Unscheduled Deferment

Shell Exploration & Production
EP 2007-9014
Unscheduled Deferment, ORIP and RCA Process Guide
Operational Excellence Delivering Continuous Performance Improvement

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Restricted EP 2007-9014 Unscheduled Deferment, ORIP and RCA Process Guide Reviewed by: EPT - Surface Production Discipline Leadership Team Approved by: Global Discipline Head Surface Production (EPT-O-TFPL) Date of issue: November 2007 ECCN number: Not subject to EAR - No US content This document is classified as Restricted. Access is allowed to Shell personnel, designated Associate Companies and Contractors working on Shell projects who have signed a confidentiality agreement with a Shell Group Company. 'Shell Personnel' includes all staff with a personal contract with a Shell Group Company. Issuance of this document is restricted to staff employed by a Shell Group Company. Neither the whole nor any part of this document may be disclosed to Non-Shell Personnel without the prior written consent of the copyright owners. Copyright 2007 SIEP B.V. SHELL INTERNATIONAL EXPLORATION AND PRODUCTION B.V., RIJSWIJK Further electronic copies can be obtained from the Global EP Library, Rijswijk.
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Contents
Foreword ...................................................................................................................................................................3
Business Context .........................................................................................................................................................4 Introduction..............................................................................................................................................................4 Overview of ORIP.....................................................................................................................................................6 ORIP meeting structure ...............................................................................................................................................8 Roles and responsibilities..........................................................................................................................................10 Critical success factors.............................................................................................................................................11 Unscheduled Deferment, ORIP and RCA Process...........................................................................................................13 The Unscheduled Deferment, ORIP and RCA Process map...........................................................................................14 1. Identify.............................................................................................................................................................16 1.1 Identify opportunities ......................................................................................................................................18
2. Assess and Rank ...............................................................................................................................................20 2.1 Carry out 5 Whys on an incident.....................................................................................................................21 2.2 Categorise and risk assess ..............................................................................................................................22 2.3 Decide what action to take and allocate resources ..............................................................................................24
3. Select and Analyse............................................................................................................................................25 3.1 Establish RCA Team .......................................................................................................................................26 3.2 Conduct preparation meeting ..........................................................................................................................26 3.3 Analyse the incident .......................................................................................................................................28 3.4 Record root causes and communicate ...............................................................................................................28
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4. Decide and Act.................................................................................................................................................31 4.1 Develop corrective actions ..............................................................................................................................32 4.2 Endorse corrective actions at ORIP....................................................................................................................32 4.3 Implement the actions .....................................................................................................................................32 4.4 Review status of actions at ORIP .......................................................................................................................33
5. Analyse and Improve.........................................................................................................................................34 5.1 Monitor effectiveness......................................................................................................................................35 5.2 Identify and implement improvements ................................................................................................................35 5.3 Track and calculate benefits.............................................................................................................................36
Review of the Unscheduled Deferment, ORIP and RCA Operational Excellence Element ....................................................38
Appendices ..............................................................................................................................................................39 Appendix 1 - Typical terms of reference for an ORIP meeting ........................................................................................40 Appendix 2 - Roles and responsibilities RCA Facilitator/Team Leader .............................................................................43 Appendix 3 - Competence matrix for RCA ................................................................................................................45 Appendix 4 - 5 Whys RCA guidance.......................................................................................................................46 Appendix 5 - The Apollo process.............................................................................................................................49 Appendix 6 - Generic SAP Z8 Work Process Flow .....................................................................................................52
Glossary of terms......................................................................................................................................................54
Glossary of abbreviations/acronyms...........................................................................................................................55
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Foreword
Shell EP benchmarks indicate that unscheduled deferment is at unacceptably high levels across the Group. There is, therefore, a requirement to address this problem from the Corporate level down. Carrying out the activities of the Unscheduled Deferment, Operational Reliability/Integrity improvement Process (ORIP) and Root Cause Analysis (RCA) elements of Operational Excellence have been identified as one way of addressing the problem. The purpose of this guide is to explain how to manage unwanted incidents, with the aim of reducing unscheduled deferment and improving and sustaining operational reliability. This is a wide-ranging process that crosses the disciplines of Maintenance and Integrity and Surface Production and interfaces with the HSSE community. It is important to ensure that all site-specific knowledge is brought to the problem solving process to ensure its success. As a result of using the guide, staff will be able to: explain how the process works describe which employees will be involved in the process explain the role each employee has in the process explain where to get training in how to use the process explain what to do to implement the process determine if implementation has been successful outline some of the practices for conducting RCAs. Analytical tasks, such as RCA, are often viewed as the responsibility of qualified technical professionals, e.g. engineers. However, any attempt to execute an RCA without the participation of site staff is a missed opportunity and puts at risk the quality and credibility of the results. Consequently, given the broad range of disciplines involved in managing unscheduled deferment and the assurance of operational reliability, this guide is intended for staff involved in the following activities. Production Engineering staff involved in first line maintenance and production operations.
Asset management involved with increasing technical and operational integrity and reducing the level of risk Maintenance and operations support staff involved with Reliability Assessment, Production System Optimisation and Production Programming. Whilst the process could be used to address HSSE issues, it is not the intention of this guide to take precedence over HSSE-related incident investigation procedures. For the reporting and investigation of all HSSE incidents, refer to EP 2005-0170 Incident Reporting and Follow-up. All HSSE and loss of containment incidents are HSSE reportable. The requirements for notification, analysis and reporting of these types of incident are specified in the HSSE Standard (Incident Management Process, HSE0002). The procedures outlined in this standard should be followed for HSSE and loss of containment incidents. Security incidents are also excluded from this process guide. It is also not the intention of this guide to provide detailed information about how to conduct facilitated RCA investigations. This can be sourced through Group Learning and Development or via the Functional Discipline organisations. This guide has three parts.
The Business Context contains an introduction, overview of the process, ORIP meeting structure, roles and responsibilities and critical success factors. The Unscheduled Deferment, ORIP and RCA Process gives detailed guidance on how to establish, carry out and maintain the process. It should be used as a reference guide for those involved with the process whether as a member of the ORIP meeting or as a member of an RCA team. Both parts refer to more detailed appendices. A CD Toolbox located inside the back cover contains tools and templates that can be tailored to the requirements of any Asset. They are shown in the introduction of sections 1-5 and are referenced throughout the guide and shown as
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Business Context
Introduction
The extent of unscheduled deferment throughout the Group is large. Figure 1 illustrates its extent and main causes based on 2005 production data. Deferment is referred to as unscheduled when it is caused by events that cannot be scheduled, e.g. trips, breakdowns and interruptions by third parties, poor performance of equipment or sub-optimum settings. Full guidance on the coding structure and the appropriate root cause codes to assign to unscheduled deferment are described in the Deferment Administration Manual EP 2007-9017. Unscheduled deferment elimination is a corporate goal. It requires the use of a structured process that frequently incorporates RCA and is fundamental to: maintaining a safe workplace minimising deferment maximising equipment reliability and plant availability minimising operating cost ensuring Technical Integrity. Many of the causes of unscheduled deferment are directly related to equipment or process system failures. However, industry experience indicates that in 60-70% of incidents, people-related issues play a significant role. Improvements are being made through the use of the Unscheduled deferment, ORIP and RCA process as shown in the examples from BSP in Figure 2. In BSP West, the level of unscheduled deferment is being sustained below 6% with the monthly average currently below 4% and falling. The reduction in monthly fluctuations has made off-take scheduling and other product movement activities much easier. At Darat, significant improvements in the level of unscheduled deferment have been seen after the introduction of the process.
Figure 1: Unscheduled Deferment 2005
Total oil = 94 mln bbls 20 1200 800 10 400
Total gas = 4,500 mln m3
Separation/process
Compressors
Wells
Safeguarding and control
3rd parties/customers
Pipelines/flowlines
Others
Power generation
Produced water system
Sub-sea
Pumps
Reservoir
Power generation
3rd parties/customers
Wells
Pipelines/flowlines
Separation/process
Compressors
Others
Safeguarding and control
Pumps
Reservoir
Produced water system
Sub-sea
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Business Context
Figure 2: Unscheduled Deferment story - BSP
BSP - West
18.0% 16.0% 14.0%
% of IPSC
Unscheduled deferment trend was downward even before formal ORIP
12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0%
Unscheduled deferment/ORIP implementation commenced Jan06
4 7 5 6 4 5 6 5 7 4 5 6 7 04 -04 6 -0 -0 -0 04 v-0 05 05 v-0 06 r-06 y-0 -0 -0 -0 n-0 -0 l-0 l-0 p-0 nnppar ay ay ar a y Ju l a a ar o o ov Jan Ja Ju Ju Ja Ja Se Se M M M N M M N M M N M Se
BSP - Darat
25.0%
20.0%
Big story so far is TREND REVERSAL Commenced implementation of unscheduled deferment/ORIP
% of IPSC
15.0%
10.0%
5.0%
0.0%
6 5 4 7 6 5 4 7 5 7 6 5 4 04 -04 6 -0 -0 -0 06 r-06 y-0 05 v-0 05 04 v-0 -0 -0 -0 -0 -0 nl-0 p-0 l-0 nnppar a a a y Ju l ar ay ar ay ov Jan o o Ja Ju Ju Ja Ja Se Se M N M M N M M N M M M Se
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Overview of ORIP
ORIP is a formal, structured continuous improvement process. Inputs to ORIP are the measurements made on plant performance. These measurements may include deferment data, KPIs, inspection, audit results and benchmarking results. Outputs from ORIP are a list of ranked, appropriate, corrective actions aimed at improving performance especially of plant. ORIP has five clearly defined stages. These are: identify the unwanted incidents/conditions assess and rank those incidents select and analyse them to determine the problem decide the best course of action and act. analyse and improve process effectiveness. The relationship between the stages is shown in Figure 3 and described below. Identify Unwanted events or conditions are those which have a significant impact on the business in the areas of: integrity and reliability production loss, deferment and downtime increased expenditure damage to reputation. The significance of the impact should be identified on the basis of pre-defined, location-specific thresholds or triggers for each of these areas. Examples of trigger levels are shown in Figure 5 on page 18.
Figure 3: The Operational Reliability/Integrity improvement Process (ORIP)
Identify Unwanted events/ conditions
Assess and rank Efficiency and reliability RAM/Bad actor register Select and analyse Analysing and problem solving tools (RCA, tripod B etc)
Check thresholds Analyse and improve
Decide and act on appropriate measures Comission plant change Maintenance strategy; RRM (S-RCM, S-RBI, SIFpro) PMR; SAP PM change Competence development
Do nothing Procedural change
EIT
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Business Context
If there are no location-specific thresholds, the initiator should use the HSE RAM to carry out a preliminary assessment and log the results in the ORIP register. Assess and rank All integrity and reliability issues and production loss, deferment and downtime incidents should be subject to an initial RCA using the 5 Whys technique. The results of 5 Whys should be reviewed at the daily Operations meeting and a decision made on the appropriate actions to take. Along with expenditure and reputation opportunities, which have a significant impact on the business, they should be assessed and ranked based on the severity of their impact by the initiator and the ORIP focal point so that resources are aimed at the worst offenders. The Group HSE RAM is used for this assessment. Medium and high items are then taken to the weekly ORIP meeting for ranking and further assessment if necessary. This meeting is responsible for the final ranking and prioritisation of the incidents and should approve any requirement for a detailed RCA and allocate appropriate resources. Select and analyse After assessing and ranking the events based on degree/ severity of impact, the worst offenders should be selected and analysed using appropriate problem solving tools such as: root cause analysis, e.g. 5 Whys, Apollo lean six sigma, etc. Conducting formal RCAs will involve a team being chartered with clear objectives and goals to carry out the RCA using a suitable methodology. Subject matter experts (SMEs) will be identified, consulted and participate as needed during the analysis. On completion, the team must communicate the root causes to relevant staff and identify solutions that will prevent their re-occurrence.
Decide and act Having analysed the event, the next step is to decide what should be done and act accordingly. Appropriate actions may include the following. Plant changes. Procedural changes. Competence development. Changes to maintenance strategies. Changes to SAP. Mobilisation of equipment improvement teams (EIT). Short interval controls. The ORIP panel endorses the decision based on recommendations from the analysis team, which for RCA, will be the Reliability Engineer or RCA focal point. The endorsed recommendations are then handed over for execution. Approved actions should be put into a Corrective Action Plan (CAP). It is the responsibility of the implementation team leader to produce the CAP. This may be the leader of the investigation team or some other team assigned by line management. Actions to eliminate the root cause of the analysed incident can be tracked in the ORIP database or in SAP until closed out. Analyse and improve Success is not only about identifying root causes and implementing solutions but what has improved as a result. The Unscheduled Deferment, ORIP and RCA process and its contribution to business improvements should be reviewed periodically to ensure that they are meeting the best in class standard and that benefits are being tracked. There should be positive indicators that performance has improved as a result of the actions that were implemented. If not, the RCA study, for example, should be revisited.
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ORIP meeting structure
Please note that attendees at the ORIP meeting are sometimes known as the ORIP panel. Daily Operations meeting This meeting will primarily deal with breakdown opportunities. The Facility Operations and Maintenance Team, led by the Operations Supervisor, preferably the ORIP Focal Point, should review incidents and the resultant 5 Whys in detail as part of this meeting. It is also acceptable for a separate daily meeting to be held for ORIP only. At the start of the meeting, previous actions should be reviewed for progress and, if the actions require additional support/resources not available locally, the incident should be elevated to the ORIP register. The team should ask: has all relevant information been collected and has the 5 Whys been conducted in a rigorous manner and the true root cause identified? has the risk assessment been conducted and the severity code been entered on the 5 Whys form correctly? has the root cause Unscheduled Deferment Code been correctly entered and has the reporting system been updated? are the immediate actions taken suitable and are the short and long-term solutions practical and achievable? are any resources, external to the Facility, required to implement the short-term solution? The team should adjust the RAM assessment, deferment code, etc. if they consider it to be incorrect. The decisions and reasons for this should be fed back to the technician for learning purposes. Some form of meeting minutes or action log should be kept and actions tracked.
Weekly ORIP meeting This meeting will be chaired by the Operations Supervisor and attended by relevant functional support staff. It will deal primarily with opportunities arising from a threshold being exceeded. Prior to the meeting, action parties assigned to take specific actions should have updated their information into the tracking system so that the meeting may take decisions based on up-to-date information. At the weekly meeting, progress is reviewed and decisions made on the priorities for action, resource requirements, support activity, etc. Where there is more than one Facility within the Asset, these priorities require optimising for the whole Asset. New RCA reports should be briefly reviewed and, where required, additional RCA investigations should be initiated. Should consequential issues arise from other activities/ investigations, the meeting should initiate additional RCA investigations. Monthly ORIP meeting The monthly meeting is chaired by the Operations Manager and attended by senior functional support staff. It will deal primarily with opportunities that are common to several facilities across the Asset and those concerned with reputation and expenditure. The high priority issues should be reviewed to ensure appropriate action is being taken to eliminate major or repetitive trips/failures especially where thresholds have been exceeded. At this meeting, the appropriate Reliability Engineer may request an RCA as a result of analysis of equipment performance. The meeting will then decide whether the investigation is high priority and, if so, the RCA Lead, facilitator (if required), team composition and time scale for reporting and presentation should be decided. See Appendix 1 for typical terms of reference for an ORIP meeting.
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Business Context
Figure 4: ORIP meeting structure
Monthly ORIP meeting Operations Manager Operations Supervisor Maintenance Supervisor Programmer Reliability Engineer Discipline Engineers (as required) Technical Authorities (as required) Wells and Reservoir Management Other disciplines (as required) Weekly ORIP meeting Senior Operation Supervisors Head Onshore Support Head of Maintenance Support Programmer (as required) Well Services (as required) Operations Supervisors (preferably ORIP focal point) Reliability Engineer (where available) Maintenance Supervisor Scheduler (if at location. If not, Maintenance Supervisor takes this role) HSSE Advisor (as required) Selected Maintenance and Operations Techs (as required) Daily Operations meeting Operations Supervisors (preferably ORIP focal point) Reliability Engineer (where available) Maintenance Supervisor Discipline Maintenance Supervisors (E/I/M/P) (as required) Scheduler (if at location. If not, Maintenance Supervisor takes this role) HSSE Advisor/Medic (as required) Selected Maintenance and Operations Techs (as required)
Monthly ORIP meeting
Meeting goals: To review critical issues on the ORIP register. To confirm/verify using RAM critical ORIP issues and action accordingly. To carry out process checks to ensure consistency across asset.
Assess and rank in ORIP database
Asset weekly ORIP meeting
Meeting goals: To review critical issues on the ORIP register and report progress. To prioritise issues (using RAM) such that resources are focused in the right area (one month look ahead). To monitor the progress of the important issues.
Assess and rank in ORIP database
Platform 1
Platform 2
Platform 3
ORIP information sources Daily production reports Field/control room logs Trip panel/RCA reports
Meeting goals: To review results of 5 Whys for trips and unwanted events. To prioritise issues (using RAM) such that resources are focused in the right area. To monitor the progress of the important issues.
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Roles and responsibilities
Please note that these roles are generic and might differ from Region to Region. However it is important that all the responsibilities should be carried out. Global Process Owner Owner of this process guide. Owner of the Global ORIP database. Identifying, recommending and deploying improvements. Regional ORIP Co-ordinator Providing direct and indirect support to the Asset and the ORIP Focal Point. Giving guidance on effective meetings. Providing training and coaching on ORIP. Providing change management skills to facilitate smooth implementation. ORIP Focal Point Ensuring that ORIP is implemented and sustained. Be part of the Asset Team (and a reasonably senior person) both for credibility during implementation and for sustainability. Leading by example, and bringing achievements to the attention of senior management. Guiding and coaching staff on the process areas and be able to seek/give clarification on any issues that arise. Ensuring that individuals and teams within the Asset are performing their roles and that support functions are contributing. Ensuring that the meetings are running to the agreed schedule, RCAs being initiated at the required frequency, and that the ORIP register (database) is being maintained.
ORIP Panel Please note: ORIP panel refers to staff who participate in the different ORIP meetings. Supporting unscheduled deferment elimination business processes actively and visibly. Approving/rejecting proposals to conduct formal RCAs and other analysis activities on unscheduled deferment and/or equipment reliability incidents (endorsement of initial risk assessment and managing the overall risk presented to the business). Providing sufficient resources (people, time, budget) to conduct effective analysis. Assigning ownership within the meeting for all approved analysis events. Approving/rejecting the root causes found and the recommended solutions. Endorsing objectives for solution development, e.g. criteria, boundary conditions, minimal capital investment. Providing resources for implementation (with Asset approval). Reviewing progress and effectiveness of action items. Enabling timely follow-up and execution of corrective actions by all and removing any barriers to the implementation of corrective actions. Ownership of the quality of the implementation of approved solutions. Operations Support Staff Developing a sense of ownership in the Asset and its performance levels. Prevention is better than cure but when failures occur, these should be seen as unacceptable. Registering unscheduled deferment and reliability incidents for analysis. Conducting basic RCA using techniques such as 5 Whys.
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Business Context
Critical success factors

