You are on page 1of 20

10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review

Dashboard / My courses / ENGG 404 (LEC 501 550 SEM 601 602 651 652 Winter 2022) / Assignment 2 - The Hub Oil LI
/ Assignment 2 - The Hub Oil LI - Graded

Started on Saturday, 12 March 2022, 6:52 PM


State Finished
Completed on Saturday, 12 March 2022, 7:07 PM
Time taken 15 mins 27 secs
Marks 47.14/55.00
Grade 85.71 out of 100.00

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 1/20
10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review

Question 1

Complete

Not graded

Imagine if you will, a refinery had a small fire, but not catastrophic like those that make the global headlines. A root cause analysis was done on
this fire, of which one root from the "loss incident" through to the latent cause. You have been assigned to match the actual cause from the root
to the category and sub-category as illustrated in this graphic:
(Note: The "match" choices in the question for the intermediate causes are denoted as "First Intermediate", "Second Intermediate", and "Third
Intermediate" only to aid in your selection and scoring. There is no significance to the "First", "Second", or "Third" except as it relates to the
automatic scoring function on eClass quizzes.)

Petroleum fire Incident description

Petrol released from pump casing Immediate Cause: Sub-standard condition

Pump casing corroded (failed) First Intermediate

Casing material was incompatible Basic Cause: Design – inadequate technical design

Improper material was used Second Intermediate

Pump design was incorrect Third Intermediate

The engineering work process / program to


Latent Cause - Inadequate Program: relates to RMSE#7 Design, Construction, and Startup
design pumps at this refinery was inadequate

Your answer is partially correct.

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 2/20
10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review
The correct answer is: Petroleum fire → Incident description, Petrol released from pump casing → First Intermediate, Pump casing corroded
(failed) → Immediate Cause: Sub-standard condition, Casing material was incompatible → Second Intermediate, Improper material was used →
Third Intermediate, Pump design was incorrect → Basic Cause: Design – inadequate technical design, The engineering work process / program
to design pumps at this refinery was inadequate → Latent Cause - Inadequate Program: relates to RMSE#7 Design, Construction, and Startup

Question 2

Correct

Mark 5.00 out of 5.00

Please recall the PEAP model of losses (People, Environment, Assets, Production). Match the following with the correct PEAP category for the
losses at The Hub Oil Loss Incident:

People - Workers Two (2) fatalities, and six (6) people struck by shrapnel at the Hub Oil Plant

Environment  Large noxious plume of black smoke over several days; volume of hydrocarbons released through surface run-off.

Assets  Entire facility destroyed; loss of personal and company vehicles.


Production Facility permanently shut down - can no longer receive used oil for recycling.

People - General Wide residential areas were evacuated, with exposure to potentially harmful emissions.
Public

Your answer is correct.


People - Workers: Two (2) fatalities, and six (6) people struck by shrapnel at the Hub Oil Plant

People - General Public: Wide residential areas were evacuated, with exposure to potentially harmful emissions.

Environment: Large noxious plume of black smoke over several days; volume of hydrocarbons released through surface run-off.

Assets: Entire facility destroyed; loss of personal and company vehicles.

Production: Facility permanently shut down - can no longer receive used oil for recycling.

Distractor: The light-rail commuter line running just north of the plant was temporarily shut-down as a precautionary measure. 

The correct answer is: People - Workers → Two (2) fatalities, and six (6) people struck by shrapnel at the Hub Oil Plant, Environment  → Large
noxious plume of black smoke over several days; volume of hydrocarbons released through surface run-off., Assets  → Entire facility destroyed;
loss of personal and company vehicles., Production → Facility permanently shut down - can no longer receive used oil for recycling., People -
General Public → Wide residential areas were evacuated, with exposure to potentially harmful emissions.

