1. Root Cause Analysis Enhancement Jan 21, 2006 Presented by: Mohammed A. Al-Dossary Construction Engineering & Management Quality Management CEM 515 Term Paper Abqaiq Plants Today film

2. Outline Part I: Abqaiq Plants Overview  Plants Background  Plants Processes  Plants in Saudi Aramco Organizational Chart Part II: Root Cause Analysis Program  Initial investigation  Review Methodologies Summary Lessons Learned

3. Upset Definition An unplanned shutdown of critical equipment during normal operation which may lead to production losses.

4. Problem Statement Top Management Statement: We would like a team to work on identifying the root causes of the nuisance and repetitive upsets! We don’t want more upsets please!

5. Forming Investigation Committee Management appointed a leader from Maintenance Leader selected members from operations (customer), maintenance and engineering Committee members = 5 Op Manager Maint. Manager DCS Engineer Process Engineer Electrical Engineer Mechanical Engineer Team Leader

6. Investigation Methodology Kickoff meeting was started by the team leader and a Weekly meeting was scheduled which lasted for 4 hours

7. Investigation Methodology Initial Review of archived reports Review of Current Investigation system External Benchmarking Personnel Interviews

8. Investigation Methodology Initial Review of archived reports Review of Current Investigation system External Benchmarking Personnel Interviews

9. Investigation Methodology Initial Review of archived reports Review of Current Investigation system External Benchmarking Personnel Interviews Equipment Trip Report Workflow (Manual) Collect Data (Supv Opr) Ops. Foreman Calls for meeting Trip Meeting (All) Investigation Workflow Enter Data (Supv Opr) Verify Data Ops Foreman Area Engineer Review Engineering Review Reliability Unit Review End Division Heads Review & Remarks End Recommendation & Action plan

10. Investigation Methodology Initial Review of archived reports Review of Current Investigation system External Benchmarking Personnel Interviews

11. Investigation Methodology Initial Review of archived reports Review of Current Investigation system External benchmarking Personnel interviews Current quality of Investigation Personnel satisfaction of current system Hidden back breaks Expectations

12. Implementation Roadmap Start Develop Team Name Develop Team Mission Study Methodologies Qualitative Quantitative

13. Quantitative Methodologies Identified the data boundaries Identified data population = 400 Gathered all data for 4 years Designed Q&D Access Database Used Minitab to generate statistical analysis

14. Quantitative Methodologies 50% 24% 13% 5% 3% Instrumentation Mechanical Electrical Human Error Process Unknown By Category

15. Quantitative Methodologies By Plant 0 2 4 6 8 10 12 14 16 18 20 Percentage Plant NPlant APlant BPlant CPlant DPlant EPlant FPlant GPlant HPlant I Plant J Plant KPlant LPlant M (%)

16. Quantitative Methodologies By Season 57% 43% Winter Summer

17. Quantitative Methodologies By Shift 48% 32% 20% S1 S2 S3

18. Quantitative Methodologies By Equipment Generator St. Turbine Ind. Motor Gearbox Sync. Motor Pump Compressor Gas Turbine 0 0.5 1.0 1.5 2.0 2.5 St. Turbine Ind. Motor Gearbox Sync. Motor Pump Compressor Gas Turbine Generator

19. Quantitative Methodologies Mechanical ESD System Governor Lube Oil O/B Bearing Instrument Loop Instrument Vibration Process TemperatureO/B Bearing Instrument Loop I/B Bearing Thrust Bearing ESD System Instrument Loop ESD System Instrument Loop ESD System O/B Bearing Instrument Loop I/B Bearing Thrust Bearing ESD System Instrument Loop ESD System Instrument Loop ESD System PIB Cabinet Instrument Cable RTD Field JB …. Hardware Software PS Card I/P Card O/P Card Controller Specification Installation Wiring PS Card I/P Card O/P Card Controller Probe Field JB Proximater P Switch T. Switch Wiring Steam Turbine RTD

20. Quantitative Methodologies Established fault tree for all instrumentation upsets = 200 Involved all specialized people in the fault tree identifications Prepared an educational Root Cause Analysis Class

21. Implementation Roadmap Start Develop Team Name Develop Team Mission Study Methodologies Qualitative Quantitative

22. Qualitative Methodology Equipment Trip Report Workflow (Manual) Collect Data (Supv Opr) Ops. Foreman Calls for meeting Trip Meeting (All) Investigation Workflow Equipment Trip Collect Data (Supv Opr) Verify Data Ops Foreman Area Engineer Review Engineering Review Reliability Unit Review End Division Heads Review & Remarks End Recommendation & Action plan Data Consolidation Online Database Built-in Root Cause Analysis Tracking System Start Fill out DB (Oper. Supv. & Maint. Crew) Form Inv. Team Initial Assessment With Action Plan Fill DB Sections RCA, Recommendations Rel. Supv. Approval Eng. Supv. Approval Maint. Supt. Approval Oper. Supt. Approval Generate Final Report Yes No Upset occurs

23. RCA program Gant Chart

24. Implementation Roadmap Start Develop Team Name Develop Team Mission Study Methodologies Qualitative Quantitative

25. Conclusion Managed to improve RCA program in the plants using qualitative & Quantitative techniques through an empowered project team under the supervision of the top management

26. Lessons learned 1. Top management commitment 2. Multidiscipline and homogenous team 3. Empowered team under the supervision of one leader 4. Unlimited resources

27. Root Cause Analysis Program Jan 21, 2006 Presented by: Mohammed A. Al-Dossary Construction Engineering & Management Quality Management CEM 515 Term Paper T h a n k y o u !

28. ignificant SPURT rocess psets eview eam SPURT back

29. Team Name & Mission Mission: To provide feasible short and long-term recommendations aimed at minimizing Plants nuisance and unnecessary upsets using qualitative & quantitative methods back

30. Team Name & Mission

31. back

32. Root Cause Analysis Section back Built-in Library of fault trees