Sharing learning from incidents with colleagues. Utilising SAP to register and process equipment-related RCAs. Reliability Engineers Identifying equipment issues that impact on integrity, production reliability and/or cost performance. Escalating these to the ORIP meeting. Facilitating formal RCA investigations. Advising on composition of the RCA team. Keeping the ORIP meeting informed of the status of RCA study and corrective actions execution. Monitoring Asset performance for positive signs of business improvement resulting from implementation of the actions resulting from completed RCA events (KPIs). Receiving, processing and sharing learning from other RCA events outside their Asset Team. The senior Asset Reliability Engineer should review the RCA report for completeness and quality. RCA Team Conducting a preparation meeting. Analysing the incident. Recording root causes. Communicating root causes. Full details of the role of the RCA facilitator/team leader can be found in Appendix 2. Management and staff sensitivities Failure analysis often reveals inappropriate human intervention and flawed (or absent) management systems. It is possible that some managers may feel personally at fault and staff may be reluctant to reveal and address the real root causes of failures for fear of exposing their manager. In some cultures, this might be difficult to overcome but the behaviour of middle and senior managers in embedding an effective problem solving culture is important for sustained success. Managers should not tolerate partial or incomplete solutions. Behaviours to be encouraged include: supporting proactive behaviour challenging fire-fighting repair priorities ensuring that reward structures recognise managers and teams who have few emergencies and who practise long-term prevention and systematic problem solving. Effective implementation Characteristics of effective implementation include: the ORIP meeting being accepted as the key management process to enable the RCA process to become established leadership commitment to the process providing resources and clear decision making Critical success factors for the process include: management and staff sensitivities effective implementation competence and skills. A strong improvement culture can be developed if factors such as these are embedded and sustained.
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the preferred RCA approach must:
Competence and skills To ensure the success and sustainability of the process, the training and development of appropriate staff in the facilitation of RCA and participation in awareness training are essential. Appendix 3 shows the competence requirements for different job roles. Training is available via EP Learning and Development.
reveal the physical, human, and latent (organisational/ system) roots of the events investigated. Deductively revealing physical causes and/or human interventions alone does not reveal the root causes be as simple as possible. Field staff should be able to apply it as part of their daily activities without a requirement to understand complex tools or software and it must be usable at locations with poor or no IT leverage existing practices and well-known tools; familiarity will lead to a wider acceptance be applicable to small, chronic and major events promote and support a change in mindset. Failures are not inevitable but have causes; causes can be identified and addressed. The methodology must stress that the key question is to understand why things went wrong and why people behaved as they did, not who was to blame use an established tool and supplier. A proven approach to training and analysis is likely to yield the best results. New or novel approaches should be avoided include clear organisational roles and responsibilities with reliability at the centre of the process.
ownership by the organisation implementing and embedding the process in their normal ways of working effective performance measures in place to drive positive behaviour and performance a review process in place to validate quality and promote continuous improvement a means of communication for lessons learned and sharing of success, e.g. via Livelink or Global networks, newsletter articles, awards and continuous striving for improvement.
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Unscheduled Deferment, ORIP and RCA Process
This section of the guide gives a detailed explanation of the activities of the main activity process. Each step of the process has a section as follows. 1. Identify 2. Assess and Rank 3. Select and Analyse 4. Decide and Act 5. Analyse and Improve Detailed activities Each of these step has been broken down into its key activities. These activities form the sub-sections of the remainder of this guide and are shown on the next two pages.
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The Unscheduled Deferment, ORIP and RCA Process Map
Identify 1
Assess and Rank 2
Select and Analyse 3
Identify opportunities 1.1
Carry out 5 Whys on an incident 2.1
Establish RCA Team 3.1
Categorise and risk assess 2.2
Conduct preparation meeting 3.2
Decide what action to take and allocate resources 2.3
Analyse the incident 3.3
Record root causes and communicate 3.4
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Decide and Act 4
Analyse and Improve 5
Develop corrective actions 4.1
Monitor effectiveness 5.1
Endorse corrective actions at ORIP 4.2
Identify and implement improvements 5.2
Implement the actions 4.3
Track and calculate benefits 5.3
Review status of actions at ORIP 4.4
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1. Identify
Unwanted events or conditions are those which have a significant impact on the business in the areas of: integrity and reliability production loss, deferment and downtime increased expenditure damage to reputation. There must be a threshold or trigger level against which an event can be classified as significant. Production loss thresholds should be defined at regional levels and others thresholds at Asset level.
Tools
Tool 1 - Top 10 Bad Actors Tool 2 - Bad Actor Elimination Planning Guide
Measure Listing
Number 18.P.1 Measure Unscheduled deferment Shell EP Average 6.5% Top Quartile <1%
Process Map
Identify
Identify opportunities 1.1
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Identify
Best in Class Standard

