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
www.taproot.com
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