Plants invariably suffer deviations and breakdowns. These disrupt operations and impose a financial burden. As a result, numerous sites have created detailed investigation procedures to assist in the quest for "the cause," using the focused thought process known as root cause analysis (RCA). However, differences in RCA methodologies used and in the expertise of staff may lead to inconsistencies that complicate efforts.
The Axiall Lake Charles, La., chemicals complex has taken deliberate steps to improve its RCA process, to turn it into a consistent and comprehensive tool that provides the best possible opportunity to determine true root causes. At a minimum, this consistency of effort now lets us get closer to the actual culprit than ever before.
As with most techniques, an RCA process — if used incorrectly or incompletely — may not be worth the time spent attempting to determine true causal factors for any given incident. Our process, which has been in place for well over a decade, had experienced shortcomings, leading to a premature stop at mere physical and human contributors to daily deviations rather than digging deeper into the underlying root causes. Hopefully, the changes we made to achieve a consistent and effective process may give you ideas for improving your site's RCAs.
IMPROVING THE RCA
The logical starting point is determining whether or not an RCA process is in place at all. Without proper guidance, individual work units may allow incidents to "fly under the radar" with only a cursory investigation.
At Lake Charles, the unit level supervisors provide the first level of accountability, reviewing the operational logbook and process information and advising operating units regarding use of the RCA process. Until 2008, only the most significant incidents went through the RCA process, with more-prevalent incidents such as near misses or chronic issues either not addressed to today's extent or dealt with on a local level. In addition, there were numerous occasions of less-than-adequate communication of incident particulars across the entire facility.
In 2008, the site established the RCA specialist position to guide the incident "owner" through the entire process of scheduling, facilitating and publishing a completed formal investigation. Our incident-reporting-and-investigation process safety management (PSM) document drives critical investigation aspects. Depending upon the severity and nature of the incident, a formal RCA may be required.
The RCA specialist aids the facility in managing and controlling not only the quality and consistency of RCAs but also ultimately the quantity. Approximately one third of the 700 RCAs conducted since 2008 have been focused on incidents that previously might have received little, if any, attention. The number of non-required analyses has increased since the specialist's position was created (Figure 1 ). From an oversight standpoint, having a dedicated person (or several) manage the entire process is essential to cultivating RCA consistency.
Mere quantity doesn't guarantee consistency. Results of in-house investigations conducted by individual units largely depend upon the skills of the facilitator. In addition, a unit-only group conducting the RCA may exhibit some level of bias, unintended or otherwise. We established a pool of more than a dozen trained and independent facilitators from various areas of the complex to eliminate most of the local bias effect. The RCA specialist, who also has been trained in facilitation, serves as a facilitator in over half of RCAs conducted, and assigns the other facilitators so as to ensure not only an independent voice in the meeting but also an even distribution of facilitation responsibilities.
Prospective facilitators go through a formal training process to ensure quality and consistency. Volunteers start with an 8-hr "RCA Basics" training session. Participants then attend a specific RCA facilitator class, followed by an internship that includes: observing a meeting, navigating the RCA software while another facilitator guides the actual RCA. The internship continues until the person is comfortable with all aspects of the meeting. Graduate facilitators also get a specific checklist for each RCA meeting they will handle.
Once the person begins conducting RCAs on a solo basis, the RCA specialist periodically observes the facilitator for quality and consistency. Upon completion of the RCA meeting, incident owners receive an evaluation form, allowing customer feedback on facilitator performance. While use of this form was initiated as an optional training tool, it has evolved into a well-received aid for both facilitators and incident owners alike.
Besides ensuring facilitators are well trained, we enhance consistency during RCA meetings by using software to create cause-and-effect diagrams and then to generate a finished RCA report.