Properly defined and documented coding structure for categorising unscheduled deferment incidents that are consistently applied across all levels of the organisation. Regular analysis of unscheduled deferment to identify top deferrals. Frequency of analysis shall generally comply to weekly at Facility level, monthly at Asset level, quarterly at OU level, 6-monthly at Regional level and yearly at Global level. Daily monitoring, reporting and investigation of unscheduled deferment with properly defined trigger levels to raise the level of attention within the organisation. Proactive management of unscheduled deferment by providing a deferment improvement catalogue that is kept up-to-date showing the size of the opportunity, priority, action parties and target dates. Operational controls and recovery plans in place for different levels of unscheduled deferment scenarios to mitigate the business impact. Unscheduled deferment improvement targets are set annually for the top deferrals for which remediation actions are to be generated and performance monitored against targets quarterly. Annual benchmarking of unscheduled deferment. A process for accurately quantifying the size of the deferment, which takes into consideration the transients in facilities and wells during shutdown and start-up operations and other such related issues. All data related to unscheduled deferment are held in the companys hydrocarbon allocation (HCA) system. This implies that all data either from production historian (e.g. PI) or manually obtained data is entered into such a system. Business rules for RCA in place with trends showing improvement over time. RCA thresholds established by the Asset Team in line with deferment reduction goals and an RCA compliance measure that is established and regularly reviewed by management/supervisors. Any backlog of RCA candidates will be tracked and will be readily available and maintained. Targets will be set to ensure the backlog is reduced to <10% of annual RCAs conducted. ORIP in place, understood and owned within the Asset. Asset Leadership takes an active role in ORIP and there are effective ORIP Focal Points at Facility and Asset level. Bad actor listings are developed and the Global Minimum Standard deferment catalogue is maintained and used as input. The bad actor list is used to drive defect elimination efforts within the Asset and the status and progress of defect elimination activities is reviewed by the ORIP meeting and action taken as required.
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1.1
Identify opportunities
Incidents These are typically unexpected and must be dealt with immediately, e.g. the failure of an oil export pump. Bad actors A bad actor is an item of equipment or particular equipment type, which poses significant risk of failure. It is equipment that has, through failure history, demonstrated that it has a high risk of failure and it has experienced four failures in a 12-month period. This threshold is a starting point for all Assets and should be reviewed annually. As reliability improves, it should be possible to reduce this threshold thus encouraging continuous improvement. Equipment designated as a bad actor by the Asset Reliability Engineer should be investigated in the same way as equipment failures or reliability incidents at an investigation level according to risk.
Unwanted events or conditions are those which have a significant impact on the business. There must, therefore, be a threshold or trigger level by which an event can be classified as significant. Examples of thresholds for the major areas where unwanted events or conditions occur are shown below in Figure 5. Thresholds for production losses will be determined regionally whilst the others can be determined at Asset level. In order to improve, it is important to continually lower these thresholds, but not so far as the organisation becomes swamped with minor events. When considering the impact of an event, recurring events must be identified so that their cumulative loss can be quantified. Opportunities are likely to arise from three sources: incidents bad actors analysis driven investigation.
Figure 5: Trigger threshold
Input Focal Point
Threshold Any event that impacts integrity. Any unplanned event/work/breakdowns and equipment reliability issue or threat with a medium/high risk on the RAM matrix. Deferment/outage/capacity loss equivalent to >12,500m oil or gas equiv/>25,000m WI (*) [ie Significant on RAM]. Plan overspend by 30%. Re-work with cost of loss >$100k [ie Significant on RAM]. Any potential event as a result of non-compliance with a medium/high risk on the RAM matrix.
Integrity and reliability issues and threats
OIM/ Asset Ops Team Leader
Production loss, deferment and downtime
Production Programmer
Increased expenditure
Cost Planner/ Maintenance Team Leader OIM/ Asset Ops Team Leader
Reputation
* Actions linked to Production loss above 25000m3 oil/>3 MM sm3 gas/ >50000m3 water injection need to be closed out by the Asset Leader.
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Identify
It is recommended that a bad actor list is developed based on overall business impact. In addition, both performance of individual items of equipment and groups of equipment types should be considered. Tool 1 - Top 10 Bad Actors - a template for listing key information about bad actors.
Reliability - overall low or declining reliability (platform, train, system, equipment or component). Inspection - RBI, e.g. excessive rate of wall thinning, corrosion or erosion or other inspection findings. This situation should also include a review of the original Risk Based Inspection analysis. Audit and Reviews - undesired findings from any audit.
T T
Tool 2 - Bad Actor Elimination Planning Guide - sets out a process for eliminating bad actors.
Analysis driven investigation At the monthly ORIP meeting, a request for an analysis driven RCA may be requested. Proactive application of RCA occurs when learning from incidents takes place. In such cases, RCA would be used to determine if any risks to the business exist that have actually materialised on another Asset either inside the Shell Group or in the industry thus allowing proactive steps to be taken to prevent a recurrence of the incident. RCA can and should also be used following analysis of broader business performance. RCA should, therefore, cover the following. Learning from incidents and near misses. Well or facilities production performance, e.g. scale build-up or internal fouling. Corrective Maintenance - repetitive failures, high consumption of materials or consumables and corrective maintenance (CM) cost. An example would be equipment identified for work by an Equipment Improvement Team (EIT).
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2. Assess and Rank

All integrity and reliability issues and production loss, deferment and downtime incidents should be subject to an initial RCA using the 5 Whys technique. The results of 5 Whys should be reviewed during the ORIP part of the daily Operations meeting and a decision made on the appropriate actions to take. Along with expenditure and reputation opportunities, which have a significant impact on the business, they should be assessed and ranked based on the severity of their impact so that resources are aimed at the worst offenders. The Group HSE RAM is used for this assessment. The weekly ORIP meeting is responsible for the final ranking and prioritisation of the incidents and should approve any requirement for a detailed RCA and allocate appropriate resources.
Tools
Tool 3 - 5 Whys Template Tool 4 - Group HSE RAM
Measure Listing
Number 18.S.1 18.P.1 Measure RCA completed against threshold Percentage of Unscheduled Deferment Covered by RCA (as a percentage of IPSC) Shell EP Average 60% 80% Top Quartile >90% 90%
Process Map

A root cause analysis process that is routinely performed by Operations staff. This will lead to root cause identification and the generation of corrective actions that eliminate recurring problems. Support staff such as engineers, planners and supervisors will all have been trained in a formal RCA process. ORIP meetings are planned, held regularly, are well attended by key players (Asset Leader, Ops Manager, Maintenance Manager, Reliability Eng, Maint/Ops Support Eng, Daily Delivery Coordinator, Facility Staff). Incidents are tracked and the incident thresholds, are adopted and communicated to Asset staff and applied.
2.2
Assess and Rank
Carry out 5 Whys on an incident
2.1
Categorise and risk assess
Decide what action to take and allocate resources 2.3
CMMS Notification breakdown flags and breakdown start/end times are accurately recorded on every failure. CMMS Notifications will be used on corrective work orders and all Object/Damage/Cause and Activity codes will be populated. All CMMS notifications will be reviewed for completeness and accurate use of the Object/Damage/Cause and Activity codes.
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2.1
Carry out 5 Whys on an incident

A fit for purpose RCA should be conducted on as many trips/failures as possible. This might initially be a the 5 Whys followed by a more formal RCA such as Apollo if the 5 Whys does not reveal the root cause. When an event/failure occurs, an Operator or Maintenance Technician is sent to restore the situation and perform diagnostics to trace the fault and restore the plant to an operating condition. At the same time, s/he should conduct an initial RCA using the 5 Whys technique. However, even though this is a very simple and quick process, it is recognised that Asset and Operations staff need to prioritise their resources and focus on the tasks adding most value. If the 5 Whys does not reveal the root cause or a multiple failure pattern is identified, an Apollo investigation or equivalent should be started which should: be driven by the local equipment owner and/or maintainer in conjunction with the Reliability Engineer or RCA Focal Point be attended by representatives from both Operations and Maintenance result in actions that are clearly defined. A more detailed description of the 5 Whys is given in Appendix 4 and an overview of the Apollo process is given in Appendix 5. Tools 3 - 5 Whys template - can be used to write up a 5 Whys analysis.
When an incident occurs, it is critical that key information about the circumstances and process conditions are captured immediately. Information recorded should include: time and date incident type system affected status of the operation at the time the event occurred duration of event where applicable description of the incident SAP functional location for equipment business impact. This information should be captured in the ORIP Register (see box below) and in SAP for equipment failures via the appropriate notification. The ORIP register A web-based register for Global use is under development. Currently, this register can be in any appropriate format, e.g. paper-based, spreadsheet or database. Ideally, there should be one register for each Facility rolled up to Asset level. Typically, it should track opportunities through the following four stages. IN OPEN COMPLETED CLOSED - to register an opportunity. - to track an opportunity through the analysis. - when all corrective actions have been closed out. - when an analysis has been completed and accepted.
Note
Object Damage Codes should be used to support the RCA effort. They should be captured in the initial Z1 notifications. If additional information results from a 5 Whys analysis or a Z8 initiated formal RCA investigation for equipment failures, the data entered in the object damage codes can be updated.
It should also contain performance indicators. Maintenance staff shall use SAP through Z8 notifications and associated work orders for equipment defects. Information held in SAP should be transferred to the ORIP register as appropriate.
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2.2
Trips/failures that do not cause a deferment should also be investigated because: there may be valuable lessons to be learned that are of benefit to the Operations or Maintenance and Integrity functions similar equipment that is part of the direct production system may be at risk of the same failure it is possible to draw a parallel with world class HSSE where every near miss is investigated in order to understand the circumstances. This leads to a proven reduction in serious incidents.
Categorise and risk assess
It is essential to prioritise each opportunity correctly to ensure that all issues impacting on the business can be compared on an equal basis and that the most important unwanted events are analysed first. This includes all incidents, bad actors and analysis driven investigations. The Shell Group HSE Risk Assessment Matrix (RAM), shown in Figure 6, shall be used to quantify and prioritise identified opportunities. In general, the severity of ORIP opportunities should be based on the severity levels of the RAM Assets consequence category. The exceptions to this are opportunities from the ORIP reputation category, which should be directly mapped to the severities in the reputation consequence category.
Figure 6: Group HSE RAM

