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Re: [Root_Cause_State_of_the_Practice] $30 Million Mix-up

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  • Dr. Bill Corcoran
    Bill Salot, RHU=Resid Hydrotreater Unit I pasted a better MOM below. What can you suggest for adding? Take care, Bill Corcoran Mission: Saving lives, pain,
    Message 1 of 8 , Oct 17, 2006
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      Bill Salot,
       
      RHU=Resid Hydrotreater Unit
       
      I pasted a better MOM below.
       
      What can you suggest for adding?
       
      Take care,
       
      Bill Corcoran
      Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
      Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
       
      W. R. Corcoran, Ph.D., P.E.
      NSRC Corporation
      21 Broadleaf Circle
      Windsor, CT 06095-1634
      Voice and voice mail: 860-285-8779
      Fax and voice mail to e-mail: 206-888-6772
      ROOT CAUSE INVESTIGATION HELP LINE 860-295-8779
       
      Join the USS Scorpion Electronic Court of Inquiry by sending an e-mail to USS_Scorpion_SSN-589-subscribe@yahoogroups.com
       
      Join the on-going discussion of Root Cause Analysis problems, puzzles, and progress at http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/  
       
      Subscribe to "The Firebird Forum" by sending an e-mail to TheFirebirdForum-subscribe@yahoogroups.com

      Yahoo! Groups

      Name:  BP $30,000,000 Fire Missed Opportunity Matrix

      Table Description:  The central cause was a material mix-up, but there were multiple opportunities for multiple ordinary individuals to prevent the event by doing ordinary things ordinarily well. What were they?
      Time Sequence (10=Latest, 0=Earliest) vOrder of Importance (10=High, 0=Low)Who had the opportunity?What was the situation in which the opportunity existed?What was the action opportunity?What would the effect have been?How would this have changed the consequences?CommentComment/ ReferenceRelative Cost (10=High, 0=Low)
      0.110.0BPWriting Design StandardRequire Mistake Proofing as a Design PrincipleMistake Proofing Applied to Resid Hydrotreater Unit (RHU) Design, e.g., prevent the mistake of mixing up carbon steel with alloy steel.No mix-up. No event. No consequences.This is too vague.http://www.csb. gov./index. cfm?folder= news_releases& page=news& NEWS_ID=3121.0
      0.110.0BPWriting Design StandardRequire Failure Modes and Effects Analysis on expected maintenance sequences.Identification that mixing up carbons steel with alloy steel would lead to severe accident.Mix-up would probably have been prevented.Vague. 1.0
      0.110.0BPWriting Maintenance StandardRequire distinct marking of all components before disassembly. Require official drawing showing markings and locations.Components would have been properly installed.No mix-up. No event. No consequences.Specific, reasonable. 1.0
      0.51.0BPCorporate Program DesignDeploy a "Material Verification Program."Carbon steel elbow would have been identified after it had been installed.Elbows would have been properly relocated. No event. No consequences.This was recommended by CSB.CSB Safety Bulletin No. 2005-04-B|October 12, 20065.0
      1.010BP DesignersDesign of Resid Hydrotreater Unit (RHU)Design carbon steel elbow such that it is not interchangeable with alloy steel elbows.Mix-up would have been impossible.No mix-up. No event. No consequences.This is an example of Mistake Proofing. 1.5
      1.510.0BP DesignersDesign of Resid Hydrotreater Unit (RHU)Order all three elbows to be identical and made of alloy steel.Mix-up would have been impossible or it wouldn't matter, however one looks at it.No event. No consequencesVariation is the enemy of quality.This is an example of Mistake Proofing.1.5
      5.010BP PurchasingDrafting RFQ for Outsourced MaintenanceRequire distinct marking of all components before disassembly. Require official drawing showing markings and locations.Components would have been properly installed.Components would have been properly installed.There should be a database of lessons to be learned for RFQ drafters. 1.0
      8.010.0JV Industrial Companies (the maintenance contractor)Job PlanningRequire distinct marking of all components before disassembly. Require official drawing showing markings and locations.Components would have been properly installed.Components would have been properly installed.Contractors seldom do more than the client requires. 1.0
       

      ----- Original Message -----
      Sent: Tuesday, October 17, 2006 3:21 PM
      Subject: RE: [Root_Cause_State_of_the_Practice] $30 Million Mix-up

      What does RHU mean?


      From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of Dr. Bill Corcoran
      Sent: Tuesday, October 17, 2006 8:56 AM
      To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
      Subject: Re: [Root_Cause_ State_of_ the_Practice] $30 Million Mix-up

      Bill Salot,

      Thanks.

      This is a rich event.

      I started a Missed Opportunity Matrix (MOM) at

      It is pasted below.

      All are invited to add records and/or to tell me what to add/change.

