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Chapter 3: Problem Solving Techniques

Operational Level:

Global Maintenance Work Order


Work Permit
Complete Feed Back
Root Case Analysis
Near Miss / STOP Analysis
Risk Assessment
Job Safety Analysis (JSA)
Root Cause Failure Analysis
Failure Mode Effect Analysis

Managerial Level:
- ISO 9001
- Quality Management System
- ISO 14001
- Environmental Management System
- OHSAS 18001 - Occupational Health & Safety Assessment System
- OSHA
- Occupational Safety and Health Administration
- API-580
- Risk Based Inspection
- RCM
- Reliability Centered Maintenance
HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

1/Ch. 3

Main Forms for Maintenance Operations for Critical Systems


1) Work request
(CM=Process) or (PM=Maintenance +Process)
2) Work order
(Maintenance)
3) Job safety analysis
(Maintenance + Safety)
4) Work permit (Risk ass.)
(Safety + Maintenance +Process)

W/O for Critical Systems Must be customize


Responsibility: Maintenance Planner & Process & Safety (Owner)
Policy:
Global methodology (total view approach)
W/O Contents:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

W/O description (#, description, type PM / CM/ Shutdown, discipline, area, location, .. etc.)
Work request (#, requester, description, .. etc.)
Dates (start date, finish date, complete date, .. etc),
W/O criticality (system/ equipment criticality, W/O priority, .. etc.),
Safety condition (work permit #, type: cold, hot, main items, JSA,.. etc ),
Last maintenance (type, description, date, .. etc.)
Job plan (main steps, planned duration, actual duration, .. etc.)
Tool list (code, description, quantity, planned duration, actual duration, .. etc.)
Spare parts list (SIR #, Stock code, description, planned quantity, actual quality, etc.)
Labor list (code, description, planned quantity & hours, actual quantity & hours, . etc.),
Duration (planned duration, planned down time, actual down time, non-direct time,etc.),
Failure (fault, code and description, cause, .. etc.),
Backlog (cause, root cause, .. etc.)
Responsibility (Maintenance, Process, Safety)
HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

2/Ch. 3

WORK PERMIT:
The purpose of the W/P is to achieve a safe working
environment by providing management control over
activities which may have hazardous interactions.
The W/P requires the involvement of competent and
responsible persons as well as the application of
particular safety measures in a controlled sequence.
The necessary elements, as follows, contribute to safe working:
Good communications between all work groups.
Detailed planning of the work.
Thorough training of personnel.
Effective supervision of the work.
A skilled and dedicated workforce.
Regular auditing of the permit system.
HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

3/Ch. 3

The W/P basically consists of three main Work permits:


1. Cold Work Permit,
2. Hot Work Permit
3. Naked Flame
Six relevant certificates:
1. Confined Space Entry Certificate.
2. Electrical Isolation Certificate
3. Spade List
4. Excavation Certificate
5. Radiography Certificates
6. Pressure Test Certificate

Do Not Do Any of These Tasks


Without A Permit To Work
HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

4/Ch. 3

Root Cause Analysis (RCA)


Main Steps:
Track

&

Investigate

Measure

&

Analysis

Evaluate

&

Report

Remedy

&

Plan

Action

&

Improve

HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

5/Ch. 3

ACCIDENT Root Cause Analysis


Root Causes
Poor Management & Bad Awareness
Personal Factors

Unsafe Act

Environmental Factors

Indirect Causes

Unsafe Conditions

Unplanned release of energy


(Direct Cause)
ACCIDENT

HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

6/Ch. 3

Accident / Failure Causes


Three causation levels:
Direct Cause
Energy or hazardous material
Indirect Cause
Unsafe acts and conditions
Basic Causes (root causes)
Poor management
Bad awareness
Personal or environmental factors

HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

7/Ch. 3

Domino Theory
1932 First Scientific Approach to
Accident/Prevention - H.W. Heinrich.
Industrial Accident Prevention

Social
Environment

Fault of the
Person
(Carelessness)

Unsafe Act
or
Condition

Accident

Injury

MISTAKES OF PEOPLE
HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

8/Ch. 3

DOMINO Theory
This theory postulates that the events, which lead to an injury, are like five
dominos, standing on end, ready to knock each other over in turn.
They are:
Social
Environment

Those conditions which make us


take or accept risks.

