McElmo Creek Unit Oil Production Facility

PSD Permit No. NU 05-01

APPENDIX B

MCELMO CREEK UNIT

ROOT CAUSE FAILURE ANALYSIS 

PROGRAM

September 2016

This document shall apply to the owner(s) and operator(s) of the McElmo Creek

Unit Oil Production Facility, including Resolute Natural Resources Company, 

LLC.
McElmo Creek Unit Oil Production Facility

McElmo Creek Unit O&M Plan – Lifecycle Maintenance Plan

PSD Permit No. NU 05-01, Appendix A, Attachment A-1

September 2016

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McElmo Creek Unit

Root Cause Failure Analysis Program

PSD Permit No. NU 05-01, Appendix B

September 2016

Root Cause Failure Analysis

Root cause failure analysis (RCFA) methodology is incorporated into the 

standard operating procedures in the McElmo 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 

CO2 breakthrough.

Step 2 – Plan 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 B-1). 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 questions 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 
McElmo Creek Unit Oil Production Facility

McElmo Creek Unit O&M Plan – Lifecycle Maintenance Plan

PSD Permit No. NU 05-01, Appendix A, Attachment A-1

September 2016

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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 – Collect 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.

Step 4 – Determine Sequence of Events

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

happened during an incident 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 is 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 reevaluation of assumptions or facts 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 facilitate 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 
McElmo Creek Unit Oil Production Facility

McElmo Creek Unit O&M Plan – Lifecycle Maintenance Plan

PSD Permit No. NU 05-01, Appendix A, Attachment A-1

September 2016

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Snap Chart and asking, "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 the 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 identified, 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 corrective actions.

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, 
McElmo Creek Unit Oil Production Facility

McElmo Creek Unit O&M Plan – Lifecycle Maintenance Plan

PSD Permit No. NU 05-01, Appendix A, Attachment A-1

September 2016

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environmental performance, and reliability 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 is, 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 reach 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 corrective 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 which

includes the following information:

• Causal Factors

• Root Causes & Generic Causes

• Corrective Actions
McElmo Creek Unit Oil Production Facility

McElmo Creek Unit O&M Plan – Lifecycle Maintenance Plan

PSD Permit No. NU 05-01, Appendix A, Attachment A-1

September 2016

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• Responsible Department & Person to Implement

• Due Date for Corrective Actions Completion

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 make 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 indefinitely.