IRVING OIL REFINING
TapRooT® for Continuous Improvement
07-October-2009
Author: Theresa Guay PSM – IMT Lead Investigator
Irving Oil Refinery Saint John, New Brunswick, Canada
Irving Oil Refinery Saint John, New Brunswick, Canada
The goal of our company was to establish a consistent process to investigate incidents to the Root Cause level.
Irving Oil Refinery Saint John, New Brunswick, Canada
CHALLENGE: 1. Formalize a process for the reporting and tracking of all incidents
Irving Oil Refinery Saint John, New Brunswick, Canada
CHALLENGE: 2. Identify the Root Cause(s) of high severity / high consequence incidents
Irving Oil Refinery Saint John, New Brunswick, Canada
CHALLENGE: 3. Develop and implement “smarter” Corrective Actions to prevent recurrence
Irving Oil Refinery Saint John, New Brunswick, Canada
CHALLENGE: 4. Track incident trends to identify systemic issues which could result in high severity incidents
Irving Oil Refinery Saint John, New Brunswick, Canada
ACTION: 1. Reviewed a number of Root Cause Analysis processes
Irving Oil Refinery Saint John, New Brunswick, Canada
ACTION: 2. Selected TapRooT® as it was the best fit for our organization
Irving Oil Refinery Saint John, New Brunswick, Canada
ACTION: 3. Implemented a Web-based Database
Irving Oil Refinery Saint John, New Brunswick, Canada
ACTION: 4. Trained 15 people in the organization by enrolling them in the 5-day TapRoot® course
Irving Oil Refinery Saint John, New Brunswick, Canada
ACTION: 5. Created an Incident Management Team at the Refinery that consisted of 4 full-time Incident Investigators
Irving Oil Refinery Saint John, New Brunswick, Canada
ACTION: 6. Extended the Root Cause Analysis process on-site via: - 2-day TapRooT® training - 1-day Equifactor® training to Facilities Technicians and Maintenance personnel
Irving Oil Refinery Saint John, New Brunswick, Canada
ACTION: 7. Perform Proactive Analysis: - Loss Mgmt Instructions - Maintenance Work Practices - Process Safety Management Instruction ( in progress)
Irving Oil Refinery Saint John, New Brunswick, Canada
BEST PRACTICES: 1. Lead Investigators present to Senior Management, a summary of each Incident Investigation and the recommended Corrective Actions.
Irving Oil Refinery Saint John, New Brunswick, Canada
BEST PRACTICES: 2. Severity Assessments are performed.
Irving Oil Refinery Saint John, New Brunswick, Canada
BEST PRACTICES: 3. Risk reporting is performed using a formalized process.
Irving Oil Refinery Saint John, New Brunswick, Canada
BEST PRACTICES: 4. Near-Miss investigations are performed.
Irving Oil Refinery Saint John, New Brunswick, Canada
BEST PRACTICES: 5. A Database is used for the reporting and tracking of incidents.
Irving Oil Refinery Saint John, New Brunswick, Canada
BEST PRACTICES: 6. Proactive reports are performed.
Irving Oil Refinery Saint John, New Brunswick, Canada
RESULTS: 1. Completed 3325 Action Items 2. IMT Investigators completed investigation of 50 highseverity incidents this year
Irving Oil Refinery Saint John, New Brunswick, Canada
RESULTS: 3. IMT trained over 150 Refinery employees on-site in the 2-day TapRooT® course
Irving Oil Refinery Saint John, New Brunswick, Canada
RESULTS: 4. Identified the need for simplified Risk Reporting and implemented a formalized process
Irving Oil Refinery Saint John, New Brunswick, Canada
RESULTS: 5. Severity of injuries reported has decreased.
Irving Oil Refinery Saint John, New Brunswick, Canada
RESULTS: 6. Investigate Near–Miss incidents and “bump up” severity levels to RCA for potential high-consequence results
Irving Oil Refinery Saint John, New Brunswick, Canada
RESULTS: 8. Identify “bad actors” for equipment reliability issues 9. Focus on continuous improvement of Recordable Injury Frequency
Irving Oil Refinery Saint John, New Brunswick, Canada
RESULTS:
Irving Oil Refinery Saint John, New Brunswick, Canada
RESULTS:
Irving Oil Refinery Saint John, New Brunswick, Canada
LESSONS LEARNED: 1. Senior Management support for the successful management of Incidents and Corrective Actions is imperative.
Irving Oil Refinery Saint John, New Brunswick, Canada
LESSONS LEARNED: 2. A network-based database is a definite requirement for the effective tracking and trending of Corrective Actions .
Irving Oil Refinery Saint John, New Brunswick, Canada
LESSONS LEARNED: 3. An Organization’s culture can be successfully shifted with the support from all levels of the Organization.
Irving Oil Refinery Saint John, New Brunswick, Canada
3. An Organization’s culture can be successfully shifted with the support from all levels of the Organization.