(154c) Systematic Approach to the Root Cause of Process Safety Events at Equion Energia Ltd

The literature of Process Safety recommends as good practice that all PS events and in particular the near misses should be investigated to identify root causes and establish actions to prevent the recurrence of such events. Great efforts are made in the industry to investigate the Process Safety events but the independent causes from each do not allow to identify causes that are common to other. They typically focus on immediate causes and make difficult to define improvement plans to effectively prevent recurrence and capture learning by the organization.

Some industries have implemented process safety management systems based on the risk based concepts established by CCPS and its 20 elements. They can be used to establish causes associated to the system that can be used to track root causes associated to the RBPS elements.

EQUION Energia Ltd has developed a chart that standardized causes associated to the process safety system that is based on the 20 elements of RBPS. This is helpful when classifying causes identified during the investigations and establishing actions and plans to reinforce weak barriers and capture lessons prioritizing by specific Process Safety elements.

The model is easily applicable and adjustable to the specific needs of industry and contributes to continuously assess the health of the Process Safety elements in the organization so as to define and prioritize resources in strengthening the Process Safety Culture.