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Departments: Quality Applications

Root Cause Analysis Solves Complex Problem


Corrective Action Tracking System Improves Data Access





Root Cause Analysis Solves Complex Problem
System Improvements' TapRoot System

Huntsman Corp. manufactures basic products for a number of global industries, including chemicals, plastics, automotive, footwear, construction, paints and coatings, health care, detergent, personal care, and packaging. The family-owned business has 13,000 associates worldwide focusing on global petrochemicals, specialty chemicals, surface sciences and tioxide businesses.

Huntsman wanted to find a consistent, effective root cause analysis tool that it could use to solve problems and improve performance. During the testing and integration period for a large petrochemical manufacturing process, a large tank collapsed due to the rapid condensation of steam that was being used to clean the tank prior to maintenance work. The rapid condensation occurred when the deluge system was accidentally activated after an electrician removed a faulty bulb in one of the relays for that system's electrical power supply. The collapse of the process tank caused severe damage to the tank and significant costs for its replacement.

Huntsman sought to quickly investigate and learn how to prevent the recurrence of the collapsed process tank within the two weeks the repairs were being made and without requiring excessive support of plant personnel. The investigation was performed at a facility licensed to use the TapRooT System.

TapRooT, by System Improvements, is a systematic method for analyzing quality, safety, production or maintenance problems, finding the problems' fixable root causes and developing effective corrective actions.

System Improvements, based in Knoxville, Tennessee, has worked with a number of Fortune 500 companies and major corporations around the world. Typical industries using TapRooT to improve performance include pharmaceuticals, oil and gas, utilities, nuclear plants, hospitals, airlines, railroads, mines and chemical plants. System Improvements has helped companies sharpen their root cause analysis to improve product quality, operations and maintenance and reduce accidental environmental damage.

Normally, to learn the techniques used in the TapRooT System, either a two-day Incident Investigation and Root Cause Analysis course or five-day Advanced TapRooT Investigation Team Leader course is needed. One Huntsman employee, Don Guidry, had attended a five-day course, and the site had a two-day on-site course to train additional investigators. However, none of the people involved in this incident had been "TapRooT trained." So Guidry, a TapRooT-trained facilitator, was chosen to lead the investigation.

It took four sessions--a total of nine hours--to complete the investigation and develop corrective actions that would help prevent a similar incident from recurring.

In this short period of time, TapRooT helped Huntsman logically and quickly lay out what happened and understand the specific root causes. Huntsman found an issue concerning the reluctance to remove any safeguard from service--like the deluge system--when a system is removed from service for maintenance. Other issues uncovered included how to decide when a safeguard should be disabled and when to disable the safeguard. Huntsman is convinced that it would not have uncovered this generic problem if it had not used TapRooT.

The efficiency of the investigation process and the ability of the team to quickly adapt to TapRooT was impressive. Just nine hours of team time were used to investigate a complicated production problem. This investigation was conducted during hectic "turnaround" tempo operations with minimal impact on the operations and maintenance organization.

As a result of this investigation, the company instituted a new checklist to be used during preparation for taking systems out of service. This checklist addresses the effect of safeguards that will be left in service, the hazards posed by safeguards left in service and, if a safeguard is to be taken out of service, the process and timing for removing it.

"After reviewing our past experience," says Guidry, "we estimate that the insight from lessons learned from this one incident could save Huntsman more than $1 million a year by eliminating the sometimes expensive and dangerous unplanned events that happen during maintenance."

System Improvements' TapRoot System


  • Helps meet or exceed OSHA regulation, ISO 9000 guidelines, NRC regulation, DOE Orders, EPA RMP, DOT regulations and JCAHO requirements
  • Guides investigators to fixable root causes for accidents
  • Help TQM problem analysis