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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
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
Upset Definition
An unplanned shutdown of critical equipment
during normal operation which may lead to
production losses.
Problem Statement
Top Management Statement:
We would like a team to work on identifying the root
causes of the nuisance and repetitive upsets!
Forming Investigation Committee
• Management appointed a leader from Maintenance
• Leader selected members from operations (customer),
maintenance and engineering
• Committee members = 5
Op Manager Maint. Manager
Team Leader
DCS Engineer Process Engineer Electrical Engineer Mechanical Engineer
Investigation Methodology
Kickoff meeting was started by the team leader and a
Weekly meeting was scheduled which lasted for 4
hours
Investigation Methodology
Initial Review Review of Current External Personnel
of archived reports Investigation system Benchmarking Interviews
Investigation Methodology
INSTRUMENTATION
5% 5% Initial Review
HUMAN ERROR 18% of archived reports
56%
ELECTRICAL 11% 5%
MECHANICAL Review of Current
PROCESS RELATED Investigation system
UNKNOWN
External
Benchmarking
Personnel
Interviews
Investigation Methodology
Investigation Workflow
Equipment Collect Data Ops. Foreman Trip Meeting Recommendation
Trip (Supv Opr) Calls for meeting
Initial Review
(All) & Action plan
of archived reports
End Review of Current
Investigation system
Report Workflow (Manual)
Enter Data Verify Data Ops Area Engineer Engineering External
(Supv Opr) Foreman Review Review Benchmarking
Personnel
Division Heads Reliability Unit
End
Review & Remarks Review
Interviews
Investigation Methodology
Trip per equipment per year
Initial Review
2.5
of archived reports
2
Review of Current
1.5 Investigation system
Trip Inex
1
0.5 External
Benchmarking
0
Company A Company B Compay C Company D Company E
1 2.2 1.4 0.2 0.5
Companies Personnel
Interviews
Investigation Methodology
Initial Review
of archived reports
• Current quality of Investigation Review of Current
• Personnel satisfaction of current system Investigation system
• Hidden back breaks
• Expectations
External
benchmarking
Personnel
interviews
Implementation Roadmap
Start
Develop Team Develop Team
Name Mission
Study
Methodologies
Qualitative Quantitative
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
Quantitative Methodologies
By Category
3%
5%
5%
Instrumentation
13%
Mechanical
Electrical
50%
Human Error
Process
Unknown
24%
(%)
0
2
6
8
4
10
12
16
18
20
14
Plant A
Plant B
Plant C
Plant D
Plant E
Plant F
Plant G
Plant H
Plant I
By Plant
Quantitative Methodologies
Plant J
Plant K
Plant L
Plant M
Plant N
Percentage
Quantitative Methodologies
By Season
43%
Winter
57% Summer
Quantitative Methodologies
By Shift
20%
S1
S2
48%
S3
32%
Quantitative Methodologies
By Equipment
2.5
St. Turbine
2.0 Ind. Motor
Gearbox
1.5
Sync. Motor
1.0
Pump
0.5 Compressor
Gas Turbine
0
Generator
Quantitative Methodologies PS Card
I/P Card
O/B Bearing ESD System
O/P Card
Instrument Loop
Vibration Controller
I/B Bearing ESD System
Field JB
Instrument Loop
Probe
Instrument
Governor O/B Bearing
Proximater
….
Thrust Bearing ESD System
ESD System Instrument Loop
P Switch
Lube Oil PS Card
T. Switch
Instrument Loop
I/P Card
Wiring Hardware
O/P Card
Steam Turbine
Steam Turbine Mechanical
Temperature O/B Bearing ESD System Software Controller
Instrument Loop PIB Cabinet
Instrument Cable
I/B Bearing ESD System Field JB
Instrument Loop RTD
RTD Installation
Process Specification
Thrust Bearing ESD System Wiring
Instrument Loop
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
Implementation Roadmap
Start
Develop Team Develop Team
Name Mission
Study
Methodologies
Qualitative Quantitative
Qualitative Methodology
Start
Investigation Workflow
Upset occurs
Equipment Collect Data Ops. Foreman Trip Meeting Recommendation
Trip (Supv Opr) Calls for meeting (All) & Action plan
Fill out DB
(Oper. Supv. &
Maint. Crew)
Form End
Inv. Team
Report Workflow (Manual)
Initial
Assessment
Equipment
With Action Plan Collect Data Verify Data Ops Area Engineer Engineering
Trip (Supv Opr)
No Foreman
No Review
No Review
No
Fill DB Sections Rel. Supv. Yes Eng. Supv. Yes Maint. Supt. Yes Oper. Supt.
RCA, Recommendations Approval Approval Approval Approval
Division Heads Reliability Unit
End
Review & Remarks Review Yes
Generate
Final Report
RCA program Gant Chart
Implementation Roadmap
Start
Develop Team Develop Team
Name Mission
Study
Methodologies
Qualitative Quantitative
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
Lessons learned
1. Top management commitment
2. Multidiscipline and homogenous team
3. Empowered team under the supervision of one leader
4. Unlimited resources
Construction Engineering & Management
Quality Management
CEM 515
Root Cause Analysis Program
Term Paper
Jan 21, 2006
Presented by: Mohammed A. Al-Dossary
ignificant
rocess
SPURT
psets
eview
eam SPURT
back
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
Team Name & Mission
Team Name & Mission
back
Root Cause Analysis Section
Built-in Library of fault trees
back
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