Root Cause Analysis and Casualty Investigations by Alan Dujenski

Transcription

1 Root Cause Analysis and Casualty Investigations by Alan Dujenski Investigation of accidents, casualties, or near misses is critical in prevention of future reoccurrence. In the maritime industry valuable lessons can be learned from mishaps if they are investigated properly and expeditiously; unfortunately these are becoming a rarity. Let me explain. The way investigations used to be done... If we go back to the 1970s and earlier there was a standard format. First there was a gathering of facts called FINDINGS OF FACTS. Each of these were substantiated by some document included or referenced. When the facts were all accumulated, the investigator used to then draw some CONCLUSIONS directly from the FACTS. And lastly RECOMMENDATIONS were made strictly upon the FACTS and CONCLUSIONS. So basically everything was supported by something. Simple reports were typically completed within a month and more complicated casualty investigations maybe took about 6-8 months. The reports were released while the casualty was still fresh in mariners minds and was of value to the maritime community. Investigations Today... Today simple investigations generally take up to a year and the more involved ones two years or more. For some unspecified reason they went to a free format style that basically is a short story of what they think happened and many times the conclusions are unsubstantiated by the facts. The major marine casualties somewhat follows the old format but I defy you to make a direct link between documents-facts-conclusions and recommendations. Lets looks at some examples of problem reports... I will generalize so not to point to a particular vessel or company. EXAMPLE 1: There was an inspected charter boat that sank off of the Oregon coast. The original FINDINGS OF FACT showed that when last inspected the rear hatch which was supposed to be a watertight hatch had been replaced with with a piece of plywood and bungy cords. The loss of this hatch led to the flooding which resulted in the sinking of the vessel. In the review process these facts were removed from the report. EXAMPLE 2: A sheen was noted in the water in a populated harbor. The investigator(s) noticed a person scrubbing the vessel deck in the vicinity of the sheen and focused on that vessel. Making a long story short, the investigators got on board the vessel and took oil samples from the vessel s tanks and linked the oil in the vessel with the oil in the water from the oil analysis. The problem was that this vessel

2 along with about two dozen other vessels in the same harbor were all refueled by the same truck and fuel company but this was never investigated. EXAMPLE 3: A fire broke out on a fishing vessel causing substantial damage but not a total loss. The investigator noted that the filter on the hydraulic system was clogged with thick rubbery material. He concluded that the hydraulic system was not maintained and the pressure caused the hose to burst in the machinery space resulting in the fire. What the investigator failed to consider was the likelihood that a copper fuel line ruptured from vibration (fatigue) causing the fire and the heat from the fire caused the hydraulic hose to break down which resulted in the dark thick material in the filter. Makes a big difference determining if the vessel owner was negligent or if it was equipment failure. EXAMPLE 4: An operator connected up the flanged fuel fill line at the fuel dock using only 4 bolts as opposed to the complete 8 required. The joint started to leak during transfer and eventually the investigation report noted gasket failed as official cause. The point I am trying to make is that the free format used for investigations these days allows for errors in the real cause of a casualty. ROOT CAUSE ANALYSIS Root Cause Analysis is simply put a process the allows you to get to the WHAT, the HOW and the WHY of a situation. In the examples above the investigator never got to the real bottom line cause and therefore no valuable lessons learned could result from these. Events don t just happen. There is in most cases a clear trail of events. Identifying the underlying or ROOT CAUSE is essential in preventing similar reoccurrence. Basics of Root Cause Analysis You need to get to the underlying cause(s). It is important the investigator be as specific as possible 2. Be reasonable in your quest. You cannot use unlimited time and manpower seeking out the root causes. Have a process to help you arrive at the root problem. 3. Have realistic root causes. They need to be something that the management can deal with. For example citing the cause as severe weather is of little value since severe weather is not controlled by the company management 4. Recommendations need to be based upon SPECIFIC ROOT CAUSES. Making general type recommendations such as should adhere to company policies is to