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 3/20
10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review

Question 3

Partially correct

Mark 3.00 out of 5.00

Match the immediate cause category and sub-category with the appropriate immediate cause

Safety
devices were
made Still #2, a reclaimed pressure vessel, was not rated for the operating pressures and temperatures at the time of the loss incident
inoperable

(SP) -

Not
following
proper
maintenance The water for cleaning the feed pipes to/from Still #2 was not drained and cleared from feed pipes
procedures

or methods
(SP) -

Inadequate
protective
The over-pressure relief valve was removed from Still #2
equipment
(SC) -

Fire and
explosion The contents of Still #2 were held above auto-ignition temperature
hazard (SC) -

Not
following
proper
operating Controlling and monitoring the pressure in Still #2 system was not done following standard operating procedure
procedures

or methods
(SP) -

Your answer is partially correct.

You have correctly selected 3.


The correct answer is:

Safety devices were made inoperable (SP) - → The over-pressure relief valve was removed from Still #2,

Not following proper maintenance procedures or methods (SP) - → The water for cleaning the feed pipes to/from Still #2 was not drained and
cleared from feed pipes,

Inadequate protective equipment (SC) - → Still #2, a reclaimed pressure vessel, was not rated for the operating pressures and temperatures at
the time of the loss incident,

Fire and explosion hazard (SC) - → The contents of Still #2 were held above auto-ignition temperature,

Not following proper operating procedures or methods (SP) - → Controlling and monitoring the pressure in Still #2 system was not done
following standard operating procedure

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 4/20
10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review

Question 4

Partially correct

Mark 5.00 out of 7.00

Match the basic cause category and sub-category with the most appropriate basic cause description

Inadequate job
The skills for cleaning / lancing of pipes were not properly and completely acquired from the original contractor
procedures (Job factor) -

Inadequate training (Job


No qualification or refresher training for employees at Hub Oil
factor) -

Inadequate maintenance
of equipment (Job factor) Pressure gauges on Still #2 System were not maintained nor serviced
-

Lack of knowledge or skill


Standard Operating Procedures were locked away in manager’s office
(Personal factor) -

Inadequate engineering
standards, specifications,
or design criteria (E&D Reclaimed pressure vessel not registered with ABSA and did not meet ABSA regulations
factor) -

Improper motivation
Reclaimed pressure vessel was readily available and "would do the job"
(Personal factor) -

Inadequate assessment
Potential PEAP impacts were not identified in any aspect of the operation
of loss exposures (E&D
factor) -

Your answer is partially correct.

You have correctly selected 5.


Inadequate job procedures (Job factor) - Standard Operating Procedures were locked away in manager's office
Inadequate training (Job factor) - No qualification or refresher training for employees at Hub Oil
Inadequate maintenance (Job factor) - Pressure gauges were not maintained nor serviced
Lack of knowledge or skill (Personal factor) - The skills for cleaning / lancing of pipes were not properly and completely acquired from the
original contractor
Inadequate engineering standards, specifications, or design criteria (E&D factor) - Reclaimed pressure vessel not registered with ABSA and did
not meet ABSA regulations
Improper motivation (Personal factor) - Reclaimed pressure vessel was readily available and "would do the job without detailed engineering"
Inadequate assessment of loss exposures / risk assessment / hazard identification (E&D factor) - Potential PEAP impacts were not identified in
any aspect of the operation

The correct answer is:

Inadequate job procedures (Job factor) - → Standard Operating Procedures were locked away in manager’s office,

Inadequate training (Job factor) - → No qualification or refresher training for employees at Hub Oil,

Inadequate maintenance of equipment (Job factor) - → Pressure gauges on Still #2 System were not maintained nor serviced,

Lack of knowledge or skill (Personal factor) - → The skills for cleaning / lancing of pipes were not properly and completely acquired from the
original contractor,

Inadequate engineering standards, specifications, or design criteria (E&D


factor) - → Reclaimed pressure vessel not registered with ABSA and did
not meet ABSA regulations,

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 5/20
10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review
Improper motivation (Personal factor) - → Reclaimed pressure vessel was readily available and "would do the job", Inadequate assessment of
loss exposures (E&D factor) - → Potential PEAP impacts were not identified in any aspect of the operation

Question 5

Correct

Mark 2.00 out of 2.00

Which of the following latent causes most strongly relates to RME #1 Management Leadership, Commitment and Accountability?

Select one:
Scale of possible worse case scenario incidents were neither cross out
conceived nor planned for.

