(50b) Using Fault Tree and Bow-Tie in the Root Cause Analysis (RCA) for a Loss of Containment Incident of a Stirred Tank, How the RCA Helps to Improve Project Management Practices

As part of a new project in a food processing plant to satisfy new market demand on food additives, a new 10,000 liters stirred tank was designed, built, installed and tested. During the pre-operational tests, a loss of containment incident occurred in this tank and a Root Cause Analysis (RCA) was requested to identify possible and potential causes of the incident.

An RCA was performed in two steps, first using a Fault Tree to review potential causal factors that could have occurred during the pre-operational tests based on the physical damages observed in the equipment as well as a qualitative review of different human factors that could have been involved as potential causes of this incident.

Second, based on the potential and credible causal factors identified by the Fault Tree, a Bow-Tie was performed to review the effectiveness of the existing barriers presented during the incident. Additional and new barriers were also identified and suggested to prevent this incident happened.

As a main result, several recommendations to improve Project Management Practices were obtained including improve the safety culture of project managers. The recommendations obtained help to project managers to understand and to anticipate potential conditions related to this incident during planning and execution of similar future projects helping also them to get better Risk Management Plan.