CONSEQUENCES
Environment Reputation
INCREASING LIKELIHOOD A
Never heard of in the industry
B
Heard of in the industry
C
Has happened in the Organisation or more than once per year in the industry
Has happened Has happened at the Location or more than once more than once per year at the per year in the Location Organisation
Severity
Poeple
No injury or health effect
No damage
Assets
No effect
No impact
Slight injury or health effect Minor injury or health effect
Slight damage
Slight effect
Slight impact
Minor damage
Minor effect
Minor impact
Major injury Moderate Moderate Moderate or health damage effect impact effect PTD or up to 3 fatalities Major damage Major effect Major impact
More than 3 fatalities
Massive damage
Massive effect
Massive impact
ORIP Category Integrity and Reliability Production loss, deferment and downtime Increased expenditure
ORIP Category Reputation
Low Risk - manage for continuous improvement Medium Risk - Incorporate Risk Reduction MeasuresandDemonstrate ALARP High risk - investigate alternatives
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Tool 4 - Group Risk Assessment Matrix - gives a more detailed description of the consequence categories and severity.
The decision about which problem-solving methodology to use for the investigation is based on the complexity and priority of the problem. The final decision will be taken by the ORIP meeting. During the investigation of a seemingly minor incident, it may become apparent that the risk to the business is higher or lower than was at first thought. The incident should be re-routed and re-prioritised for escalation and appropriate action.
Figure 7 shows how in the Assess and Rank phase of the ORIP process, opportunities from the Identify stage are ranked according to their perceived risk levels, high, medium and low. This ranking determines how the opportunity will be actioned The cost impact of the incident can be calculated from deferment and/or Opex either as a single cost for a single event or annually when a recurring incident is ranked and prioritised.
Figure 7: Opportunity ranking

Action High Mitigation mandatory and shall be applied immediately the opportunity is identified Escalate to monthly ORIP meeting or deal with immediately. Example Line break leading to loss of containment will require immediate isolation of broken section. Action necessary where the ORIP meeting structure is in place and incidents could be closed out at either weekly or daily meetings. Operations supervisor refers to person-in-charge at location. Sudden degradation in efficiency leading to a situation where two duty pumps out of three are unable to maintain the level in a vessel. The third pump (standby) needs to be put into operation to control the level thereby avoiding a trip of the entire process train. To operate in this mode, the logic needs to be overridden to allow simultaneous operation of all the pumps. Action is applicable where the ORIP meeting structure is in place and incidents could be closed out at the daily meeting
Operations Supervisor to endorse rating. Medium Mitigation necessary but shall be applied after endorsement of Operations Supervisor.
Escalate to weekly ORIP meeting
Endorsement by ORIP Focal Point Low Mitigation not mandatory No escalation required No endorsement required
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Decide what action to take and allocate resources

The maximum time allowed for completion of the RCA study is dependent on the outcome of the risk assessment as follows: RAM Category High Medium Low Complete study within 6 weeks 8 weeks 12 weeks
The results of 5 Whys and subsequent risk assessments should be reviewed in the ORIP section of the daily Operations meeting and a decision made on the appropriate actions to take. Operations can then decide whether the original incident should be proposed for the formal RCA process at the weekly ORIP meeting. See pages 8 and 9 for a description of the ORIP meeting structure and Appendix 1 for typical agendas. This step is designed to ensure that the right people in the organisation are fully informed about the events within their Assets, which are having a negative impact on performance. The weekly ORIP meeting will decide whether a formal RCA should be carried out. Its members are accountable for the decisions made about which incidents to investigate and which solutions to implement. The Reliability Engineer needs to prepare for the ORIP meeting by quantifying the number and type of resources that will be required for the Analysis phase. A member of the ORIP meeting should sponsor an RCA team which will be led by a facilitator. For more information, see step 3.1 Establish RCA Team. If it is decided that a formal approach should be used, a Z8 notification should be raised in SAP for equipment-related incidents to initiate the process. This should be done by the Reliability Engineer or equivalent position in Operations. A generic SAP Z8 work flow process can be found in Appendix 6 and a user guide explaining how to input data on the CD-ROM.
A report of all RCAs registered in SAP should be submitted to the ORIP meeting by the Reliability Engineer or equivalent Focal Point for ranking, approval and progress reporting. This report is the register of proposed and ongoing RCAs and ensures that the focus on current business needs is not lost by ranking any new priority RCAs against other existing RCAs. If it is decided that an RCA should not be carried out, the decision and reasons should be communicated to the initiator. If there is no requirement for further analysis, move to step 4.1 Develop corrective actions.
Note
In the event of an incident, where an immediate response is required, key members of the Asset Leadership Team should be consulted and an investigation instigated without waiting for a submission through ORIP, i.e. they are fast-tracked.
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3. Select and Analyse

After assessing and ranking the events based on the degree/ severity of impact, the worst offenders should be selected and analysed using appropriate problem solving tools such as: Root Cause Analysis, e.g. 5 Whys, Apollo, TapRoot Tripod Lean Six Sigma, etc. The team must then communicate the root causes to relevant staff and identify solutions that will prevent their re-occurrence. Conducting the more formal RCAs will involve a team being chartered with clear objectives and goals to carry out the RCA using a suitable methodology. Subject matter experts (SMEs) will be identified, consulted and participate as needed during the analysis.
Tools
Tool 5 - RCA report form Tool 6 - Generic investigation study
Measure Listing
Number 18.S.1 Measure RCA completed against threshold Shell EP Average 60% Top Quartile >90%
Process Map

Operators and Reliability Specialists who are knowledgeable about RCA concepts and have either undergone RCA training or participated in several RCAs. There will also be RCA champions who have received training on the RCA Process and managers and supervisors who demonstrate support and participate in RCAs. An RCA Process Guide that has been communicated to Asset teams is well understood and is being actively worked. The guide will include a recommended causal process, i.e. TapRoot, 5 Whys, and will be used to facilitate completing an RCA analysis. A documented method for identifying repeat failures and a thorough Reliability Review of all available data will be performed for each required RCA.
Select and Analyse 3
Establish RCA Team 3.1
Conduct preparation meeting 3.2
Analyse the incident 3.3
Record root causes and communicate 3.4
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Establish RCA Team

Persistent. The facilitator should not give up in the face of problems or difficulties but at the same time needs to recognise when the team cannot progress without more data. Tactful. The facilitator will come across situations where people are reluctant to participate or give information. This needs to be handled diplomatically and assertively to get what is required to complete the RCA. Strict in conducting meetings, e.g. stop arguments and make sure the investigation moves forward. Thorough. The facilitator will ensure that all possible contributing factors to the incident are incorporated into the analysis, corners are not cut and people factors missed. For issues that are considered as high, a management representative shall be included in the RCA investigation team.
Once the ORIP meeting approves the need for a formal multidiscipline RCA, the resources identified by the Reliability Engineer are assigned to a team after discussion with the Asset Team and Functional Groups. For high risk events, a senior manager is always involved plus a core team. The team is chartered by the Team Leader to agree deliverables and roles. Team composition will vary depending on the problem and its severity. Factors that will ensure the success of the RCA team include: a clear problem statement the use of, and adherence to, a robust RCA methodology cross-functional membership factual data used as the basis for all analysis activities (RCA is part of a fact-based problem solving process) commitment from the ORIP meeting to evaluate findings and recommendations fairly measurement of progress in implementing solutions competent facilitation participation of staff responsible for the analysed activity or equipment with the analysis preferably done at the worksite a balanced team with enough subject matter experts to allow discussion. The performance of the facilitator can make the difference between a successful or unsuccessful RCA even if there is a culture where RCAs are valued and their results acted upon. The successful RCA facilitator will meet the following criteria. Impartial. The facilitator should have nothing to gain or lose by the results of the RCA. Specifically, they should extract information efficiently from the people who know the details (those who were there, experts, etc.) without being biased by their own experience or interpretation. They do not listen only to the loudest voice. Organised. The facilitator should be skilled at organising information and putting it into a clear format for presentation to others.
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3.2
Conduct preparation meeting
A preparation meeting, teleconference or individual briefings should be held with the team members to develop the charter and the terms of reference for the analysis. The meeting should last about an hour and, ideally, the ORIP sponsor should make an opening statement to set out: the business impact of the issue being investigated objectives for solution development, e.g. criteria, boundary conditions, constraints such as HSSE and/or life cycle cost and/or production and/or minimum capital investment his/her expectations and, most importantly, give his/her commitment to support the process through to full completion of the resulting recommendations. The charter should be a brief, one paragraph problem statement setting out why the team has been formed. Prior to the meeting, the following activities should be carried out where appropriate. Identify and invite external observer(s) for lateral learning and/or an HSSE representative.
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Example problem statement

