# APPENDIX B



# MCELMO CREEK UNIT

ROOT CAUSE FAILURE A NALYSIS

PROGRAM

McElmo Creek Unit Oil Production Facility

PSD Permit Number: NU 05

- 01

This document shall apply to and be binding upon the owner(s) and operator(s) of

the McElmo Creek Unit Oil Production Facility , including the Resolute Natural

Resources Company

.McElmo Creek Unit Root Cause Failure Analysis

PSD Permit No. NN 05

- 01 

### Root Cause Failure Analysis Program

Root Cause Failure Analysis

Root cause failure analysis (RCFA) methodology is incorporated into the standard operating procedures in the McE l mo Creek Unit field area. It provides a structured format in analyzing an event and helps to determine necessary measures to prevent future occurrences. The RCFA program includes the following components:

Step 1

– Notification

Field supervisor determines that an investigation is warranted and appoints personnel to conduct a root cause failure analysis for each Flaring Incident, except for those Flaring Incidents caused by scheduled maintenance or a CO 2 breakthrough

.

Step 2

– P lan Investigation

Once the decision is made to investigate a Flaring Incident, the investigator develops an investigation strategy. To do this an investigator can use the information initially available to develop a preliminary Snap Chart (see attachment ). This will help the investigator understand what happened, identify areas where more information is needed, and identify conflicting

information.

For each of the causal factors (problems) on the Snap Chart, the investigator can rapidly consider the que stions that need to be answered to identify root causes using the Root
Cause Tree.

With insight gained from using these two techniques, the investigator or the investigation team can plan the initial investigation strategy by:

• Identifying the key plant parameters and event times that need to be checked to verify the incident's sequence of events and technical accuracy.

• Identifying key pieces of evidence (broken parts, logbooks, chart recorders, computer printouts, etc.) that need to be collected and preserved.

• Requesting copies of the applicable procedures that should have been used during the

incident.

• Selecting an initial group of individuals for interviews to fill in gaps in the information or to resolve conflicting information.

Step 3

– Collec t Information

Collecting information (interviewing people and analyzing physical evidence) is an ongoing process throughout the investigation and crucial to understanding the incident and why it occurred. The investigator(s) are instructed to consult the TapRoot User Guides for each technique.McElmo Creek Unit Root Cause Failure Analysis

PSD Permit No. NN 05

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Step 4

– Determine Sequence of Events

An investigator or team collects several people's perceptions of what happened during an

inci dent and the problems that were associated with the activities and equipment during an incident. The investigator has to blend these various perceptions into the story of what happened. The best technique for doing this is the Snap Chart.

A Snap Chart i s an excellent graphic tool. In developing the Snap Chart, the investigator organizes the information being collected on a graphical chart to better understand it. This organization of the information often causes the re

- evaluation of assumptions or fact s that conflict with other information. This organization also helps the investigator identify gaps in logic of what happened.

When you have team investigations or if you are interviewing several people at one time, drawing a Snap Chart together helps fa cilitate gathering everyone's information and increases the effectiveness of meetings or group interviews. During individual interviews, the investigator may find it helpful to sketch a Snap Chart with the interviewee to verify their verbal

communication. The investigator should keep a master Snap Chart updated as "facts" are

verified.

Step 5

– Identify Incident's Causal Factors

Once the sequence of the incident is thoroughly understood, the investigator needs to identify all the factors that, if eliminated, would have prevented the incident from occurring or would have significantly mitigated its consequences. These factors are called causal factors.

Often investigators can identify the causal factors by simply inspecting the Snap Chart and

aski ng, "If I could remove or correct the problems identified on this chart, which ones would prevent this incident from occurring or make it less severe?" A more formal technique is called Barrier Analysis and is used as an optional approach to identifying t he causal factors (which in barrier analysis would be called broken barriers). In the next step, the investigator analyzes each causal factor for its root cause(s) using the Root Cause Tree.

Step 6

– Identify Root Causes

Once the causal factors are ide ntified, the next step is to identify the root causes. This is done using the Root Cause Tree. The Root Cause Tree User's Manual provides questions that help the investigator pinpoint the incident's root causes.