Safety performance objectives and targets were not established.


cross out

There was a cross Correct - "There was a complete absence of a risk management program at Hub Oil.". There is a difference
out
complete between a "risk management program", (the overall "umbrella" as discussed in Topic #15 Chapter 3.1 The Risk
absence of a Management Program, Chapter 3.2 The Risk Management Work Process, and Chapter 3.3 The Risk
risk Management System and Elements), and RM Element #2 Risk Assessment and Management of Risks, which is
management but one of 11 elements of the risk management program. The scope of Element #2 includes Hazard
program at Identification (FLRA, SQRA, JSA, Checklists, Reporting & Correcting Substandard Conditions & Practices,
Hub Oil.

Planned Inspections, etc.) and the control measures necessary to eliminate the risks, or reduce and control
risks to an acceptable level. Management would need to commit to the development and implementation of a
risk management program, and would need to lead its people and organization in the effective implementation
of that risk management program. 

Maintenance was done on an "as needed” basis, and "if it ain't broke, cross out
don't fix it”.

Your answer is correct.


The correct response is "There was a complete absence of a risk management program at Hub Oil." There is a difference between a "risk
management program", (the overall "umbrella" as discussed in Topic #15 Chapter 3.1 The Risk Management Program, Chapter 3.2 The Risk
Management Work Process, and Chapter 3.3 The Risk Management System and Elements), and RM Element #2 Risk Assessment and
Management of Risks, which is but one of 11 elements of the risk management program. The scope of Element #2 includes Hazard
Identification (FLRA, SQRA, JSA, Checklists, Reporting & Correcting Substandard Conditions & Practices, Planned Inspections, etc.) and the
control measures necessary to eliminate the risks, or reduce and control risks to an acceptable level. Management would need to commit to the
development and implementation of a risk management program, and would need to lead its people and organization in the effective
implementation of that risk management program. 

Other RME's:
Scale of possible worse case scenario incidents were neither conceived nor planned for. - Incorrect. Worse case scenario planning would best be
aligned with either RM Element #2 Risk Assessment and Management of Risks, or  RME #3 Community Awareness and Emergency
Preparedness. In many cases, the scenario is identified in RME #3 as well as the program and plans for community awareness and emergency
preparedness. The plans and program for identifying risks and control measures for those scenarios fall under RME #2.  

Safety performance objectives and targets were not established. - Partially correct. Although this statement does align, it is only one of many
things that management would need to do in order to lead its people and organization in the effective implementation of that risk management
program. Part marks awarded. 

Maintenance was done on an "as needed” basis, and "if it ain't broke, don't fix it”. - Incorrect. This statement - which was the de-facto
maintenance program at Hub Oil - would best align with RME# 8 Operations and Maintenance. 

The correct answer is: There was a complete absence of a risk management program at Hub Oil.

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 6/20
10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review

Question 6

Correct

Mark 2.00 out of 2.00

For the latent cause given below for RME #1, to which characterization of a latent cause does it most strongly belong? 
Latent Cause: There was a complete absence of a risk management program at Hub Oil.
Reminder, alignment is defined as 
"P” = Inadequate Program,
"S” = Inadequate Program Standards,
"C” = Inadequate Compliance with Standards

Select one:
P cross out

S cross out

C cross out

Your answer is correct.


Latent Cause: There was a complete absence of a risk management program at Hub Oil. 

The correct response is P:  


Explanation: Management neither held nor had stated a set of safety values, and had minimal, if any, concept of engineering safety and risk
management. Hub Oil had not created a set of corporate safety values, lacked a comprehensive Risk Management Program, and their leadership
lacked knowledge to understand engineering safety and risk management, and to commit resources to develop an acceptable safety culture and
risk management program. Other objectives, such as production, costs, marketing, and employee welfare and satisfaction were managed
instead of safety.

The correct answer is: P

Question 7

Correct

Mark 2.00 out of 2.00

Which of the following latent causes most strongly relates to RME #2 Risk Management and Management of Risks?

Select one:
Community was in close in proximity and not aware of plant cross out
operations

The risk assessment program did not include formal risk cross out
assessments for critical plant operations.

Safety performance objectives and targets were not established.


cross out

No qualification process for selecting contractor companies or cross out


contractor employees

Your answer is correct.