Compressor XYZ has failed three times in the last 12 months. These failures have resulted in production deferment of xxx bbls and associated maintenance costs of $yyy. This team has been formed to identify the root causes of the failure of compressor XYZ and recommend cost-effective solutions that can be readily implemented.
recommendations that they make will be accepted by the ORIP meeting. Acceptance criteria could include the following. Eliminate or mitigate the consequences of the cause in cases where it is not technically or economically possible or desirable to eliminate causes. It might not always be possible to eliminate a cause. For example, if scheduled shutdowns are too long, it would not be possible to eliminate them altogether but it might be possible to reduce their duration and/or the time between them. Provide a predicted percentage return on investment. This is likely to be the impact that correcting the problem has on production reliability and/or unit operating cost. No conflict with scheduled projects. Before starting an RCA, it is good practice to check that plans are not in place to make changes to the equipment or area in which it operates within a reasonable time frame, i.e. before a next potential repeat incident could occur. Clear resource and cost justifications. The recommendations should include clear cost justification and resource requirements. Positive effects on the whole system. Recommendations should not be accepted if they deal with a root cause but might cause problems in other parts of the system. This often arises with partial solutions. There will be a number of possible recommendations. These need to be ranked against acceptance criteria, e.g. the solution must, should and must not criteria. The team should make sure that they understand all the criteria that decision makers at the ORIP meeting will consider before giving the go-ahead to implement recommendations. A form, such as the completed example shown in Figure 8 on page 29 and 30, should be used to record the key facts. Tool 5 - Root Cause Analysis Report Form - template that can be used for the report.
Presentation by the Asset Team of the current maintenance and operating strategy for the equipment under analysis. This should include performance indicators (MTBF), maintenance costs, PM programme, etc. Provision of historical information such as drawings, SAP data, warehouse data, operating information, interviews with key staff, etc. Provision by the Asset Team of spend data split by Maintenance/Projects associated with the failure being analysed to help quantify potential benefits from implementing the RCA recommendations. Develop a failure/cost history in order to establish the base line impact on business performance. Arrange a site visit. Activities such as these will not be discussed at the preparation meeting other than to verify that they will be available at the appropriate point in the RCA. The meeting should be chaired by the RCA facilitator or Team Leader who will brief team members about: individual roles and responsibilities (including data collection) the role of the facilitator objectives and deliverables (including acceptance criteria) time-line (including next meeting) post-RCA process. Before getting started, it will be useful for the team to be aware of any criteria that will be used to judge whether or not the
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Analyse the incident
3.4
Record root causes and communicate
It is not the purpose of this guide to give a prescriptive methodology for carrying out RCAs. Any recognised methodology meeting the criteria listed in Critical Success Factors on page 11 can be used. Apollo is frequently used and an overview of it can be found in Appendix 5. It is important to remember that most RCA experts agree that 60% to 70% of all RCA root causes are people related rather than equipment related. If the RCA and its recommendations focus only on technical or hardware issues, important people related issues may either be missed or not given sufficient attention. After the analysis, the results should be used to summarise the results of the review and record the actions from the RCA.
The root causes should be recorded in the ORIP Register and SAP via the Z8 notification if equipment-related. Relevant staff should be made aware of the root causes of the incident. Typically, these will be Operators, Maintainers and Engineers. This should be done through appropriate communication channels such as meetings or by e-mail. If the root causes have the potential to cause further damage, the facilitator should communicate this to the key personnel who are likely to be affected as soon as it is identified rather than waiting until all the RCA work is complete.
Tool 6 - Generic investigation study - an example of an investigation study.
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Figure 8: Root Cause Analysis Report

Problem Definition Frequent failure of the ORINOCO-09 condensate pumps P-605/06/07 resulting in poor availability, high maintenance costs and deferment when the second pump trips as well. Occurrence The 3 pumps 20 times in about 2 years of operation 2004 (newly installed) = 1 failure 2005 = 5 failures 2006 (until September) = 14 failures Randomly over the year, unpredictable, no tendency recognised. Production deferment will show an increasing trend as decreasing reservoir pressure will require more compression and result in increased utilisation of the condensate pumps.
Date Occurred
Significance Safety Environmental Production Loss Maintenance Costs Frequency Total Cost Reputation Investigation Team None None 2 Million Nm3 (over 2006) @ 3 cts/ Nm3 = $ 60.000,- deferment costs. $ 62.000,- since July 2004 (year average $ 57.000,-) P-0605 = $ 26.300, P-0606= $ 21.800, To date September 2006: 20 times since start up in 2004 $ 117.000, - per annum As reliable supplier Geveke Erik Nijman Andre Westerlaken Renee Ippel Kees Laseur Henk Blaauw Rieks Everts Bas de Jong Joop Maat Geert Meursing Technician Regio Service Manager Project Engineer Project Engineer Offshore installation manager Operations Support Process Engineer Rotating Discipline Engineer Sr. Maintenance and Reliability Engineer P-0607 = $13.800, -
Maybelle
Summary of investigation Summary: The Condensate pumps P-0605/06/07 were analysed to address the randomly, unpredictable increasing failure rate. A variety of defects have been reported in SAP since the start up of the new designed condensate system in 2004. These defects were analysed and discussed in the RCA study.
Conclusion: Although a variety of defects were recorded a common direction could be identified towards the process conditions for the suction valves. Investigation on the platform showed a variable suction pressure and pulsation dampeners installed outside the design range. Verification on the line up and material investigation on the failing parts did not show deficiencies from the design documents. The start-up procedure is rated effective. Material investigation on the failed parts did conclude no material or chemical issues related to the failures. The design parameters are reviewed if they cover the operational envelope/parameters. The hydraulic dynamic processes conditions were checked and verified against the design criteria and the suction piping sizing was recalculated. The results showed that the piping diameter was too small and the pulsation dampeners were not effective. Replacement of the 3 suction piping system with 10 is will make it effective. The Project Management Process was reviewed to verify if the process controls were well applied. The review observed some shortcomings in the control and hand over process. The investigation was completed and corrective actions were formulated to prevent failures of a similar type. Follow up of SAP and QWR initiated actions are tracked via these systems.
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Figure 8: Root Cause Analysis Report (continued)

Investigations Possible Causes
No early warning mechanism installed to detect a membrane failure. The present 4 mA signal gives the actual pressure between the two membranes but no alarm. Foreign materials such as loose bolts are reported on failures Loose/broken parts of the "sluisventiel"
Investigation Actions
Check if the signal can be transferred into an alarm. Investigate if failure types are reported/and known
Assigned to
Henk Blaauw
Due
01.06.06
Done
01.06.06
Investigate if failure types are reported/and known
Joop Maat
01.06.06
01.06.06
Report the metallurgical investigation, check the correctness and suitability of the material for the process conditions, and correct sizing, Review the start up procedure/sequence in relation to the condensate flow. 1. Check the hydraulic dynamic processes conditions and verify the design criteria. 2. Recalculate the discharge piping when suction piping needs to modified Verify if small diameter parts as reduced bore valves are fitted in the suction lines and if suction filters/strainers are fully open 1. Check the datasheet as it's thought that it stated one pressure instead of a pressure range 2. Investigate if the design parameters cover the operational envelope/parameters
Joop Maat/ Geveke
01.08.06
01.08.06
The start of the second and/or third pump causes additional vibrations Limited capacity of the suction line
Henk Blaauw
15.06.06
15.06.06
Bas de Jong
01.08.06
01.08.06
Restricted capacity of the suction line
Henk Blaauw
15.06.06
15.06.06
Inadequate design/datasheets
Joop Maat
15.06.06
15.06.06
Solutions Possible Causes

Limited capacity of the suction line Ineffective project controls
Investigation Actions
Raise a SAP Z5 notification to start the PIR/modification process. Replace suction piping/system with increased diameter Raise a QWR to start the process to close the controls gaps in the Engineering process.
Assigned to
Henk Blaauw Geert Meursing
Due
01.09.06 01.09.06
Done
01.09.06 01.09.06
Report Writer: Report Date: Approval: Name:
Geert Meursing 17 September 2006
Function:
Date:
Appendix 1 Cause and Effect Chart
For Lateral Learning, the report to be copied to: (tick the appropriate box) Principal Discipline engineer: q Civil and abandonment q Electrical engineering q Safety engineering q Inspection q q q q Control and automation Reliability engineering Static engineering Pipelines q Corrosion engineering q Rotating equipment q Structure equipment q ...
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4. Decide and Act

Having analysed the event, the next step is to decide what should be done and act accordingly. Appropriate actions may include the following. Plant changes Procedural changes Competence development Changes to maintenance strategies Changes to SAP Mobilisation of Equipment Improvement Teams (EIT) Short interval controls. The Reliability Engineer or RCA Focal Point should ask the ORIP meeting to endorse the findings and recommended solutions. Approved solutions should be put into a Corrective Action Plan (CAP). It is the responsibility of the implementation team leader to produce the CAP. This may be the leader of the investigation team or some other team assigned by line management. The RCA or other interventions are only considered closed when all follow-up actions have been implemented.
Tools
Tool 7 - SIC Template
Measure Listing
Number 18.P.2 Measure Overdue action items Shell EP Average >5 Top Quartile <2
Process Map

A Corrective Action Plan should be produced for each RCA that is conducted. All actions are tracked and the plan will have a compliance measure based on the required close-out dates. This will be reviewed regularly by management and supervisors. Corrective actions will be tracked for close-out accuracy by a Reliability Engineer or RCA Focal Point.
Decide and Act 4
Develop corrective actions 4.1
Endorse corrective actions at ORIP 4.2
Implement the actions 4.3
Review status of actions at ORIP 4.4
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4.1
Develop corrective actions
4.2
Endorse corrective actions at ORIP
The solutions which result from the 5 Whys, the more formal RCA investigation or any other type of analysis activity will vary in terms the amount of budget and resources required. Some will require little and can be implemented as part of day-to-day activities. Others might be large and require a change proposal. However, whatever the scale, the solutions should: eliminate the causes or mitigate the consequences of the problem be practical be clear be cost effective comply with any recommendation criteria set prior to the start of any RCA study be implementable in the short to medium-term wherever possible. Investigation activities are not seen as part of the solution or corrective action plan. All solutions should be endorsed by the relevant Subject Matter Expert/Technical Authority. One solution that is recommended is the use of short interval controls. These allow process owners to review and react to changes in key production parameters over a short time period (generally two to four hours). Control limits are set for the key parameters (usually slightly inside the alarm limits) and performance against these limits monitored. If a process or piece of equipment starts to perform outside these limits this will be identified at the next review interval and before the alarm limits are reached. Tool 7 - SIC Template - explains how to use short interval controls and gives several examples. A short interval control process guide is also available on the Shell Wide Web.
In many cases, ORIP participants will determine the course of action appropriate to the issues being discussed. However, corrective actions (including budget and resource estimates) to issues that have been addressed via an RCA study should be forwarded to the monthly ORIP meeting by the Reliability Engineer or RCA Focal Point for discussion and if ORIP does not have the authority, then forwarded to the relevant parties for approval. The ORIP meeting should assign appropriate priority to the implementation of the actions and recommend that the required budget and resources required to complete them be approved. If the recommended corrective actions are rejected, the RCA team should revise them and re-submit them to the ORIP meeting.
4.3
Implement the actions
In most cases, the allocation and subsequent implementation of actions from ORIP will be straightforward. Where corrective actions have been proposed from an RCA, there may be a need to engage with staff who were not part of the analysis to make sure they understand the requirements and priority of the actions that have been approved by ORIP. It is essential that effective communication between the two parties takes place to make sure that ownership is transferred and that all parties are clear about the progress monitoring process at ORIP. Approved corrective actions should be put into a Corrective Action Plan (CAP). It is the responsibility of the Implementation Focal Point to produce the CAP. At one end of the scale, the CAP could and should be no more than the list of corrective actions in the RCA investigation report. At the other end of the scale, it could be a detailed project plan requiring significant resources, chartered teams, etc. The Corrective Action Plan should include: incident record number risk assessment of incident causes of the defect solutions/actions name of responsible party for completing action due date of action.
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Where maintenance work must be executed, the Work the process specified in the Work Preparation, Scheduling and Execution process guide (EP 2006-5445) should be followed. Note that between 60% and 70% of root causes will be human factors related and will not require a formal work order to be raised. The solutions are likely to be process or procedural changes and associated communication and training. However, planners and schedulers will need to allow for staff to have time off to attend appropriate events and this should be allowed for in any allocation of resources.
The following indicators are useful for informing the ORIP meeting where things are stuck or whether things are progressing to plan. RCA investigation study completed. All actions ranked and work orders created. Work orders listed in 90-day plan or Capex approved and execution year allocated for Capex items. Actions actually executed in field. Full RCA actions closed out.
4.4
Review status of actions at ORIP
During all ORIP meetings, the progress of all action implementations, including RCAs, should be tracked using the ORIP register, SAP-generated reports and information submitted by the Reliability Engineer(s) and/or implementation focal points. This is to identify any slippage and/or backlog that is building up and to ensure that appropriate remedial action is taken. An historical weakness of the RCA process was the potential for those in charge of RCA management to lose focus during implementation and to fail to identify that work resulting from RCAs was not being completed. This step, involving the ORIP meeting is, therefore, very important in ensuring that progress is monitored effectively. An RCA can only be considered closed when all action items have been completed. Furthermore, the RCA can only be considered effective when there are positive indicators that the implementation of the RCA actions has lead to an improvement in performance.
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5. Analyse and Improve