3 vague and the analysis has not gone deep enough. The FOUR Basic Steps... These make up the four-step process of Root Cause Analysis: STEP 1. Good data collection. You cannot arrive at meaningful conclusions of what is the root cause(s) if you are gathering incomplete facts. The stop-and-go method of gathering a few facts and then trying to analyze and then gather a few more facts often result in erroneous and invalid conclusions and recommendations. You need all the facts to see the whole picture STEP 2. Charting of causes. It often makes it clearer if you plot the data on a chart showing the sequence of events as the information is acquired. If any of you watch Law and Order or CSI on TV you will see them using this process all the time. It will help you to see the big picture, identify gaps in the sequence. It should be drawn concurrent with the gathering of facts. The chart will help drive the fact finding process. The charting will identify both major sources of the problem as well as causal contributors. The causal contributors are things that would have either prevented or mitigated the outcome. I would like to interject that this is similar to what OSHA is trying to accomplish by their rule for RECORD KEEPING on a very simplistic form. The idea is to list casualties/accidents and watch to see if there is a pattern to these events. STEP 3. Identifying Root Causes. When all the facts are in and the diagram is complete, the identification of the root cause(s) is the next step. There are several methods used by various proponents of this system often referred to as mapping or flow diagrams. STEP 4. Recommendations. Lastly we get to the generating of recommendations to prevent reoccurrence(s) of the situation. If Steps 1-3 are done properly, Step 4 should be obvious and simple to generate. But all is for naught if these recommendations are not implemented. There really should be a FINAL STEP of tracking the recommendations to completion/implementation. (Let me note here how similar this looks to the way they used to conduct proper investigations...hmmmm.) Presentation of information results... A preferred method of layout of results is in TABLE FORMAT: COLUMN 1: Provide a generalization of causal factor along with basic background information to be able to understand why this is part of the problem

4 COLUMN 2: This will list the path(s) on your mapping associated with the causal factors COLUMN 3: This lists recommendations to address each of the root causes Finally, the REPORT The format of the report is not critical since the supporting documentation (above) is generally self explanatory. The report is basically an executive summary and if the reader needs details he or she will look at the ROOT CAUSE ANALYSIS process used to develop the report. Worked out EXAMPLE Lets use the example of the leaky flange resulting in oil pollution incident. An operator connected up the flanged fuel fill line at the fuel dock using only 4 bolts as opposed to the complete 8 required. The joint started to leak during transfer and eventually the gasket failed resulting in an oil spill. Basically, when the flange started leaking the engineer used a wrench to tighten the bolts. The leak continued and then worsened. The transfer was stopped but not until it had spilled enough oil to go overboard. EXAMPLE STEP 1: FACTS--Diesel fuel transfer spill had pre-transfer meeting between facility and vessel personnel Pre-transfer checklist completed (Declaration) required by state and federal regulations; no problems (33 CFR ) received shoreside hose onboard and removed blank flange on the end of the hose. The hose was suspended by shoreside crane about 8 ft above deck to allow for tidal movements and clear the railing. 4. The transfer maximum pressure was to be 90 pounds per square inch 5. Both flanges are ANSI B pound raised face flanges, 8 bolt, 8 inch flanges 6. A gasket was pre-cut from 1/8 inch neoprene material 7. The federal regulations only require half the number of bolts on ship-shore connections (33 CFR ) 8. The engineer used four (04) steel bolts (later found to be hardware store variety bolts (ungraded) 9. The bolts per ANSI B16.5 are required to be is 8 3/4 inch grade 5 steel bolts 10. The gasket for that pressure and diesel is required to be 1/4 inch thick neoprene 11. The bolts were tightened with standard socket set (no torque value) the engineer reviewed the oil transfer procedures and ensure valves properly aligned notified Mate ready to commence oil transfer; Mate gave approval to commence.

5 facility commenced oil transfer, initially at half fill rate 15. Minor drip noted at flange connection so engineer used a wrench with a bar extension to torque down on the bolts. 16. Bolts were tightened in a clockwise pattern. 17. Drip was lessened but continued. 18. Engineer was not concerned because the portable 5 gallon drip container required by regulations was in place under the flange connection the ship engineer gave the command to the shoreside facility to commence full pumping rate 20. The engineer noted after several minutes leak was worsening. 21. The engineer attempted to again tighten the bolts; this time shearing off the bolt in the 4 o clock position. 22. With the failure of the bolt a steady stream of fuel flowed into the 5 gallon drip container and within about 2 minutes the container was filled and overflowing onto the deck the engineer called the shore facility operator to stop transfer. 24. The transfer pumps take about 3 minutes to stop. 25. In spite of the pumps stopping there was still a head of oil in the hose line 26. There were deck plugs in overboard drains 27. The oil flowed aft and to a point where it accumulated went over the deck combing (4 inch) 28. Engineer contacted mate who sounded alarm and gathered crew for spill clean up 29. Mate made notification to US Coast Guard 30. ABC Spill Clean Up Contractor was called 28. Estimated spillage from calculations was about 100 gallons 29. Estimated oil in the water was 50 gallons 30. XYZ engineering company was contacted regarding the flange arrangement and this was what they noted in their report: A. The flange connection requires 1/4 inch neoprene material for size and pressure B. The flange requires 8 Grade-5 steel bolts C. The bolts need to be torqued to XXX foot-pounds D. They noted that flanges are designed to provide proper gasket seating pressure to ensure nonleakage. The practice of using only 4 bolts does not always provide sufficient seating pressure on the gasket to make it a tight joint. Attempts to stop the leak with further tightening caused the bolts to become overstressed resulting in failure of one of the bolts. The report noted that even with the right bolts, the bolt probably would not have failed but the gasket was too thin and would have continued to leak because the irregular seating pressure did not make for a tight joint. Flanges are designed for a specific number of bolts of specified strength to be torqued to a specified amount corresponding to a specific gasket material and thickness for the pressure, temperature during. Additionally bolts need to be tightened diagonally and not clockwise pattern. 31. Response was quick (10 minutes) and in accordance with SOPEP (spill