The correct answer is: The risk assessment program did not include formal risk assessments for critical plant operations.

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 7/20
10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review

Question 8

Incorrect

Mark 0.00 out of 2.00

For the latent cause given below for RME #2, to which characterization of a latent cause does it most strongly belong? 
Latent Cause: The risk assessment program did not include formal risk assessments for critical plant operations.
Reminder, alignment is defined as 

"P” = Inadequate Program,


"S” = Inadequate Program Standards,
"C” = Inadequate Compliance with Standards

Select one:
P cross out 

S cross out

C cross out

Your answer is incorrect.


Latent Cause: The risk assessment program did not include formal risk assessments for critical plant operations.
The correct response is S: 
Explanation: The risk assessment program did not include process safety reviews, ABSA pressure vessel data / specification sheets, processes
for ensuring compliance with ABSA regulations, and OH&S legal requirements.  Although Hub Oil had a very basic risk management program
that addressed the most simple of hazards (hot surfaces, ignition sources, and the like), the program completely overlooked all regulatory
requirements (ABSA Reg'ns and OH&S Code), and the hazards and risks associated with refining and recycling spent oils (process safety).
Employees had minimal understanding of occupational safety hazards, and requirements of the Alberta Occupational Health and Safety Act,
Regulations, and Code. 

The correct answer is: S

Question 9

Correct

Mark 2.00 out of 2.00

Which of the following latent causes most strongly relates to RME #4 Management of Change?

Select one:
There was no MOC program to effectively ensure plant operations cross out
did not degrade over time

No monitoring of safety performance


cross out

There was a complete absence of a risk management program at cross out


Hub Oil.

No process for effectively learning contractor skills.


cross out

Your answer is correct.


The correct answer is: There was no MOC program to effectively ensure plant operations did not degrade over time

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 8/20
10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review

Question 10

Correct

Mark 2.00 out of 2.00

For the latent cause given below for RME #4, to which characterization of a latent cause does it most strongly belong? 
Latent Cause: There was no MOC program to effectively ensure plant operations did not degrade over time
Reminder, alignment is defined as 

"P” = Inadequate Program,


"S” = Inadequate Program Standards,
"C” = Inadequate Compliance with Standards

Select one:
P cross out

S cross out

C cross out

Your answer is correct.


Latent Cause: There was no MOC program to effectively ensure plant operations did not degrade over time
The correct response is P:
Explanation:  There was no program, process, procedure, or any documented administrative control to manage changes relating to the process
unit operations at Hub Oil.  Management did not consider that changes in operations or equipment needed to be closely managed and
documented; management assumed that these changes would be managed by the workers. Management did not implement an MOC Program
and MOC Work Process.  

The correct answer is: P

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 9/20
10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review

Question 11

Correct

Mark 2.00 out of 2.00

Which of the following latent causes most strongly relates to RME #7 Design Construction and Start-up

Select one:
No real emergency preparedness or emergency planning internal to cross out
the company nor with local authorities.

Safety not a value. Other objectives such as production, costs, cross out
employee satisfaction were managed instead of safety

The engineering and design program did not abide by rigorous cross out
standards for specifying, procuring, fabricating, or modifying the
process equipment and pressure vessels in the plant. Plant was
built based on trial and error of legacy knowledge, and not properly
designed or engineered. 

Complete lack of understanding of process safety hazards.


cross out

Your answer is correct.


The correct answer is: The engineering and design program did not abide by rigorous standards for specifying, procuring, fabricating, or
modifying the process equipment and pressure vessels in the plant. Plant was built based on trial and error of legacy knowledge, and not
properly designed or engineered. 

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 10/20
10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review

Question 12

Correct

Mark 2.00 out of 2.00

For the latent cause given below for RME #7, to which characterization of a latent cause does it most strongly belong? 
Latent Cause: The engineering and design program did not abide by rigorous standards for specifying, procuring, fabricating, or modifying the
process equipment and pressure vessels in the plant.
Reminder, alignment is defined as 

"P” = Inadequate Program,


"S” = Inadequate Program Standards,
"C” = Inadequate Compliance with Standards

Select one:
P cross out

S cross out

C cross out

Your answer is correct.