Success is not just about identifying root causes and implementing solutions but what has improved as a result. The unscheduled deferment, ORIP and RCA process and its contribution to business improvements, should be reviewed periodically to ensure that they meet the best in class standard and that benefits are being tracked.
Measure Listing
Number 18.S.2 18.S.3 18.P.2 Measure Number of RCAs Completed per Annum Repeat failure listing by equipment RCA Overdue Action item Compliance Shell EP Average Total number Equipment Specific >5 Top Quartile Total number Equipment Specific <2
Process Map

A history of completed RCAs for each Asset for a period of five years. Subject Matter Experts (SMEs) will also be identified, consulted, and participate, as needed, while conducting RCA analysis. A periodic review of completed RCAs and Corrective Action Plans. These will check for data quality, accuracy, completeness and thoroughness of the RCA process. They will be conducted by an SME or Reliability Engineer and the findings will be reviewed with the Asset Teams.
Analyse and Improve 5
Monitor effectiveness 5.1
Identify and implement improvements 5.2
Track and calculate benefits 5.3
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5.1
Monitor effectiveness
When it has been proven quantitatively (KPIs) that solutions have worked, this information should be shared within the Asset Team and cascaded within the work place (as a minimum). The Reliability Engineer should also consider what information should be shared with relevant Principal Technical Experts with a view to wider distribution. Deferment Identification and Reporting Ideally, all OUs should use the Global Deferment Coding Structure which has been implemented in Energy Components (EC) and which is the preferred tool for Hydrocarbon Production Information Management in Shell EP. The process will be built into the role of the Surface Production Team in EPT as an annual Global roll-up exercise, and thus facilitate the sharing of learning and continuous adjustment of Global Support Resource Pool to address common and recurrent bad actors across the Regions. The annual top deferral analysis will complement the benchmarking exercise, which currently does not cover all Assets and in most cases is not carried out annually.
Asset leadership is responsible for the overall monitoring of all aspects of performance. An integral part of this process is the follow-up and quantification of the success of solutions designed to reduce unscheduled deferment. Depending on results, the Asset Team should adjust the trigger thresholds. The quantification of value as a result of successful implementation can be based on: reduced production loss, deferment and downtime improved reliability reduction in loss of containment reduction in corrective maintenance reduction in labour, consumables or spares consumption improved safety performance. For equipment related events, this will be the responsibility of the Reliability Engineer. Suitable KPIs will need to be determined when a solution is implemented. An example is given below.
5.2
Identify and implement improvements
Example
The mean time between failure for a centrifugal pump is 3 months. An RCA shows that lubrication is ineffective and a different bearing is being used to the one recommended by the pump manufacturer. The lubrication regime is improved and the recommended bearings used. Improvements can be measured as follows. Measure MTBF (increasing trend should be visible). There should be no failures due to the causes identified in the RCA. Cost savings due to manpower not being used for corrective maintenance and a reduction in replacement bearings can be quantified and extrapolated over the working life of the pump.
When improvement areas have been identified, the next step will be to implement them. This will involve analysing the KPIs to ascertain areas for improvement and, subsequently, analysing the reasons for inadequate performance. When the causes have been identified, and possible solutions developed, an action plan should be created to address some or all of the issues identified. The activities on the action plan should be commensurate with the business risk or opportunity.
Note
It should be a matter of routine that measures such as MTBF for critical equipment should be tracked and analysed regularly by the Reliability Engineer and Operations staff An ORIP meeting should be used to agree appropriate actions and implement them.
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5.3
Track and calculate benefits

Benefit Calculations
Implementing improvements requires significant effort and it is important to demonstrate that the effort is paying off. Benefits from the process come through four main areas. 1. Reduced unscheduled deferment leading to more uptime and more sales revenue. 2. Less time spent fixing failed equipment leading to reduced labour costs (both direct and indirect). 3. Less materials consumed to re-instate equipment to its desired state leading to less material costs. 4. Fewer human errors. Measuring the benefits is not as easy as it may seem. Most managers usually ask for cumulative performance reports such as year-to-date operating costs, production volumes or unscheduled deferment and Asset availability at a high level rather than individual equipment level. Consequently, this net performance often masks the true contribution made by the individuals in an organisation who are driving the defect elimination process and reducing the costs that would otherwise have been incurred by repetitive failures. Net Cost = actual cost to run the business for one year
Example 1
A pump has an MTBF of four months and has been identified as one of the Asset Bad Actors, i.e. it fails at a frequency that impacts the business performance and the Assets ability to achieve Top Quartile targets so much that the Reliability Engineer and/or ORIP decide to investigate the situation. The repair costs of this pump every time the failure occurs is estimated at $50k ($35k for labour and $15k for materials and consumable spare parts). Unscheduled deferment associated with the failure is, on average, 2000bbls of crude. Following the RCA investigation and subsequent implementation of all recommendations in a timely manner, the MTBF is seen to increase to 16 months. The benefits from this exercise are calculated as follows. Benefit Calculation
Cost per failure Labour (hourly rate times no. of hours to repair) Materials and consumables Unscheduled deferment cost assume 17$/bbl), = 2000x17 Total cost Annual cost of failure = (12 x Total Cost)/MTBF, Therefore Annualised cost = (12 x 84)/4 $252k 16 months $63k $189k The new MTBF following the RCA action implementation is Therefore the new Annualised cost is (12x84)/16 Annualised benefit or cost avoidance overall = (252 63) $35k $15k $34k $84k
Potential Cost = actual cost + cost that would have been incurred without RCA The difference between potential cost and net cost is the direct contribution that the defect elimination process brings to improved performance, i.e. without it, the costs and unscheduled deferment figures would have been worse.
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Analyse and Improve
In example 1, the resulting MTBF was 16 months. However, this information can only be determined after a period of time has elapsed, often greater than the end of a reporting year. Example 2 shows how the cost of avoidance can be calculated for a given reporting year.
failures in that reporting year so it is essential that the equipment is monitored throughout the year to ensure accurate MTBFs and cost avoidance figures are retained. In some cases, there may be uncertainty about the size of the deferment reported with any given failure. This uncertainty should be discussed at the ORIP meeting and an agreement reached about the sensitivities of the calculation. For example, in terms of cost avoidance, it may be decided to only claim a certain percentage of the reported total coast as delivered cost avoidance. Benefit tracking themes To track the benefits from defect elimination and RCA effectively, a set of measures should be monitored on a regular basis (at least monthly). This should include: unscheduled deferment for the plant/Asset. This is the ultimate measure that will indicate improvement towards Top Quartile performance the MTBF of critical equipment, trended on a rolling 12-month basis and indicating when any RCA investigations took place availability of critical plant and equipment such as oil or gas export systems and major rotating equipment cost avoidance both in terms of operating costs and production revenue as described above. It is expected that the accountable parties for these measures will be the Reliability Engineer and/or a Production representative.
Example 2
Taking the same pump as in example 1, MTBF of four months, and assume that the pump has failed again in May. An effective RCA analysis is performed and solutions to the problem are implemented via the corrective action plan. Benefit Calculation An initial estimate of the cost avoidance can be made by applying the formula below. Annualised Cost avoidance = No. months left in the year x cost per failure Original MTBF In this example the cost avoidance would be (7 x 84)/4 = $147k This is because it was assumed that the next 1.75 failures in the remaining year were prevented!
These examples show that the calculations will only ever be approximations. MTBF is, by definition, an average figure so there is always the possibility that the cost avoidance could be higher or lower. In some cases, especially those failures and/or investigations that take place later in the year, it may not be possible to complete the analysis and all the associated solution corrective action plans before year end. This may result in additional
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Review of the Unscheduled Deferment, ORIP and RCA Operational Excellence Element
The externally facilitated Operational Excellence Review is the primary means for assessing the effectiveness of this Operational Excellence element. This should be complemented with self-assessments and internal reviews using this process guide and the Operational Excellence Standard, Volume 4, Element 21 and its associated best in class standards, measures and control documents.
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Appendices
Appendices
Appendix 1 - Typical terms of reference for an ORIP meeting. Appendix 2 - Roles and responsibilities RCA Facilitator/Team Leader. Appendix 3 - Competence matrix for RCA Appendix 4 - 5 Whys RCA guidance Appendix 5 - The Apollo process Appendix 6 - Generic SAP Z8 Work Process Flow
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Appendix 1 - Typical terms of reference for an ORIP meeting

Daily operations meeting
Frequency/Duration: Daily, 1 hour Attendees: Operations Supervisor (preferably ORIP Focal Point) Discipline Maintenance Supervisors (E/I/M/P) (as required) Maintenance Offshore Supervisor Scheduler (if at location. If not, Maintenance Supervisor takes this role) Meeting Aims and Objectives Plan the following days activity commencing 0600 + 1 day. Review events from previous 24 hours. Prioritise issues (using RAM) such that resources are focused in the right area. Monitor the progress of the important issues. Review planned visitors/presentations/meetings, etc. for following day. Agenda Review previous assigned actions. (Action Log) - 5 min. HSSE Issues - 5 min. Review previous days unscheduled deferment/reliability issues/TI (Trips/Events) - 10 min. Feedback from Event Investigations -10 min. Review progress, discuss, prioritise and plan activity for following day (PMs, CAs TSW, etc.) - 25 min. Summarise agreed actions - 5 min. Input (Pre-requisite Material) Risk Assessment Matrix. Daily action log. Daily operation report/highlights for previous day. Chairperson ( ) ______________ Work progress report. Previous RCA reports. Daily work schedule (WPS). Outputs Assigned 5 Whys Root Cause Analysis. Activity plan for feedback at 0600 briefing. Initiation of Equipment Improvement Teams (EIT) (as required). Work orders generated. Action log. Next day schedule. Ground Rules Start and finish on time. Come prepared. Individuals responsible for their own assigned actions. Open and honest communications between individuals. Demonstrate commitment to delivering the result. Solution, results and action focused. Silence is agreement. Supported By ( ) _______________ Maintenance Supervisor HSSE Advisor/Medic (as required) Selected Maintenance and Operations Technicians (as required) Time: 16.30 Location: Chairman: Senior Offshore Supervisor
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Appendix 1 - Typical terms of reference for an ORIP meeting
Onshore Weekly Unscheduled Deferment/ORIP meeting

