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Solving and Preventing Problems - Root Cause Analysis and Failure Mode and Effect Analysis.ppt

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Solving and Preventing Problems - Root Cause Analysis and Failure Mode and Effect Analysis

* The BP monitoring case is a handout. Have small groups use one of the RCA tools to analyze the case. The case, and an answer key, is available online. Solving and Preventing Problems Root Cause Analysis Failure Mode and Effect Analysis Professor James A. Hewett New York Hub Director, Northeast Biomanufacturing Center Professor of Biology, Finger Lakes Community College Goals for Workshop Introduce you to the concepts of RCA and FMEA Review examples of where RCA tools are applied Immerse you in some problem solving activities Direct you to resources for further study (Note: We do not expect to make you RCA and FMEA experts) A structured investigation that aims to identify the true cause of a problem and the actions necessary to eliminate it RCA is a problem solving process A tool that enables the identification and prevention of process or product errors before they occur FMEA is a problem prevention process March 23rd, 2005Texas City, TX BP refinery Isomerization unit startup Liquid hydrocarbons released from blowdown drum Subsequent vapor cloud explodes 15 killed, 180 injured BP Isom Unit VideoRefinery investigation animation Putting you to work(without “tools”) Define the Problem Identify Cause(s) Which causes are at the ROOT (ultimate causes) Suggest Potential Solutions for BP BP’s RCA of the Texas City Event Fault or Logic Tree Analysis Root Causes Senior executives: inadequately addressed controlling major hazard risk. did not provide effective safety culture leadership did not provide resources to prevent major accidents BP Texas City Managers did not: create an effective reporting and learning culture ensure supervisors enforced plant policies and procedures. incorporate good practice design in the operation of the ISOM unit. ensure that operators were supervised and supported by experienced, technically trained personnel during unit startup effectively incorporate human factor considerations in its training, staffing, and work schedule for oper