Page 64 - Root Cause Failure Analysis

Root Cause Failure Analysis Methodology 55

Incident Summary
The incident summary should be a short, concise description of the incident or event.
It should not elaborate on the factors that may have contributed to the incident.

Initial Plant Condition

This section should include a brief description that defines the plant’s status at the
start of the incident. It should include any abnormal conditions that contributed to the
incident. This section is not intended to provide a quantitative analysis of the incident,
but should be limited to a clear description of the boundary conditions that existed at
the time of the event.

Event Initiating Investigation
Give a brief description of the initial failure or action that triggered the incident or led
to its discovery and the resulting investigation. Do not use specific employee names or
titles in this section of the report. Instead use the codes and descriptors that identify
functions within the affected area.

Incident Description

This section should include a detailed chronology of the incident. The chronology
should be referenced to the sequence-of-events diagram developed as part of the anal-
ysis. The diagram should be included as an appendix to the report.
This section should include a description of how the incident was discovered, the facts
that bound the incident, identification by component number and name of any failed
equipment, safety-system performance, control-system actions, significant operator
actions and intervention, and transient data for important plant parameters.

It also should include any special considerations observed in the incident, such as
unexplained or unexpected behavior of equipment or people, inadequate or degraded
equipment performance, significant misunderstandings by operations or maintenance
personnel, common failure modes, progression of the event beyond the designed
operating envelope, violation of technical specifications or design limits, or failure of
previously recommended corrective actions.

Immediate Corrective Actions

Many of the failures or events having a direct impact on production require immediate
corrective actions that will minimize downtime. As a result, temporary actions often
are required to permit resumption of production. This section should describe what
intermediate or quick-fi actions were taken to permit resumption of production.