Frequency/Duration: Weekly, 30 min (Max) Attendees: Senior Operations Supervisors Head Onshore Support Head of Maintenance Support Programmer (as required) Maintenance Supervisor HSSE Advisor (as required) Reliability Engineer (where available) Operations Supervisors (preferably ORIP focal point) Scheduler (if at location. If not, Maintenance Supervisor takes this role Time: Location: Net Meeting Chairman: Asset Offshore Supervisor
Selected Maintenance and Operations Technicians (as required)
Meeting Aims and Objectives Maintain Asset ORIP register. Prioritise issues (using RAM) such that resources are focused in the right area. Monitor the progress of the important issues. Forward top 5 issues to Monthly Asset ORIP meeting. Agenda Review previous assigned actions. (Action Log) - 5 min. Review actions assigned by weekly offshore meetings and provide required resources - 5 min. Feedback from Event Investigations - Highlights -10 min. Prioritise new issues (RAM) and identify top 5 issues for Asset monthly ORIP meeting - 5 min. Summarise agreed actions - 5 min. Input (Pre-requisite Material Deferred Wells list. Unscheduled deferment report. Previous weeks action log. Action logs from weekly platform ORIP meetings. Risk Assessment Matrix. Chairperson ( ) ______________ Supported By ( ) _______________ Asset ORIP register. SAP generated RCA reports. Outputs Action log. Assigned Root Cause Analyses. SAP PM changes. Mobilisation of Equipment Improvement Team (EIT). Work orders generated. Prioritised top 5 issues for monthly ORIP meeting. Ground Rules Start and finish on time. Come prepared. Individuals responsible for their own assigned actions. Open and honest communications between individuals. Demonstrate commitment to delivering the results. Solution, results and action focused. Silence is agreement.
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Monthly Unscheduled Deferment/ORIP Meeting

Frequency/Duration: Monthly, 2 hours (Max) Attendees: Operations Manager Operations Supervisor Maintenance Supervisor Programmer Reliability Engineer Discipline engineers (as required) Technical Authorities (as required) Well and Reservoir Management Other disciplines (as required) Time: Location: Net Meeting Chairman: Head of Operations
Meeting Aims and Objectives Maintain Asset ORIP register. Prioritise issues (using RAM) and ensure resources are focused in the right area (Asset top 5). Monitor the progress of the important issues. Ensure that activities are completed to plan. Ensure lessons learned are disseminated appropriately. Agenda Review previous assigned actions. (Action Log) - 5 min. Review priority issues from weekly ORIP meeting to determine Asset top 5 events - 10 min. Initiate any new RCA investigations required - 10 min. Feedback from formal RCA Investigations and assign any additional actions required - 60 min. Summarise agreed actions - 5 min. Input (Pre-requisite Material) Unscheduled deferment report. Previous months action log. Action logs from weekly onshore ORIP meetings). Risk Assessment Matrix. Asset ORIP register. SAP-generated RCA reports. Chairperson ( ) ______________
Outputs Action log. Assigned Root Cause Analyses. SAP PM changes. Mobilisation of Equipment Improvement Teams (EIT). Work orders generated. Prioritised top 5 issues for monthly ORIP meeting. Ground Rules Start and finish on time. Come prepared. Individuals responsible for their own assigned actions. Open and honest communications between individuals. Demonstrate commitment to delivering the results. Solution, results and action focused. Silence is agreement.
Supported By (
) _______________
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Appendix 2 - Roles and responsibilities RCA Facilitator/Team Leader
Appendix 2 - Roles and responsibilities RCA Facilitator/Team Leader
The Facilitator/Team Leader should carry out the following activities as appropriate. Before the analysis Initial ranking of trip, failure or deferment followed by data capture, e.g. photographs, readings, trip logs, broken parts, list of witnesses. Plan the analysis with the Asset Owner. Identify who, individually, is going to be in the RCA team. Arrange or deliver RCA training for group members who have not yet been trained. Produce a schedule for the work including dates/times of meetings, plus expected completion date and management presentation. Circulate the plan to group members, their bosses and Asset owner. Collect relevant data including P&IDs, PFDs, operating manuals, history records. Be involved in the pre-planning with the workshop sponsor. Clarify the process and provide guidance from beginning to end. Record the groups expectations, ideas and decisions. During the analysis Act as contact point between the RCA team and external parties for implementation and audit review, trip, failure and deferment co-ordination. Bring the group back on track if the discussion digresses. Encourage everyone to actively participate, maintain momentum by continually asking questions. Keep the group in harmony and non-confrontational, be a mediator.
Help to clarify ideas by summarising; ensure there is common understanding. Ensure that each group member understands the problem to be solved, the analysis objectives and agree when and how they will to be measured. Apply the RCA process, dont skip parts or take answers for granted. Ensure that the group reaches fact-based conclusions. Identify and extract appropriate information from relevant people. Collect facts, test hypotheses, identify physical human and latent causes. Be positive, dont embarrass group members and provide positive feedback in response to positive contributions, keep the group motivated. Ensure that people actually attend meetings. Encourage everyone to participate, prevent dominant personalities from taking over the meeting. Perform sanity checks on the data and findings and assist the group in distinguishing between think, know and prove. If something feels very wrong, check it out. Recognise when the group doesnt know something and more information is needed, i.e. when the group simply doesnt know enough to make a decision. Keep up the momentum - dont let the meetings become a discussion on redesign (trying to do redesign during meetings wastes a lot of time). Make sure time during or between meetings is not wasted. Set targets, identify specific questions that need to be answered before the next meeting. Assign out-of-meeting tasks to group members, e.g. calling a vendor for clarification, checking a set point. Communicate on any urgent findings as they arise. Ensure recommendations address root causes and that they are cost effective and practical. Feedback progress against plan.
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Highlight problems or bottlenecks with the analysis that you cant fix to ORIP meeting/Asset Owner. Aid the groups performance, consider breaks or ice-breakers. Bring best practices to the table from elsewhere, apply lessons learned from other workshops. Get results. Capture lessons learned. After the analysis Produce written report and upload in SAP against the appropriate Z1 or Z8 notification. Use terms everyone understands (including technicians, design engineers and senior managers) for findings, supporting facts, recommendations. Avoid abbreviations. Make a short management presentation showing how the objectives of the analysis have been, or will be, achieved and what has been done to achieve them. Try to ensure recommendations are implemented quickly. Detailed monthly progress report to RCA champion and Asset Owner on status of each RCA recommendation and its status.
Facilitators should not: be confrontational make the group uncomfortable with the result take an intellectually superior position belittle any of the team members force the use of best practice from elsewhere if there is strong resistance get into much detail on cost or risk get into arguments on technical details.
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Appendix 3 - Competence matrix for RCA
Appendix 3 - Competence matrix for RCA
Roles
5 Whys Process
Facilitation
SAP Z8 Work flow
ORIP Process 4
ORIP meeting (Senior Managers, e.g. Ops Manager) ORIP Focal Point Asset Manager Line Supervisors Reliability Engineer (or production equivalent) RCA Focal Point Production/Operations staff Maintenance staff (inc Contractors) RCA Facilitator RCA Team Members Total Reliability Change Agents Technical Authorities Subject Matter Experts Discipline Engineers Head of Maintenance Planners/Schedulers HSSE advisors
1 1 3 4
1 1 2 4
1 1 2 3
4 3 1 2
4 2 3 3 2 3 3 1 1 1 3 1
4 1 3 2 3 3 2 2 1 2 2
3 1 2 3 2 3 1 1 1 1 3 1
3 1 1 2 1 2 1 1 1 2 1 1
Key:
1 Awareness
2 Knowledge
3 Skill
4 Mastery
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Appendix 4 - 5 Whys RCA guidance
Why use the 5 Whys approach? In the workplace, it is rare to get to the root cause because the symptoms of the problems are often treated instead. However, unless the root cause is addressed, problems will keep reappearing. Most people have heard of the concept of the Root Cause of Failure and the tool most commonly used to assist in the search for the root cause is the 5 Whys. The 5 Whys is a simple technique of asking why 5 times and recognises that after answering 5 whys, they will arrive at the root cause. World class organisations use this approach to eliminate defects. Advantages No-one needs to be an expert in anything to do a 5 Whys investigation. Using 5 Whys will not swamp the team in paper work. It is simple, practical and quick. It can be done quickly by an individual or a small team with minimal preparation. Identifies easy root cause issues. Requires minimal data. How to use the 5 Whys The 5 Whys process is a simple way of finding ONE root cause. There may be others so its not an exhaustive technique. Remember, the simplest solution is likely to be right. It is not necessary to go to 5 levels, although this is the most powerful way of getting past the obvious. To avoid jumping to conclusions, stay open minded and look for a balance between technical issues, human issues and process issues. If several possibilities are presenting themselves and the issue is appearing to be more complex than first assumed, then raise
the issue up the line to the ORIP meeting via a SAP Z8 RCA notification to be raised. This process is more thorough but will handle the multiple options. Key steps involved 1. Find a problem. 2. Work through it either individually or with a small group. 3. Write down a problem statement. 4. Then simply ask, WHY - the first answer is the most important as this sets the scene for the subsequent questions and answers.
Example
Problem Statement: SW - P - 1260 has suffered frequent mechanical seal failures over the last seven months. 1. WHY does the seal fail? a. Because the seal faces are cracking. 2. WHY are the seal faces cracked? a. Because of excess vibration in the pump. 3. WHY is the pump vibrating? a. Because there is misalignment. 4. WHY is there misalignment? a. Because the motor holding bolts have come loose. 5. WHY are the bolts loose? a. Because the bolts are not positively secured.
How to use the template Figures 9 and 10 explain how to use the 5 Whys RCA Report and templates are provided on the CD.
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Appendix 4 - 5 Whys RCA guidance
Figure 9: Completing the 5 Whys RCA Report
If the event has caused deferment, enter an estimate of the volume Ensure Risk Assessment Matrix rating is entered. If in doubt consult your Supervisor
Estimated volume
5 Whys - Root Cause Analysis Report

Date and time of event
Duration Owner
bboe
RCA Lead RCA Team members (include designation) Brief description of incident
Entered in ORIP database Closed in ORIP database RAM rating
Sketch or photograph
Deferment code
Enter the Root Cause deferment code again, if in doubt, consult your Supervisor Accurately describing the incident/problem is the first step to good cause analysis
Location
Equipment description/Tags nos etc.
Immediate actions taken 1 2 3 4 5
Date
By
Enter what was done, who did it and when
Enter equipment description and Tag No (SAP No) to allow equipment history to be kept
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Figure 10: Completing the 5 Whys RCA Report
Root Cause/5
Why 1 Why 2 Why 3 Why 4 Why 5
Notes/comments:
Why
Technician fills in this section as a record of the thinking logic digging into the issue
Short term actions:

1. 2. 3. 4. 5. To be completed by the supervisor
Technician fills in this section as a record of the immediate or short term action taken as a result of the above analysis. Maybe less than 5 actions
Proposed actions to prevent recurrence Options

Instruction
:
Required Reference number
Do nothing
PMR; SAP PM change Use SAP amendment process
Y/N
Supervisor completes this as a record of the actions beyond the platforms immediate control. Chooses one or more of the 5 options
Y/N
SAP notif .no. PIR. no.
Initiate plant change Change operational procedures/ instructions Other
Raise PIR
Y/N
Amend CMS/ ODT**/POPM/ SOP***
Y/N
POP M*
Details:
Y/N
Other might include raising the issue to the Asset Manager for escalation into the ORIP process and launching a full Apollo RCA
Supervisor name:
Date:
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Appendix 5 - The Apollo process
The Apollo process is illustrated in Figure 11 and explained below.
Figure 11: The Apollo process
Step 1 Define the problem
Step 2 Create a cause and effect chart
Step 3 Identify effective solutions
Step 4 Implement best solution
Step I. Define the problem Firstly the following questions need to be answered. What happened? Primary Effect - the thing you want to prevent from occurring. When did it happen? Date? Time? Status? Where did it happen? Physical Location? Process Location? What was the significance of the event?