      Take care,
       
      Bill Corcoran

      Yahoo! Groups

      Name:  BP $30,000,000 Fire Missed Opportunity Matrix

      Table Description:  The central cause was a material mix-up, but there were multiple opportunities for multiple ordinary individuals to prevent the event by doing ordinary things ordinarily well. What were they?

      Time Sequence (10=Latest, 0=Earliest) v

      Order of Importance (10=High, 0=Low)

      Who had the opportunity?

      What was the situation in which the opportunity existed?

      What was the action opportunity?

      What would the effect have been?

      How would this have changed the consequences?

      Comment

      Comment/ Reference

      Relative Cost (10=High, 0=Low)

      0.1

      10.0

      BP

      Writing Design Standard

      Require Mistake Proofing as a Design Principle

      Mistake Proofing Applied to RHU Design, e.g., prevent the mistake of mixing up carbon steel with alloy steel.

      No mix-up. No event. No consequences.

      This is too vague.

      http://www.csb. gov./index. cfm?folder= news_releases& page=news& NEWS_ID=312

      1.0

      0.1

      10.0

      BP

      Writing Design Standard

      Require Failure Modes and Effects Analysis on expected maintenance sequences.

      Identification that mixing up carbons steel with alloy steel would lead to severe accident.

      Mix-up would probably have been prevented.

      Vague.

      1.0

      0.1

      10.0

      BP

      Writing Maintenance Standard

      Require distinct marking of all components before disassembly. Require official drawing showing markings and locations.

      Components would have been properly installed.

      No mix-up. No event. No consequences.

      Specific, reasonable.

      1.0

      ----- Original Message -----

      Sent: Monday, October 16, 2006 8:39 PM

      Subject: RE: [Root_Cause_ State_of_ the_Practice] $30 Million Mix-up

      Bill C,

      I share your “concern” about CSB’s recommendation to use an X-ray fluorescence analyzer when re-assembling components.  Manufacturers typically mark their pipe elbows with the correct ASTM material spec and grade.  If true in this case, there is little point in applying the alloy “analyzer” to confirm the ID of the material.  The pipefitters may still install the elbows in the wrong place.  To avoid installing the right elbow in the wrong place, the use of “match marks” would be simpler and surer.  Pipefitters understand the purpose of “match marks”, but are not much on X-ray fluorescence.

      But I don’t share your chagrin about CSB failing to use the term “mix-up”.  What difference would it make if they did use it?

        

      Bill Salot


      From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of Dr. Bill Corcoran
      Sent: Sunday, October 15, 2006 1:43 PM
      To: Undisclosed- Recipient: ;
      Subject: [Root_Cause_ State_of_ the_Practice] $30 Million Mix-up

      Here's another one for your mix-up folder.

      I note with chagrin that CSB does not use the term mix-up.

      I am also concerned that CSB doesn't mention any of the low-tech, but tried and true methods of making sure that things are put back together the way they were before they were taken apart.

      Your tax dollars at play?

      OBTW: BP seems to have had a really bad year or two. Who knows about their safety culture? 

      Take care,
       
      Bill Corcoran



      CSB Issues Safety Bulletin on BP Texas City Major Fire: Better Material Identification Needed, Errors During Systems Maintenance Cited; Fire Caused $30 Million in Property Damage

      The following message is from the U.S. Chemical Safety Board, Washington , D.C.

      Houston, Texas, October 15, 2006- The U.S. Chemical Safety Board (CSB) issued a safety bulletin and new safety recommendations today based on the investigation of the July 28, 2005, hydrogen fire in the resid hydrotreater unit (RHU) at the BP refinery in Texas City, Texas.

      The fire occurred four months after the explosion in the refinery’s isomerization (ISOM) unit that killed 15 workers and injured 180.  The July 28 fire caused $30 million in property damage.  Weeks later, this accident was also cited in the CSB’s urgent recommendation for BP to examine its safety culture at all its North American refineries.

      The fire occurred at about 6:00 p.m. on the evening of July 28 when a piping elbow failed catastrophically and without warning, releasing highly flammable hydrogen gas at high temperature and pressure which immediately ignited.  A huge fireball erupted and a fire burned for approximately two hours.

      The safety bulletin notes that the piping system for an RHU heat exchanger contained three elbows of identical dimensions and appearance.  Two elbows were constructed of alloy steel and were resistant to the effects of high-temperature hydrogen, but the third elbow was made of carbon steel, which is not resistant.

      In February 2005, five months prior to the fire, the unit was shut down for routine scheduled maintenance.  During the maintenance shut down, the contractor JV Industrial Companies inadvertently switched the positions of the carbon steel elbow with one of the alloy steel elbows, placing a carbon steel elbow on the outlet side of the heat exchanger, where it would be exposed continuously to high-temperature hydrogen.  The investigation found that BP had not informed the maintenance contractor that the elbows were not interchangeable.

