RCA Monthly Report Aug 15

RCA Monthly Report Aug, 2015 Prepared by : Attiah H. Al-Zahrani, 9/2/2015 Reliability & Integrity Department Reliability Engineering Section

Contents1. Executive summary ............................................................................................................................ 22. Introduction ....................................................................................................................................... 33. RCA status .......................................................................................................................................... 4 3.1 RCA studies by Status................................................................................................................. 4 3.2 RCA studies by event types........................................................................................................ 5 3.3 RCA Performance KPI ................................................................................................................. 54. Recommendation status .................................................................................................................... 6 4.1 RCA Recommendation Status (for published studies) ............................................................... 6 4.2 Implementation of RCA recommendations KPI ......................................................................... 65. Department Contributors to RCA Business (by Departments) .......................................................... 7 5.1 Top 10; Leading RCAs................................................................................................................. 7 5.2 Top 10; Participating in RCAs ..................................................................................................... 76. Cause category (Theme) .................................................................................................................... 87. RCA training ....................................................................................................................................... 88. Findings & assignment ....................................................................................................................... 99. Appendix .......................................................................................................................................... 10RCA Monthly Report Page 1 of 11

1. Executive summaryRoot Cause Analysis (RCA) is one of Failure Elimination processes in Meridium system, used to define the problem, uncover the underlying causes and develop recommendations that deals with them to prevent itfrom happening again.This report covers the Root Cause Analysis (RCA) activities with reference toIncident management system, RCA Procedure and Proact® for Meridium as of 31Aug 2015.This month findings were; (1) the RCA studies initiated in Proact® are lower thanexpected compared to Production Loss Accounting (PLA) Meridium and SAP-EHSM events. (2) Some RCAs have exceeded the allowable duration. (3) ManyRCA recommendations have passed their target date.In general, improvement is needed for better incident investigationperformance. Above challenges can be improved through more compliance toIMRS 15, RCA Procedure, Production Loss Accounting (PLA) and morecommitment from concerned departments.The report contains more details on the following topics: RCA status Recommendation status Performance Indicators Theme /Cause Category Training update Findings and action required AppendixRCA Monthly Report Page 2 of 11

2. Introduction This report covers the Root Cause Analysis (RCA) activities with reference to Proact® for Meridium (RCA software) as of 31 Aug 2015. (refer to RCA workflow: Fig.1) The RCAs and recommendations status are extracted from Meridium Proact® though customized queries (automatically updated).Tasnee Root Cause Analysis Workflow Sponsor RCA Team Leader/Member Department Plant /Area Implement Recommendation Failure /undesirable 1- Select RCA team Event is initiated in Event occur 2- RCA Charter Proact ? No Yes No All recomndtaion implemented? Captured in utilize Yes Appropriate New Analysis Yes system builder Approve/close Wizard in Proact recommendation NO ImplementationRCA Process Initiate and process in Manage Analysis appropriate system * Preserve RCA data Develop Event diagram RCA result Reveiw Develop Logic Tree Develop recommendations Is study accepted? NO RCA result ready for Yes Sponsor/Managment review ? * EHS events shall be started in SAP /EHSM . Production events shall be started in Meridium/ PLA module NO Yes Issue RCA report/ Publish the Analysis Presentation Figure 1 RCA WorkflowRCA Monthly Report Page 3 of 11

3. RCA status RCAs status 3.1 RCA studies by Status In progress Completed  65 RCAs are in progress, 4 RCAs 14% within the duration (≤ 21 Working 86% days). 61 RCAs had exceeded the duration (˃ 21 Working days)  11 RCAs have been completed and published  76 RCAs in total, since inception (i.e. 2011) to Aug 31st 2015. Chart 1 Overall RCA status 79% of the RCAs studies had exceeded the allowable duration for completing the study. (See Appendix 1 & 2)RCA Monthly Report Page 4 of 11

