but are they the best place to spend your resources. The answer might be yes but it could also be no.

 


Make sure to evaluate the justification before making the recommendation. How much are you spending and how much are you saving? If the investigation team can do that ahead of time, it’ll save the person getting the recommendation a lot of headaches.

 

Also, consider simpler but possibly just as effective mitigations. Items like training, modifications to operator rounds, operating limits, or alarm modifications can also be simple effective ways to address vulnerabilities. Not everything needs new equipment.

 
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