      Lead Investigator John B. Vorderbrueggen, PE, said “Merely disassembling and reassembling piping components during maintenance resulted in an unacceptable hazardous system modification.  BP should have required positive materials verification of these pipe elbows using an x-ray fluorescence test device.  This would have identified the mistake in the reassembly of the identically appearing elbows before the unit was returned to service.  The accident would not have occurred.”

      The fire resulted in a Level 3 community shelter-in-place alert in Texas City .  Level 3 is the second highest emergency classification that applies to an incident where the situation is not under control and protective action may be necessary for the surrounding or offsite area.  The Board issued several formal safety recommendations. The BP Texas City Refinery was urged to revise its maintenance program to include materials testing or verification of all alloy steel piping components and to inform work crews of material handling precautions. 

      The Board also recommended that JV Industrial Companies update its piping component installation procedures to require material identification for components removed during maintenance to ensure they are reinstalled in the correct locations.

      “There are important safety lessons for oil and chemical companies from this incident,” said CSB Chairman Carolyn W. Merritt.  “Positive materials verification of the components in piping systems can avoid simple mix-ups that can have devastating consequences.”  The bulletin also emphasized what is termed “human factors based design” – that is, designing components so that foreseeable human errors are less likely to occur.

      The safety bulletin and recommendations were issued at a news conference in Houston on Sunday, October 15, at 11 a.m.  The CSB’s investigation of the ISOM unit accident remains ongoing with a final report expected in the first part of 2007.  CSB lead investigator Don Holmstrom and his team have been continuing to conduct interviews of top BP executives and gathering additional documentary evidence.

      The CSB is an independent federal agency charged with investigating industrial chemical accidents.  The agency’s board members are appointed by the president and confirmed by the Senate.  CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in safety management systems.  The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA.  Please visit our website, www.CSB.gov.

      For more information, contact Daniel Horowitz (202) 441-6074 cell or Jennifer Jones (202) 577-8448 cell.

      This message was transmitted at 12:30 PM Eastern Time ( U.S.A. ) on October 15, 2006.

      Visit us on the World Wide Web at http://www.csb. gov

    • Michael Mulligan
      I think knowing the exact cause to the BP mix-up explosion creates more of an illusion in our minds, than in clarity of what caused it. It would be better if
      Message 2 of 8 , Oct 18, 2006
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        I think knowing the exact cause to the BP mix-up explosion
        creates more of an illusion in our minds, than in clarity of
        what caused it. It would be better if the accident vaporized
        the elbows...and we really had no idea what caused it. These
        real factors just gives us the illusion that we know what
        caused it. Better yet, it removes the necessity of looking for
        the real causes...of creating real changes in order to remove
        the threat of massive human rights abuses....the right to work
        in an environment without the threat of death and injury.

        Everyone knows what the real cause(s) with these accidents at
        BP...we got a fundamental dysfunction in our free market and
        political system in order to maintain price, capacity factor
        and reliability of the refinery system....in order to keep us
        away from chaos with this sector of the energy sector.

        The dysfunction is characterized by having decades of
        inadequate investment and inadequate modernization in our
        refineries...of having decades of these refineries for the
        public good, being maintained at extremely high and dangerous
        capacity factures....with poor and getting poorer quality of
        maintenance of these facilities. Fundamentally, contractor
        services in safety applications creates insurmountable
        communications and control problems....it blinds the owner
        organization from having a clear view of what’s going on in
        their property. The owner organization doesn’t having much
        control in maintaining training and quality of employees
        within contractual services...but it makes for lazy
        executives.

        So why isn’t the free market creating order and investment
        stability within the refinery business....brutally punishing
        chaos and disorder...rewarding humane efficiencies and
        adequate excess capacity for safe maintenance...they are
        taking about an additional 100 million increase in our
        population by 2048...25%...it’s appalling and dangerous with
        us not planning for our future and our kids future. Think
        about what the refining business will look like in 10 years.

        Most of us get their municipal water from these great public
        works programs such as our reservoir and water projects. What
        would we think of our grand-fathers if they didn't plan and
        build these monuments of public good...these guys though about
        25 and 50 years ahead with their planning?

        What a disgrace this generation is with playing our role
        within human history. You bet...it's about the culture of the
        whole industry...and what they think their role is in
        providing for the public good!

        Blaming the latest BP accident on mismatched elbow metals...is
        like puting out a umbrella within the first rain drops of
        Katrina...hey, I am dry now.

        Thank
        mike mulligan
        Hinsdale, NH






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      • Salot, William
        Bill C, Your Missed Opportunities Matrix (MOM) below looks complete to me. Here is a comment related to the utilization of the MOM in an RCA: Notice what is
        Message 3 of 8 , Oct 19, 2006
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          Bill C,

           

          Your “Missed Opportunities Matrix” (MOM) below looks complete to me.