How to collect the data: conduct interviews collect statements review records

operating logs correspondence inspection surveillance records maintenance records meeting minutes computer process data procedures and instructions vendor manuals drawings and specifications functional test specification and results equipment history records design basis information related quality control evaluation report trend charts and graphs facility parameter readings sample analysis and results work orders.
Safety: Injuries? Potential? Environmental: Regulations? Spills? Potential? Production: Euros? Rates? Delay? Hours? Quality? Service: Delay? Customer Satisfaction? Maintenance: Materials? Labour? Hours? Euros? Frequency: Occurrences? Timeframe?
There are numerous sources for this information.
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Step II. Create a cause and effect chart The steps for creating a cause and effect chart (see Figure 12) are: identify the problem determine the significance of the problem identify the causes (conditions or actions) immediately preceding and surrounding the problem identify the reasons why the causes in the preceding step existed, working back to the root cause (the fundamental reason which, if corrected, will prevent recurrence of these and similar occurrences throughout the Facility).
The Apollo cause and effect chart is used for the analysis of the problem. The problem is broken down into its parts or causes by asking the why questions. The cause and effect chart is a very powerful communication tool. The chart provides a visual dialogue of the problem and simplifies complex issues by breaking them into individual cause and effect relationships.
Tool 8 - Example cause and effect diagrams - give examples of a bearing failure and a flange fire.
Figure 12: A Cause and effect chart
Cause/ Effect
CB
Cause/ Effect
Primary Effect
Cause/ Effect
CB Evidence Evidence
Evidence
Evidence
Cause/ Effect
CB
Cause/ Effect
Evidence
Evidence
Cause/ Effect For every effect ask why? Look for causes in actions and conditions Connect causes with caused by Support causes with evidence or use a question mark (?)
Evidence
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The investigation consists of evidence-based causes. If there is no evidence to support a cause, it must be identified with a question mark (?). Question marks in an investigation are very useful because they point out the information that is missing. A question mark on a cause and effect chart is an action item directing where there is a need to collect more information. The exercise of formulating the cause and effect chart is done typically by a group of three to six people representing all of the disciplines involved in the incident. Step III. Identify effective solutions At this stage you should challenge each cause that has been identified, offer possible solutions and above all be creative. The best solutions must: prevent recurrence be within your control meet your goals and objectives. You should use tools such as brainstorming to gather ideas about possible solutions (from your team and people who perform the process). Step IV. Implement the best solutions All the corrective actions should now be documented in a Corrective Action Plan: causes solution/corrective actions name date.
All actions need to be tracked and the plan should have a compliance measure established based on the required close-out dates. Corrective actions should be tracked for close-out accuracy by a Reliability Engineer. A complete list of Corrective Action Plans should be maintained for a period of five years.
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Appendix 6 - Generic SAP Z8 Work Process Flow

Role
Operations staff/Reliability Engineer Register RCA Request Create Z8 Cancel RCA Request - Set Z8 to CNCL
ORIP Panel Approve RCA Request No Corrective Action Plan approved? Yes
RCA Request approved?
No
Approve Solutions/ Action Plan
Yes Reliability Engineer/RCA Facilitator Capture RCA reports attach documents to Z8
No RCA Complete - Set COMP status Yes Hard actions?
Approve Z8 Set APPR status
Yes RCA Team Conduct RCA RCA completed?
No
Implementation Team
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Appendix 6 - Generic SAP Z8 Work Process Flow
No
Close out approved?
Yes
Approve close out of RCA
Yes Record all hard and soft action plans in Z8 Task fields Complete action plan. Complete task in Z8 All Tasks in Z8 completed with appropriate history? No Close out RCA. Set CLSD status in Z8
Create Z1, Z5 or Z6
Handover and agree actions with Implementation Team
Yes Implement solutions Action plan completed? Feedback to ORIP Panel
No
Non-SAP activity (manual) SAP activity
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Glossary of terms
Concept
A Asset B Bad Actors C Computerised Maintenance System (CMMS)
Definition
Either a machine, platform, or system. It is the basic unit of maintenance. Unlike in the accounting definition, in maintenance this is commonly taken to be any item of physical plant or equipment. A bad actor is an item of equipment or particular equipment type, which poses significant risk of failure. A computerised system to assist with the effective and efficient management of maintenance activities through the application of computer technology. It generally includes elements such as a computerised work order system, as well as facilities for scheduling routine maintenance tasks, and recording and storing standard jobs, Bills of Materials and task lists, as well as numerous other features. SAP BLP is the computerised maintenance management system currently being used by Shell EP. Any maintenance activity which is required to correct a failure that has occurred or is in the process of occurring. This activity may consist of repair, restoration or replacement of components. Equipment Improvement Teams can be used to focus improvement efforts towards enhancing skills and knowledge, establishing autonomous maintenance practices, and improving equipment design and manufacture. A group of equipment used to perform a useful function for the EP business. An item of equipment has suffered a failure when it is no longer capable of fulfilling one or more of its intended functions. Note that an item does not need to be completely unable to function to have suffered a failure. For example, a pump that is still operating, but is not capable of pumping the required flow rate, has failed. In reliability centred maintenance terminology, a failure is often called a functional failure. Time interval that commences with the initiation of the concept and terminates with the disposal of the item. Any activity carried out on an Asset in order to ensure that the Asset continues to perform its intended functions, or to repair the equipment. A measure of equipment reliability. Equal to the total equipment downtime in a given time period, divided by the number of failures in that period. Maintenance carried out at predetermined intervals or according to prescribed criteria and intended to reduce the probability of failure or the degradation of the functioning of an item. Any activity which returns the capability of an Asset that has failed to a level of performance equal to, or greater than, that specified by its functions, but not greater than its original maximum capability. An activity which increases the maximum capability of an Asset is a modification. Is a structured process that uncovers the physical, human, and latent causes of an undesirable event in the work place. True RCA involves getting past the physical components of failure and into specific actions by humans that triggered the cause and effect chain that led to physical failure. It also involves finding "why they did it". The standard Computerised Maintenance Management System (CMMS) for EP.
Corrective Maintenance (CM) E Equipment Improvement Teams (EIT) F Facility Failure
L Life cycle M Maintenance Mean Time Between Failures (MTBF) P Preventive Maintenance (PM) R Repair
Root Cause Analysis (RCA)
S SAP Blueprint (SAP BLP)
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Glossary of abbreviations/acronyms
Glossary of abbreviations/acronyms
Abbreviation/ Acronym
C CM CMMS E EC EIT H HCA HPIM HSSE I IPSC K KPI M MTBF O OE ORIP OU P P&ID PIR PFD PM PSO R RAM RBI RCA S SIC SME
Definition
Corrective Maintenance Computerised Maintenance Management System Energy Components Equipment Improvement Team Hydrocarbon Allocation Hydrocarbon Production Information Management Health, Safety, Security and Environment Integrated Production System Capacity Key Performance Indicator Mean Time Between Failure Operational Excellence Operational Reliability/Integrity improvement Process Operating Unit Piping and Instrumentation Diagram Post Implementation Review Probability of Failure on Demand Preventive Maintenance Production System Optimisation Risk Assessment Matrix Risk Based Inspection Root Cause Analysis Short Interval Controls Subject Matter Expert
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Shell Exploration & Production

EPT Shell International Exploration & Production B.V. Kesslerpark, Rijswijk (ZH), 2288 GS Rijswijk The Netherlands.
The copyright in this document is vested in Shell International Exploration and Production B.V., The Hague, The Netherlands. All rights reserved. Neither the whole or any part of this document may be reproduced, stored in any retrievable system or transmitted in any forms by any means (electronic, mechanical, reprographic, recording or otherwise) without the prior written consent of the copyright owner. EP 2007-9014

Unscheduled Deferment

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Unscheduled Deferment

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Unscheduled Deferment, ORIP and RCA Process Guide

Operational Excellence Delivering Continuous Performance Improvement

Unscheduled Deferment, ORIP and RCA Process Guide

Unscheduled Deferment, ORIP and RCA Process Guide

Unscheduled Deferment, ORIP and RCA Process Guide

Unscheduled Deferment, ORIP and RCA Process Guide

Figure 1: Unscheduled Deferment 2005

Total oil = 94 mln bbls 20 1200 800 10 400

Total gas = 4,500 mln m3

Safeguarding and control

Produced water system

Safeguarding and control

Produced water system

Figure 2: Unscheduled Deferment story - BSP

Unscheduled deferment trend was downward even before formal ORIP

12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0%

Unscheduled deferment/ORIP implementation commenced Jan06

Unscheduled Deferment, ORIP and RCA Process Guide

Figure 3: The Operational Reliability/Integrity improvement Process (ORIP)

Identify Unwanted events/ conditions

Check thresholds Analyse and improve

Do nothing Procedural change

Unscheduled Deferment, ORIP and RCA Process Guide

ORIP meeting structure

Figure 4: ORIP meeting structure

Monthly ORIP meeting

Assess and rank in ORIP database

Asset weekly ORIP meeting

Assess and rank in ORIP database

Unscheduled Deferment, ORIP and RCA Process Guide

Roles and responsibilities

Critical success factors

Unscheduled Deferment, ORIP and RCA Process Guide

the preferred RCA approach must:

Unscheduled Deferment, ORIP and RCA Process

Unscheduled Deferment, ORIP and RCA Process

Unscheduled Deferment, ORIP and RCA Process Guide

The Unscheduled Deferment, ORIP and RCA Process Map

Assess and Rank 2

Select and Analyse 3

Identify opportunities 1.1

Carry out 5 Whys on an incident 2.1

Establish RCA Team 3.1

Categorise and risk assess 2.2

Conduct preparation meeting 3.2

Decide what action to take and allocate resources 2.3

Analyse the incident 3.3

Record root causes and communicate 3.4

Unscheduled Deferment, ORIP and RCA Process

Decide and Act 4

Analyse and Improve 5

Develop corrective actions 4.1

Monitor effectiveness 5.1

Endorse corrective actions at ORIP 4.2

Identify and implement improvements 5.2

Implement the actions 4.3

Track and calculate benefits 5.3

Review status of actions at ORIP 4.4

Unscheduled Deferment, ORIP and RCA Process Guide

Identify opportunities 1.1

Best in Class Standard

Unscheduled Deferment, ORIP and RCA Process Guide