Tag Archives: oil spill

Root Cause Analysis - Incident Investigation

Pipeline Spill in Alberta Threatens Drinking Water

by ThinkReliability Staff

A pipeline spill in Alberta, Canada of up to 480,000 litres was noticed on the evening of June 7, 2012.  Although pipelines are estimated to spill approximately 3.4 million litres a year, they are not frequently near populated areas or water sources.  However, due to the proximity of this spill to a drinking water source, there was the potential of impact to drinking water.  An issue of this magnitude, with this type of impact, is thoroughly investigated to reduce the risk of recurrence.  We can examine this issue in a visual root cause analysis performed as a Cause Map.

We begin with the impacts to the goals.  In this case, the safety goal is impacted because of the potential impact to drinking water.  The environmental goal is impacted because of the spill of sour crude oil.  The spill is impacting area residents in a variety of ways, which can be considered an impact to the customer service goal.  The production goal was impacted due to a 10-day shutdown of a portion of the pipeline.  The property goal is impacted by the damage to the pipeline, and the labor goal is impacted by the response and cleanup required.

Once we have developed the impacts to the goals, we can ask “Why” questions to develop the cause-and-effect relationships that resulted in those impacts.  The potential impact to drinking water resulted from the proximity of the spill to a drinking water source, because the spill was in a populated area, and the oil spill itself.  The oil spill resulted from damage to the pipeline and the time elapsed before the spill was stopped.  Because the longer a spill goes undetected, the more environmental impact it has, consideration of the adequacy of monitoring, inspection and testing must be considered to ensure that this risk is reduced.

Although the cause of the pipeline damage is still being investigated, causes that have resulted in prior pipeline damage include construction damage, internal corrosion, and external corrosion.  External corrosion can result from exposure to water, which in this case was impacted by recent flooding of the river and shallow burying of the pipe, as was typical with earlier installations.  The age of the pipe may have also impacted the internal corrosion, as the more time that pipe is exposed to hydrocarbons (which the pipe transmits) the more corrosion will occur.

Immediate solutions include isolating the damaged area with a valve.  Then repairs were made to the pipeline, and cleanup began.  Cleanup is expected to take most of the summer.  There have been calls for increased monitoring, testing, and inspection of the line, and with an incident of this type, that frequency should be examined to ensure it is appropriate to minimize these types of risk.

To view the Outline, Cause Map, and Solutions, please click “Download PDF” above.

Root Cause Analysis - Incident Investigation

Dig Deeper to get to the Causes of the Oil Spill

By ThinkReliability Staff

On Sunday (September 26th, 2010) the lead investigator for the Deepwater Horizon oil spill was questioned by a National Academy of Engineering committee.  The committee brought up concerns that the investigation that had been performed was not adequate to address all the causes of the spill.  Said the lead oil spill investigator: “It is clear that you could go further into the analysis . . . this does not represent a complete penetration into potentially deeper issues.”

Specifically, the committee was concerned that the study focused on decisions made on the rig (generally by personnel who worked for other companies) but did not adequately consider input from these companies.  The study also avoided organizational issues that may have contributed to the spill.

In circumstances such as this one – where an extremely complicated event requires an organization to spend most of its resources fixing the immediate problem, an interim report – which may not delve deeply into underlying organizational issues or obtain a full spectrum of interviews – may be appropriate.  However, it’s just an interim report and should not be treated as the final analysis of the causes relating to an issue.  The organizations involved need to ensure that after the immediate actions – stopping the spill, completing the cleanup, and compensating victims – are complete, an in-depth report commensurate with the impact of the issue is performed.

In instances such as these, causes relating to an incident need to be unearthed ruthlessly and distributed freely.  This is generally why a governmental organization will perform these in-depth reviews.  The personnel involved in the investigation must not be limited to only one organization, but rather all organizations that are involved in the incident.  Once action items that will improve safety and processes have been determined, they must be freely distributed to all other organizations participating in similar endeavors.  The alternative – to wait until similar disasters happen at other sites – is unacceptable.

Root Cause Analysis - Incident Investigation

A Serendipitous Solution

By Kim Smiley

Investigating the recent massive oil spill in the Gulf of Mexico is a tall order.  There are many contributing causes and a multitude of creative solutions are going to be needed to restore the environment.

During any investigation of this magnitude, there are guaranteed to be a few surprises.  And the Deep Horizon oil spill is no exception.

Scientists have discovered a previously unknown type of oil-eating bacteria feasting on oil from the spill.

This microbe is unique from previously studied varieties because it doesn’t consume large quantities of oxygen along with the oil.  Oxygen consumption is a concern because oxygen is needed in the sea to support life.

This microbe also thrives in cold water temperatures associated with the deep ocean, which might explain why it hasn’t been seen before.  Some scientists are theorizing that the microbe adapted in the deep ocean to consume the oil that naturally seeped from the ocean floor.  Since the huge influx of oil to the water, the bacteria populations have exploded.

Scientists are in a disagreement over how much oil remains in the Gulf, but there is no doubt that less is better.

This serendipitous solution is a welcome addition to the clean up efforts.  Obviously, there are many other solutions that will needed, but anything that safely reduces the overall amount of oil is a positive development.  Hopefully, with some additional research this microbe could be a potential solution to future incidents.

When performing an investigation, the unexpected sometimes happens.  The better understood the problem is, the easier it is to adapt to any new information. The Cause Mapping method of root cause analysis is an effective way to organize all information needed during an investigation.  Clearly understanding the causes that contribute to an incident will allow an organization to adapt as new information comes available and make sure that resources are used in the most efficient ways when implementing solutions.

Root Cause Analysis - Incident Investigation

Containment Cap Removed from Gulf Oil Leak

By ThinkReliability Staff

Last Wednesday, another set back occurred in the attempt to stem the flow of oil in the Gulf of Mexico from the a well head that was damaged when the Deepwater Horizon Oil Rig exploded on April 20 and sank 36 hours later .

The containment cap used to siphon oil from the damaged well head for the last three weeks had to be temporarily removed for more than 11 hours.  Before being removed, the containment system was sucking up about 29,000 gallons an hour.

So what happened?  Why remove a containment cap that had been working successful?

A root cause analysis of this problem can be built as a Cause Map.  A Cause Map is started by considering the impact to the goals and asking “why” questions to add Causes.  In this example, the first goal we will consider is the Environmental Goal.  Obviously, the environmental goal is impacted because there was additional oil released to the environment because the cap was removed.

Continuing to ask “why” questions we can add additional causes.  The cap was removed because the ship connected to the containment cap system needed to be moved away from the well because there a safety concern because of the potential for an explosion.

There was an explosion concern because there was evidence that flammable gas was flowing up from the well head because liquid was being pushed out of a valve in the containment system.  This gas was getting into the containment cap system because an underwater vent was bumped by one of the remote-controlled submersible robots being used to monitor the damaged well.

More detail could be added to the Cause Map by continuing to ask why questions.  The detailed Cause Map could then be used to develop solutions that could be implemented to help prevent the problem from reoccurring.

Click on the “Download PDF” button above to view an initial Cause Map.

The containment cap was put back into place around 9 pm on June 23.  The efforts to contain and clean up the oil spill will continue for months and possibly years to come, but at least this small issue has been fixed.