Latent Cause: The engineering and design program did not abide by rigorous standards for specifying, procuring, fabricating, or modifying the
process equipment and pressure vessels in the plant.
The correct response is C
Explanation: "At the very least, the professional engineers and operating engineers at Hub Oil should have known to access the ABSA
Regulations and comply with those regulations." Anyone doing any kind of design work at Hub Oil was not aware that they needed to comply
with the ABSA Regulations (legal requirements). The plant was built based on trial and error of legacy knowledge, and not properly designed or
engineered.  ABSA Regulations for pressure vessels, pressure safety relief valves, and other plant safety systems were not followed or tracked
as they should have been. In other words, the ABSA regulations ARE the engineering and design program complete with standards for pressure
vessels for ALL facilities operating pressure vessels in Alberta; thus the "C" and not "P" or "S". 

The correct answer is: C

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 11/20
10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review

Question 13

Correct

Mark 2.00 out of 2.00

Which of the following latent causes most strongly relates to RME #8 Operations and Maintenance?

Select one:
ABSA Regulations for pressure vessels, pressure safety relief valves, cross out
and other plant safety systems were not considered,
not tracked, not
followed.

Employees had minimal understanding of occupational safety cross out


hazards and requirement of Alberta Occupational Health and Safety
Act,
Regulations, and Code; ABSA requirements.

Latent Cause: The Maintenance Program was not planned, cross out
scheduled, nor coordinated in any sustainable manner; it was
executed on an "as needed" basis. 

Management did not fully value the contractor's knowledge and cross out
expertise. Management marginalized the contractors i.e.
"they can do
the dirty work”.

Your answer is correct.

The correct answer is: Latent Cause: The Maintenance Program was not planned, scheduled, nor coordinated in any sustainable manner; it was
executed on an "as needed" basis. 

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 12/20
10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review

Question 14

Correct

Mark 2.00 out of 2.00

For the latent cause given below for RME #8, to which characterization of a latent cause does it most strongly belong? 
Latent Cause: The Maintenance Program was not planned, scheduled, nor coordinated in any sustainable manner; it was executed on an "as
needed" basis. 
Reminder, alignment is defined as 

"P” = Inadequate Program,


"S” = Inadequate Program Standards,
"C” = Inadequate Compliance with Standards

Select one:
P
cross out

S
cross out

C
cross out

Your answer is correct.


Latent Cause: The Maintenance Program was not planned, scheduled, nor coordinated in any sustainable manner; it was executed on an "as
needed" basis. 
The correct response is S.

Explanation: Equipment maintenance was based on a series of "must do's” that gradually eroded with time, without adequate fundamental
understanding of the operating process. Hub Oil had deficient maintenance procedures, hence maintenance of critical equipment was only done
on an as-needed basis when non-functional. The Maintenance Program was extremely basic "If it ain't broke, don't fix it", and did not include a
comprehensive set of maintenance and repair procedures / manuals, nor a routine preventative maintenance schedule.  

The correct answer is: S

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 13/20
10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review

Question 15

Correct

Mark 2.00 out of 2.00

Which of the following latent causes most strongly relates to RME #9 Employee Competency and Training?

Select one:
a. Minimal understanding of occupational safety hazards and cross out
requirement of Alberta Occupational Health and Safety Act,
Regulations, and Code; ABSA requirements; and other Alberta
Codes.

b. There was no cross out  Knowledge was passed from worker to worker based on "word-of-mouth” and "on-the-job
formal program training" without effective checks to confirm that all critical knowledge was being learned
to train, qualify / accurately. There was no formal program to train, qualify / certify, and confirm that the
certify, and workers were competent on the process unit operations. 
confirm that the
workers were
competent on
the process unit
operations. 

c. No monitoring of safety performance


cross out

d. Plant was built based on trial and error of legacy knowledge, and cross out
not properly designed or engineered. 

Your answer is correct.

The correct answer is: There was no formal program to train, qualify / certify, and confirm that the workers were competent on the process unit
operations. 