Undesirable
Human Traits

Anger, carelessness, tiredness, lack


of understanding, inattention.

Unsafe Acts or
Conditions

HSEM

Poor planning, unsafe equipment,


hazardous environment.

Accident

The accident occurs when the


above events conspire to cause
something to go wrong.

Injury

Injury occurs when the person


sustains damage.

HSE management View Part I - Dr. Attia Gomaa - 2007

9/Ch. 3

Near miss: (discover the hidden hazard)


Unsafe condition
(Awareness & No blame)


Bad Event has the potential to become an incident or accident.

STOP card (detect the early hazard):


Safety Training Observation Program
Unsafe act
(Awareness & No blame)



Bad Event that degrade the efficiency of an operation.
HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

10/Ch. 3

Near-Miss:
Unsafe Conditions (Environmental Factors)

HSEM

Poor housekeeping.
Defective equipment.
Unsafe dress or apparel.
Improper PPE.
Improper tools.
Improper guarding.
Improper ventilation.
Improper lighting.
Hazardous arrangement.

HSE management View Part I - Dr. Attia Gomaa - 2007

11/Ch. 3

STOP
Unsafe Acts (Personal Factors)

Unsafe loading, placing, mixing, combining.

Taking an unsafe position or posture.

Working on moving equipment.

Defecting safety devices.

Failure to use personal protective equipment.

Failure to secure or warn.

Operating without authority.

Operating or working at an unsafe speed.

Horseplay.

HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

12/Ch. 3

Unsafe Personal Factors

HSEM

Fatigue.
Unclassified
Improper attitude.
Defective hearing.
Defective eyesight.
Muscular weakness.
Lack of required skill.
Intoxication (alcohol, drugs).
Lack of required knowledge.

HSE management View Part I - Dr. Attia Gomaa - 2007

13/Ch. 3

Initial
Accident
1
Incident
10
Unsafe Conditions (Near-Miss)
300
Unsafe Acts (Stop Card)
12,000

Stable
1
10
600
24,000

Accident
Incident
Unsafe Conditions
Unsafe Acts
You only see the tip of the iceberg
HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

14/Ch. 3

You See What You Want to See !!!

When You See a Problem, You Welcome !!!

No Blame !!!

HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

15/Ch. 3

Observation Categories:
- Reactions of people
- Positions of people
- Personnel Protective Equipment (PPE)
- Tools & Equipment
- Procedures
- Orderliness
HSEM

Reactions of People

HSEM

Stopping / leaving job


Attaching earth / lockout
Rearranging job
Changing position suddenly
Adjusting / adding personal
protective equipment

HSE management View Part I - Dr. Attia Gomaa - 2007

17/Ch. 3

Personal Protective Equipment


Provides a barrier
Reflects state of mind
Match the activity with the
protection worn

HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

18/Ch. 3

Tools
Observe People Using Tools
Right for the job?
Used correctly?
Safe condition?

HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

19/Ch. 3

Equipment
Observe People Using or Operating
Equipment
Right for the Job?
Used correctly?
Safe condition?

HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

20/Ch. 3

Procedures (Standards)
Evaluate Standards by Observation
Adequate for the job?
Established?
Maintained?

HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

21/Ch. 3

Orderliness
Evaluate Standards by Observation
Standards established?
Standards understood?
Orderliness maintained?

HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

22/Ch. 3

Follow Up
Keep talking to your employees
Audit - follow up on findings
Review safety procedures
periodically
Act as necessary on safety-related
reports
Follow up on orientation and training
HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

23/Ch. 3

Use of Information

HSEM

Record of observations
System for follow-up
Analysis of data
Review of management of safety
Communication of information
Training

HSE management View Part I - Dr. Attia Gomaa - 2007

24/Ch. 3

Near-Miss Analysis:

Major

29
300

HSEM

Medium

Minor

1
29

Major

Medium

600

Minor

(New case)

(Stable case)

INITIAL STUDIES

RECENT STUDIES

HSE management View Part I - Dr. Attia Gomaa - 2007

25/Ch. 3

Near Miss Analysis

HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

26/Ch. 3

Case Study: Near Miss Analysis


DegreeofNear Target Weight
Miss
ratio
D= Minor
600:
0.001
C= Medium
30:
0.01

2004

2005 Recommendation

590

560

Normal

360

170

Good

B= Major

10:

0.1

Bad

A= fatality

Bad

953

733

Good

Total
Conclusion:
HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

27/Ch. 3

Case Study: Near Miss Classification for 2004


Degreeof
NearMiss

Total
Target
ratio NearMiss

Responsibility
Process

Utilities

Maintenance

D= Minor

600:

590

100

200

290

C= Medium

30:

360

80

120

160

B= Major

10:

A= fatality

953

180

323

450

Good

Bad

Good

Total
Evaluation
Recommendation:
HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

28/Ch. 3

Case Study: Near Miss Classification for 2005


Degreeof
NearMiss

Total
Target
ratio NearMiss

Responsibility
Process

Utilities

Maintenance

D= Minor

600:

560

60

200

300

C= Medium

30:

170

20

50

100

B= Major

10:

A= fatality

733

80

253

400

Good

Very
Good

Very
bad

Good

Total
Evaluation
Recommendation:
HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

29/Ch. 3

The Safety Observation Cycle


for STOP for Employees
DECIDE

ACT

Before you
begin any work
activity, DECIDE
to make safety
your first
priority.

Take whatever action


is necessary to elimina
and prevent unsafe act
and unsafe conditions.

THINK

STOP

What might happen?


Could you get hurt?
Could someone else get hurt?
How can you do your job more
safely?

Give your full attention


to the work area.
What is going on there, and
what you will be doing.

OBSERVE

Look for any unsafe acts


or unsafe conditions that
may cause injury to you
or other employees.

HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

30/Ch. 3

STOP: 1) Awareness program


2) Observe people working
3) Use all senses
4) Enter into conversation
5) Aware & no blame
6) Make agreement
7) Record & analysis
8) Follow up
9) Blame, if it is repeated
10) Corrective action
HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

31/Ch. 3

To reduce risk to all, you will be


dismissed form the company if you
break any of our Fundamental safety
rules. These rules are shown below:

1. Physical Fighting.

2. Unauthorized removal of isolation.
.
3. Smoking in unauthorized areas.
4. Being under the influence of drugs or .
alcohol.
.
5. Being in possession of alcohol or

illegal drugs.
.
6. Unauthorized entry into a confined
.
space.
.
7. Taking passengers on a fork lift truck.
.
8. Deliberate damage to safety
equipment.

HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

32/Ch. 3

Weekly Observational Safety Site Inspection Tour


WOSSIT

ELNG & Contractor Managers Carryout Site Inspections Together


Mondays at 9 AM 10 AM
Meet at ELNG Building; Inspection Areas will be Assigned
All Contractor Managers are Expected to Participate

HSEM

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33/Ch. 3

Benefits of Safety Audits

Displaying your interest


Getting people thinking about safety
Enhancing employee relations
Letting you learn what is happening
Teaching others about benefits of audits
Clarifying your standards
Increasing safety efforts
Evaluating performance of subordinates

HSEM

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34/Ch. 3

Benefits of Safety Audits (continued)

Teaching others about benefits of audits


Clarifying your standards
Increasing safety efforts
Evaluating performance of subordinates
Providing a good way to communicate
Identifying people with promotion potential
Providing early warning information
Stimulates others to audit their own actions

HSEM

HSE management View Part I - Dr. Attia Gomaa - 2007

35/Ch. 3