94: Hazard/Defect Identification and Analysis Issue
Definition/Typical Issues
This major root cause category addresses issues related to methods used to identify and analyze hazards and defects. It includes:
- Readiness reviews (including pre-startup safety reviews)
- Change control
- Proactive risk/safety/reliability/quality/security analyses
- Reactive risk/safety/reliability/quality/security analyses
- Inspections that are not part of normal maintenance activities
- Audits
- Measurement programs and metrics
Was there a problem with the readiness review performed prior to starting the equipment? Did the readiness review fail to address all appropriate portions of the system?
Was there a problem with the management of change program? Were changes improperly assessed or were responses to changes improperly implemented?
Were inappropriate or insufficient proactive analyses (safety, reliability, quality, and security analyses) performed? Were process hazard analyses, reliability-centered maintenance analyses, vulnerability analyses, and potential defect analyses not performed when appropriate? Did the analyses fail to address all the appropriate issues? Were inappropriate recommendations generated? Were the recommendations not implemented in a timely manner?
Were reactive analyses, such as root cause analyses, not performed when appropriate? Were inappropriate recommendations generated? Were the recommendations not implemented in a timely manner?
Were audits and inspections not performed when appropriate? Did they have inappropriate scope? Were inappropriate recommendations generated? Were the recommendations not implemented in a timely manner?
Were inappropriate measurements and metrics specified, measured, or analyzed? Were inappropriate recommendations generated? Were the recommendations not implemented in a timely manner?
Were inappropriate risk acceptance criteria used during the analyses? Were the criteria improperly applied?
Examples
Example 1
- A new supplier was selected to supply product barrels to the facility. Barrels from the new supplier were cheaper but only came in one color (black). This caused shipment problems because different-colored barrels had been used previously to easily identify the barrel contents. Purchasing did not realize the importance of the color coding. No management of change had been performed.
Example 2
- A control valve failed to the wrong position upon loss of instrument air. A pre-startup safety review was not performed because the valve was installed as part of a replacement-in-kind.
Example 3
- A new air compressor was installed. A pre-startup review of the installation was performed to ensure that it was installed correctly. However, no operational tests of the compressor were performed. As a result, the compressor failed soon after startup because of an insufficient cooling water supply.
Example 4
- No analysis had been performed to determine the operational risks associated with a new conveyor system.
Example 5
- SO2 (a toxic gas) was released because a stiffer gasket was installed in an SO2 line. The gasket installed could last longer in this chemical service, but would not seal properly using previous torque settings. The management of change system defined "replacement-in-kind" as use of "similar or better" materials. Because the maintenance department considered the new gasket material superior, a change review was not performed.
Example 6
- As a result of a facility risk/reliability analysis, recommendations were made to have a final inspection performed of unusual and partial shipments to ensure that they are correct. This recommendation had not been implemented yet. As a result, a partial shipment was sent to a customer that was incorrect.
Example 7
- An engineer noted oil dripping from a pump seal. The process for reporting and documenting the problem required a lot of forms to be filled out. The engineer did not want to take the time to complete the forms. As a result, he did not report the problem and the pump subsequently failed.
Typical Recommendations
- Train all employees to understand the difference between a change and a replacement-in-kind.
Note: A replacement-in-kind is a replacement item that is functionally the same as the part or item it replaces. If the item is not functionally the same, then a change assessment should be performed. - Develop examples of situations that do and do not require a change assessment.
- Provide a list of issues that should be considered during a change assessment.
- Enforce requirements to have change assessments completed prior to performing the modification.
- Conduct an assessment of field changes and new installations to ensure proper operation of the equipment following startup.
- Require authorization signatures for all design/field changes.
- Track and document the final resolution for all recommendations.
- Provide a safety/hazard/risk review procedure that complies with all applicable orders, regulations, and guides.
- Track implementation of recommendations to ensure timely completion.
- Measure the effectiveness of selected recommendations.
- Refer design/development of recommendations to specialists when teams have difficulty identifying practical solutions.
- Reward personnel for completing recommendations.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 72 | Safety/Hazard/Risk Review |
| RBPS Element(s) |
|---|
| Hazard Identification and Risk Analysis |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 84 | Safety/Hazard/Risk/Security Review Issue |