Success Story

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					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.


				
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posted:10/27/2009
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Description: Success Story was a presentation of Irving Oil Refinery in Satin John, New Brunswick, Canada. This is a best practice presentation at the 2009 TapRooT Summit.