The Human Performance Troubleshooting Guide on the Root Cause Tree helps an investigator decide which human performance related causes need further investigation. It also ensures

that experienced investigators consider all potential causes of human performance difficulties (rather than just concentrating on the ones that they understand the best).

In some cases, the root causes of an incident are impossible to identify. When the Root Cause Tree is used to analyze these difficult cases, the failure to identify the root cause is

clear because the investigation stops before the lowest level on the Root Cause Tree is

reached.

A particular incident's specific root causes identified using the Root Cause Tree are used in the next two steps to identify programmatic causes and to develop/evaluate c orrective actions.McElmo Creek Unit Root Cause Failure Analysis

PSD Permit No. NN 05

- 01 Step 7

– Identify Generic ( Programmatic) Causes

The specific causes for a particular incident may stem from more pervasive problems

- generic or programmatic causes. For example, if a particular incident is caused by a valve not having a label plate, other incidents may occur because of similar valve labeling problems with different valves. Therefore, the investigator needs to look at each specific cause for a particular incident and decide if a more program

- wide weakness exists that

needs broader corrective action.

Generic causes can be identified by investigating the pervasive nature of the problem. The pervasive nature of the problem can be determined by the investigator's experience, performing a special programmatic evaluation, or by reviewing previous incident statistics.

Correcting generic problems can have a much broader impact on safety, environmental performance, and re liability since they address whole classes of problems rather than just the specific causes of an incident.

Step 8

– Develop Corrective Action

The specific and generic causes that are identified in steps 6 and 7 provide a list of problems that require corrective action implemented in a timely manner. No matter what corrective action is proposed, there is always a chance to somehow circumvent the intent of the corrective action. Therefore, proposing corrective actions for each cause identified (that i s, multiple corrective actions) provides a defense

- in

- depth to preventing the incident from recurring. In some cases, correcting a particular root cause may be too difficult. In these cases, the investigator should ensure that there are sufficient other corrective actions proposed to reduce the likelihood of the incident's recurrence.

If the root cause level was reached in the incident investigation, the corrective actions are usually fairly straightforward to identify. If the investigator could not rea ch the root cause level, he/she will still need to develop ideas for corrective actions. If the incident has been identified as a repeat of a similar past incident, the investigator should ask if the corrective actions proposed are different from the cor rective actions previously tried and why the previous corrective actions failed.

Investigators should work with line management as much as possible when developing corrective actions. They should have thoughtful consideration to ensure the corrective

actions recommended are SMART:

S

- Specific

M

- Measurable

A

- Accountable

R

- Reasonable
T

- Timely

The investigator should develop a Corrective Actions Matrix Table to use in conjunction with the Snap Chart for effective management presentations . The Corrective Actions Matrix should have headings as shown below:

Causal Factors Root Causes &
Generic Causes Corrective
Actions Responsible Department &
Person to Implement Due Date For
Corrective
Actions CompletionMcElmo Creek Unit Root Cause Failure Analysis

PSD Permit No. NN 05

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Step 9

– Report

All of the information and analysis performed up to this point allows the investigator to write a clear, complete incident report describing what happened, why it happened, and what needs to be corrected to prevent the incident (or similar incident), and m ake effective management presentations. Reports and presentations are extremely important because the case made

therein often determines whether the recommended corrective action is expeditiously implemented or is given a low priority and delayed indefini tely.

An important part of incident reporting communication is the Snap Chart. A Snap Chart can be particularly helpful in providing an o rganized display of what happened and why it happened.
When used with the Corrective Actions Matrix described in step 8, these two tools make a powerful presentation of much information in a short time to provide management with knowledge needed to make t he best decisions about using resources to improve performance.

# ATTACHMENT

## Develop SnapCharT®

Get Started

- Determme what you are investigating

Define sequence of events

- Identify missing or needed

information

- Investigate further to find missing

information

Define causal factors



## Root Cause Analysis

Analyze each Causal Factor’s Root
Causes

- Analyze one Causal Factor at a

time

- begin at the top of the Tree and work

through the questions to determine

what Basic Cause Categories apply

- Examine all of the Basic Cause

Categories that apply to determine

what root causes apply

Use the TapRoor® Root Cause Tree®
Dictionary for definitions to all of the questions and root causes on the Root

Cause Tree® 

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OCopynght 2000 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.