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 14/20
10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review

Question 16

Correct

Mark 2.00 out of 2.00

For the latent cause given below for RME #9, to which characterization of a latent cause does it most strongly belong? 
Latent Cause: There was no formal program to train, qualify / certify, and confirm that the workers were competent on the process unit
operations; it lacked in standards to train, qualify / certify, and confirm that the workers were competent on the process unit operations. 
Reminder, alignment is defined as 

"P” = Inadequate Program,


"S” = Inadequate Program Standards,
"C” = Inadequate Compliance with Standards

Select one:
P
cross out

S
cross out

C
cross out

Your answer is correct.


Latent Cause: There was no formal program to train, qualify / certify, and confirm that the workers were competent on the process unit
operations; it lacked in standards to train, qualify / certify, and confirm that the workers were competent on the process unit operations. 
The correct response is S.

Explanation: 
The employee competency and training program was defined and managed as hiring graduates from SAIT with a diploma in operating
engineering and hiring experienced "ticketed operating engineers". The training program was based on "word-of-mouth" and on-the-job" training;
it lacked in standards to train, qualify / certify, and confirm that the workers were competent on the process unit operations. Knowledge, skills,
and expertise in operating the plant were passed from worker to worker based on "word-of-mouth” and "on-the-job training" without effective
checks to confirm that all critical knowledge was being learned accurately and being retained. There were no documented training materials nor
a means to test and certify / qualify that employees were skilled and competent in their roles to operate the plant within critical operating
limits. As time progressed and with changes in personnel, this resulted in major gaps in process unit operations / maintenance expertise which
resulted in the gradual deviation from critical operating limits. 

The correct answer is: S

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 15/20
10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review

Question 17

Correct

Mark 2.00 out of 2.00

Which of the following latent causes most strongly relates to RME #11 Operations and Facilities Information and Documentation?

Select one:
Latent Cause: The D&I Program restricted access to the operations cross out
standards and maintenance standards, which prevented employees
from following and complying with those standards. 

Maintenance was done on an "as needed” basis, and "if it ain't broke, cross out
don't fix it”.

Although changes were made and acknowledged as changes, the cross out
changes were not effectively and formally managed.

There was a complete absence of a risk management program at cross out


Hub Oil.

Your answer is correct.

The correct answer is: Latent Cause: The D&I Program restricted access to the operations standards and maintenance standards, which
prevented employees from following and complying with those standards. 

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 16/20
10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review

Question 18

Correct

Mark 2.00 out of 2.00

For the latent cause given below for RME #11, to which characterization of a latent cause does it most strongly belong? 
Latent Cause: The D&I Program restricted access to the operations standards and maintenance standards, which prevented employees from
following and complying with those standards. 
Reminder, alignment is defined as 

"P” = Inadequate Program,


"S” = Inadequate Program Standards,
"C” = Inadequate Compliance with Standards

Select one:
P
cross out

S
cross out

C
cross out

Your answer is correct.


Latent Cause: The D&I Program restricted access to the operations standards and maintenance standards, which prevented employees from
following and complying with those standards. 
The correct response is C. 

Explanation: The detailed operating procedures (administrative controls) existed but employees were not able to follow and comply with them.
Employees did not have access to instructions and documentation for critical operating conditions, unit operations, and maintaining safe
operation of the plant. Even though one of the plant engineers had written a set of training documents and standard operating procedures for
plant operations, these were "locked away" and the employees had no access to these standardized administrative controls. 

The correct answer is: C

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 17/20
10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review

Question 19

Partially correct

Mark 5.14 out of 6.00

Referring back to the previous set of questions on the latent causes, match each RMS Element with an appropriate recommendation to improve
safety and risk management at this and other similar facilities in the future.

RME#7:
Design, Implement a program that incorporates pressure vessel safety systems into similar facilities in the future using current design crit
Construction, 
and Start Up

RME# 11:
Operations and
Facilities Implement a program for employees to gain access to all critical plant operation information, not only as part of their training, but
Information

and
Documentation

RME#9:
Employee Implement a program on all aspects of plant operations with requirements for initial qualification and certification, and periodic re
Competency 
and Training

RME#1:
Management
Leadership, Implement a program for management to create a set of safety values, communicate the value of safety within the organization, a
Commitment,

and
Accountability

RME#4:
Management Implement a program to include management approval prior to employees undertaking tasks and executing procedures that are o
of Change

RME#2: Risk
Assessment
and Implement a program with a comprehensive set of maintenance and repair procedures / manuals.
Management 
of Risk

RME#8:
Implement a program with a comprehensive set of maintenance and repair procedures / manuals.
Operations and
Maintenance 

Your answer is partially correct.


