Next Generation Root Cause Investigation and Analysis

As with all industrial process safety incidents, there are lessons to learn from systemic failures that have the potential to end in the tragic loss of life, insult to the environment, and/or equipment loss.

Dow has had a long and successful history of reducing process safety incidents. This started with the establishment of formal generational goals in 1995 to reduce incidents by 90% over 10 years. These goals and progress metrics were and are externally published on www.Dow.com.

In 2005 another 10 year goal was established to further reduce process safety incidents and their severity by 75% and 90% respectively.

By 2008 it was clear that our performance had plateaued and we were not continuing to make progress towards meeting our 2015 goal for reducing incidents. As process safety incidents were analyzed, the data showed a lot of repetition. While an incident may not be on the same equipment or in the same plant, it was clear that the same failure mode(s) and management system(s) were involved.

Analysis of the data also showed an opportunity to ensure every required protection layer failure and its associated management system failure were identified and fixed and to improve how the investigation results were leveraged across the company.

By 2009 we were back on track and actually surpassed our 2015 goal in 2011. Of the many factors supporting this performance, this paper will focus on 4 factors:

1. Effective root cause investigations (RCI),
2. Senior manufacturing and process safety RCI Effectiveness reviews for process safety incidents which includes a repetitive incident analysis,
3. Leveraging incident investigation learnings through actions at the appropriate level consistent with the level of management system failure, and
4. Broadly communicating incident investigation learnings in formal Learning Experience Reports (LERs) across the company.

The paper also contains examples demonstrating RCI and follow-up.