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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
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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.)
Casing material was incompatible Basic Cause: Design – inadequate technical design
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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
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.
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
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.
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.
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Question 3
Partially correct
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) -
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
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Question 4
Partially correct
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 maintenance
of equipment (Job factor) Pressure gauges on Still #2 System were not maintained nor serviced
-
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) -
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,
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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
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.
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”.
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.
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Question 6
Correct
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
Question 7
Correct
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.
The correct answer is: The risk assessment program did not include formal risk assessments for critical plant operations.
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Question 8
Incorrect
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
Select one:
P cross out
S cross out
C cross out
Question 9
Correct
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
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Question 10
Correct
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
Select one:
P cross out
S cross out
C cross out
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Question 11
Correct
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.
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Question 12
Correct
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
Select one:
P cross out
S cross out
C cross out
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Question 13
Correct
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.
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”.
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.
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Question 14
Correct
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
Select one:
P
cross out
S
cross out
C
cross out
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.
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Question 15
Correct
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.
d. Plant was built based on trial and error of legacy knowledge, and cross out
not properly designed or engineered.
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.
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Question 16
Correct
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
Select one:
P
cross out
S
cross out
C
cross out
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.
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Question 17
Correct
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.
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.
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Question 18
Correct
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
Select one:
P
cross out
S
cross out
C
cross out
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.
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Question 19
Partially correct
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
RME #2: "Develop and implement a comprehensive risk assessment program for the recycle oil refining process systems."
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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
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.
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