You have correctly selected 6.
Latent causes should be exclusive to or pertain to only one risk management system element. 
A latent cause can and should only be related to one risk management system element. Consider the following latent cause statement from the
selections in this question, "Implement a program for management to create a set of safety values, communicate the values of safety within the
organization, and commit resources to developing and implementing a comprehensive risk management program." The key phrase is commit
resources which pertains to RME #1 MLCA. 
So, the latent cause statement should be correctly stated to include the element name e.g. "Implement a leadership and commitment program
for management to create a set of safety values, communicate the values of safety within the organization, and commit resources to developing
and implementing a comprehensive risk management program".
It does not relate to #2 Risk Assessment and Management of Risks; a latent cause statement would start with or relate to "the risk assessment
program". Also recall that a synonymous phrase for this element is "#2 Risk Assessment and Control of Risks".
RME #1 MLCA: "Implement a leadership and commitment program for management to create a set of safety values, and communicate the
values of safety within the organization." 

RME #2: "Develop and implement a comprehensive risk assessment program for the recycle oil refining process systems."

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 18/20
10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review
The correct answer is: RME#7: Design, Construction, and Start Up → Implement a program that incorporates pressure vessel safety systems into
similar facilities in the future using current design criteria, regulations and standards, and appropriate engineering expertise i.e. ABSA
Regulations., RME# 11: Operations and Facilities Information and Documentation → Implement a program for employees to gain access to all
critical plant operation information, not only as part of their training, but also as an ongoing part of their daily activities., RME#9: Employee
Competency and Training → Implement a program on all aspects of plant operations with requirements for initial qualification and certification,
and periodic refresher training in order to maintain the skill set at the highest and most effective level., RME#1: Management Leadership,
Commitment, and Accountability → Implement a program for management to create a set of safety values, communicate the value of safety
within the organization, and commit resources to developing and implementing a comprehensive risk management program., RME#4:
Management of Change → Implement a program to include management approval prior to employees undertaking tasks and executing
procedures that are outside of normal operating parameters., RME#2: Risk Assessment and Management of Risk → Implement a program to
include process safety reviews., RME#8: Operations and Maintenance → Implement a program with a comprehensive set of maintenance and
repair procedures / manuals.

Question 20

Partially correct

Mark 3.00 out of 4.00

Chapter 4: Incident Investigation, Analysis, Causation, and Action


A Risk Management Program consists of different components as depicted by the slices in the Swiss Cheese Model. The
model as shown in this graphic depicts a Risk Management Program with successful outcomes. Match the most appropriate
description for each of the slices for the graphic shown: (4 marks total; 1 mark for each correct response; no penalty for
incorrect response or no response)

Slice A: Action that reflects "the culture of the organization” is depicted at this slice. 
Slice B:
Documentation of the organization as managed within the program is depicted at this slice. 
Slice C:
Ineffective implementation at this slice sets the latency for causing loss incidents. 
Slice D:
Effective implementation at this slice sustainably prevents loss incidents. 

Your answer is partially correct.

You have correctly selected 3.


The correct answer is: Slice A: → Action that reflects "the culture of the organization” is depicted at this slice., Slice B: → Documentation of the
organization as managed within the program is depicted at this slice., Slice C: → Installed equipment and software as managed within the
program are depicted at this slice., Slice D: → Effective implementation at this slice sustainably prevents loss incidents.

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 19/20
10/5/22, 10:13 AM Assignment 2 - The Hub Oil LI - Graded: Attempt review

◄ Assignment 1 - RCA Exercise - Graded

Jump to...

Before Attempting Assignment #3, Read These Instructions to Learn About Assignment #3 ►

https://eclass.srv.ualberta.ca/mod/quiz/review.php?attempt=10153332&cmid=5830141 20/20

You might also like