           

          Here is a comment related to the utilization of the MOM in an RCA:

           

          Notice what is listed in Column 5 of the MOM under the heading, “What was the action opportunity?”  The entries in that column look like “actions” that should be “recommended” by the RCA team.  Such recommendations are presumably what stakeholders want and expect, and certainly what they need from RCAs.  The investigation by CSB missed most of them.

           

          What are the implications of Column 5?

           

          1. I can’t think of a single “recommended action” that could not have been done earlier.

           

          The fact that any “recommended action” was not done earlier means, by definition, that it must have been a “missed opportunity” in the past.

           

          If any “missed opportunity” was an adverse factor, then it automatically generates its own “recommended action”.  

           

          Doesn’t that mean the real purpose of RCA is not to identify “root causes”, but instead to identify “missed opportunities”?

           

          1. I notice that you developed the MOM below without first building a “factor tree”.

           

          Now we need to discuss the purpose of a “factor tree”.

           

          Doesn’t your demonstrated ability to determine “recommended actions” without a “factor tree” indicate that “factor trees” are unnecessary?

           

          All this has me in a dither.

           

          Bill Salot

           


          From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto: Root_Cause_State_of_the_Practice@yahoogroups.com ] On Behalf Of Dr. Bill Corcoran
          Sent: Tuesday, October 17, 2006 4:49 PM
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Subject: Re: [Root_Cause_State_of_the_Practice] $30 Million Mix-up

           

          Bill Salot,

           

          RHU=Resid Hydrotreater Unit

           

          I pasted a better MOM below.

           

          What can you suggest for adding?

           

          Take care,
           
          Bill Corcoran

          Yahoo! Groups

          Name:  BP $30,000,000 Fire Missed Opportunity Matrix

          Table Description:  The central cause was a material mix-up, but there were multiple opportunities for multiple ordinary individuals to prevent the event by doing ordinary things ordinarily well. What were they?

           

          Time Sequence (10=Latest, 0=Earliest) v

          Order of Importance (10=High, 0=Low)

          Who had the opportunity?

          What was the situation in which the opportunity existed?

          What was the action opportunity?

          What would the effect have been?

          How would this have changed the consequences?

          Comment

          Comment/ Reference

          Relative Cost (10=High, 0=Low)

          0.1

          10.0

          BP

          Writing Design Standard

          Require Mistake Proofing as a Design Principle

          Mistake Proofing Applied to Resid Hydrotreater Unit (RHU) Design, e.g., prevent the mistake of mixing up carbon steel with alloy steel.

          No mix-up. No event. No consequences.

          This is too vague.

          http://www.csb. gov./index. cfm?folder= news_releases& page=news& NEWS_ID=312

          1.0

          0.1

          10.0

          BP

          Writing Design Standard

          Require Failure Modes and Effects Analysis on expected maintenance sequences.

          Identification that mixing up carbons steel with alloy steel would lead to severe accident.

          Mix-up would probably have been prevented.

          Vague.

           

          1.0

          0.1

          10.0

          BP

          Writing Maintenance Standard

          Require distinct marking of all components before disassembly. Require official drawing showing markings and locations.

          Components would have been properly installed.

          No mix-up. No event. No consequences.

          Specific, reasonable.

           

          1.0

          0.5

          1.0

          BP

          Corporate Program Design

          Deploy a "Material Verification Program."

          Carbon steel elbow would have been identified after it had been installed.

          Elbows would have been properly relocated. No event. No consequences.

          This was recommended by CSB.

          CSB Safety Bulletin No. 2005-04-B|October 12, 2006

          5.0

          1.0

          10

          BP Designers

          Design of Resid Hydrotreater Unit (RHU)

          Design carbon steel elbow such that it is not interchangeable with alloy steel elbows.

          Mix-up would have been impossible.

          No mix-up. No event. No consequences.

          This is an example of Mistake Proofing.

           

          1.5

          1.5

          10.0

          BP Designers

          Design of Resid Hydrotreater Unit (RHU)

          Order all three elbows to be identical and made of alloy steel.

          Mix-up would have been impossible or it wouldn't matter, however one looks at it.

          No event. No consequences

          Variation is the enemy of quality.

          This is an example of Mistake Proofing.

          1.5

          5.0

          10

          BP Purchasing

          Drafting RFQ for Outsourced Maintenance

          Require distinct marking of all components before disassembly. Require official drawing showing markings and locations.

          Components would have been properly installed.

          Components would have been properly installed.

          There should be a database of lessons to be learned for RFQ drafters.

           

          1.0

          8.0

          10.0

          JV Industrial Companies (the maintenance contractor)

          Job Planning

          Require distinct marking of all components before disassembly. Require official drawing showing markings and locations.

          Components would have been properly installed.

          Components would have been properly installed.

          Contractors seldom do more than the client requires.

           

          1.0

           

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