6 response manual) 32. Training for transfer monthly plus pretransfer meeting 33. Training for spill response monthly EXAMPLE Step 2: Root Cause Map The FACTS are not quite as detailed as they could be but for this example they are adequate (see Figure 1). EXAMPLE Step 3: Root Cause Summary Table This takes the facts from the investigation and puts them in an executive summary type format. (See Table 1). EXAMPLE Step 4: Conclusions/Recommendations As you review the Root Cause Map and subsequently the Root Cause Summary Table you see that the spill resulted from regulations that are misleading and/or faulty and lack of understanding about the engineering basics of flange joints. You can t control how the government writes rules but you do have the ability to correct the problem. In our EXAMPLE we noted: (1) Flanges need to have proper gaskets, bolts, torquing of bolts, and ALL bolts installed (not half as the regulations permit). (2) Need to realize spill containment is ONLY meant to catch minor leakage (3) Plugging the deck drains is only part of the prevention of oil getting into the water. It is necessary to have sorbent materials such as maybe a sausage boom surrounding the spill containment sufficient for at least 100 gallons of diesel. WRAP-UP This was a simplified example to point out the merits of the ROOT CAUSE ANALYSIS approach. As you go through gathering FACTS and plotting them on the ROOT CAUSE MAP, gaps in the FACTS become apparent. These gaps are then filled in and the result is a trail to the root cause(s) for the incident. This process not only is used for accident investigations but can be used even for quality control issues. The guide for this article was Root Cause Analysis for Beginners by James Rooney and Lee Vanden Heuvel. Resources: Other good resources are: Root Cause Analysis Handbook: A Guide to Effective Incident Investigation, by American Bureau of Shipping Consulting The Root Cause Analysis Handbook: A Simplified Approach to Identifying, Correcting,

7 and Reporting Workplace Errors, by Max Ammerman, Max Ammerman Root Cause Analysis: Improving Performance for Bottom-Line Results, by Robert J. Latino, Kenneth C. Latino Root Cause Analysis System For Problem Solving And Problem Avoidance, by Pietro Savo Class: Also not that the American Bureau of Shipping Consulting Group offers a class on the subject, details which can be found at: Note that there are many other resources you can use for instruction classes you can identify by searching the web. The ABS course was identified because it is specific to the maritime industry. Summary To make it simple, ROOT CAUSE ANALYSIS is just a process where you keep asking WHY until you get to the root of the matter. It is peeling away the layers until you reach the heart of the problem/issue (generally this is about 5 layers of WHYs). Most important is the follow-up. It does little good to identify the problem and do nothing about it! Another benefit of learning the ROOT CAUSE ANALYSIS process is that it can be applied to problem solving not just casualty analysis. Please note that I have taken a simplistic approach to this topic compared to that covered in the referenced classes and books but sometimes the KISS approach is the best. In our next issue, we will look at one of the main root causes of problems in the maritime industry: FATIGUE.

8 ROOT CAUSE ANALYSIS EXAMPLE (Figure 1) OIL SPILL INVESTIGATION PROCEDURES EQUIPMENT TRAINING RESPONSE Meets Regulations Good Condition Satisfactory Satisfactory Regulations are inadequate regarding ship-shore connections Ship-shore flange connection inadequate (gasket, bolting) Not an issue Not an issue Require bolts for all flange bolt holes Change gaskets to 1/4 neoprene Require bolts to be properly tightened (specify torque requirement) Tightening sequence needs to be specified as diagonal vs clockwise Bolts need to be 3/4 Grade 5 for ship-shore flange Need 8 bolts in ship-shore flange 5 gallon containment and deck drain plugs inadequate; lay 30 ft of sorbent boom on deck Alan Dujenski

9 Root Cause Summary Table Causal Factor 1 Description: Paths Through Root Cause Map Regulations are inadequate regarding ship-shore transfer hose connection Recommendations --8 not just 4 bolts --Grade 5 bolts --Proper torquing bolts --1/4 neoprene gasket Causal Factor 2 Paths Through Root Cause Map Recommendations Description: Regulations are inadequate regarding transfer containment --require 30 ft sausage sorbant boom on deck in event of overfilling 5 gallon containment Alan Dujenski