3.2 RCA studies by event typesEvents are classified to three categories: EHSS, Reliability and Quality. Many incidents initiated in SAP/EHSM RCAs by event type have been closed without RCA investigation. (Incompliance to IMRS Total 15). (more details in Appendix 3) 45 25 Many Production Loss Accounting (PLA) 6 events (high Cost value) are not investigated through RCA. (more EHS Quality Reliability details in Appendix 4) Chart 2 RCA Event Types3.3 RCA Performance KPI KPI#1: target is 100%RCA is required to be conducted for any high consequence events with reference to the CompanyMatrix that can be reported in Production Loss Accounting (PLA) Meridium and SAP/EHSM. PLA data provided above (chart 3) is according to high cost value events (i.e. C4 and above with reference to Company Risk matrix No. of RCAs ������������������ ������������������������������������������������������������ 70% and RCA procedure) as a first 70 60% trigger. 60 50% Event duration that is more than 24 50 40% hrs. will be considered in coming 40 30% monthly reports as another trigger 30 20% for RCA. 20 10% 10 SAP-EHSM data was not includedabove (Chart 8) due to lack of PLA Events Qty 0 0%information. SAP-EHSM and EC HDPE PDH PP1 PP2 LDPE SAPCO Unit 13 Unit 14 OverallMeridium is not mapped due to 3 13 8 11 6 13 2 3 0 59 RCA Cond. 2110000004 Performance (Tgt. = 100%) 67% 8% 13% 0% 0% 0% 0% 0% 0% 7%SAP-EHSM limitations. Chart 3 RCA Performance with reference to PLA Plant wiseRCA Monthly Report Page 5 of 11

4. Recommendation status4.1 RCA Recommendation Status (for published studies) 45 Recommendations have been developed out of 11 RCAs Studies (completed andpublished). 13 have been implemented. 56% of the RCAs recommendations RCA Recommendation Status had exceeded their target date. 4% 11% Created 56% 29% In progress Implemented Overdue Chart 4 RCA Recommendation detailed Status for published RCAs4.2 Implementation of RCA recommendations KPI KPI#2: target is Zero overdue This KPI#2 measure the effectiveness of RCA Recommendation Status implementing the recommendations developed to prevent the repetition or 45 reduce the frequency of the investigated event 25 13 The Overdue Recommendation: 25 Proact system is enhanced to assign the Total Recommendatios implemented Overdue recommendation to department manager instead of RCA members as it used to. This will improve tracking and follow-up. Chart 5 Overdue RCA recommendationsRCA Monthly Report Page 6 of 11

5. Department Contributors to RCA Business (by Departments)5.1 Top 10; Leading RCAs Ethylene Cracker is the highest department/Plant who participated 25 times in leading RCA teams. Participation as RCA leader 25 886443322 Chart 6 as RCA Team Leader5.2 Top 10; Participating in RCAs Reliability & Integrity is the highest participation in RCA studies with candidate Participation as RCA Memebers 39 33 32 30 28 21 20 17 14 14Ethylene Cracker PP PDH HDPE Reliability and Integrity Engineering SAP Operations UTOS Central Maintenance Services LDPEReliability and Integrity Maintenance Monomers Process Engineering Polymers & QA Ethylene Cracker Maintenance Polymer ISD & Loss Control UTOS PP LDPE Process Eng. Mono/Process Control Chart 7 as RCA Team MemberRCA Monthly Report Page 7 of 11

6. Cause category (Theme) Cause Categories 7% 6% 30% Policies, STD, Procedures 7% 19% Design15% Asset Maintenance Strategies Training 16% Quality Assurance / Control Work Direction Communication Chart 8: RCA Cause Categories Seven main categories have been selected to trend the overall causes. The highest category was related to lack of Policies, Standards and Procedures.7. RCA training RCA trainind person by Depart 18 17 12 10 777 32111 Chart 9 Number of RCA training Attendance 86 candidates from different Plants/departments were trained as follows: Sponsor and Leadership 21 candidates RCA lead/Professionals 65 candidates Candidates participated in conducting RCAs after receiving the training: 32 candidates.Trained candidates perspiration need to be improved through more involvement.RCA Monthly Report Page 8 of 11

8. Findings & assignment1. 79% of the RCAs studies had exceeded the allowable duration for completing the study.2. Many incidents initiated in EHSM /SAP were closed without RCA investigation.3. Many Production Loss Accounting (PLA) events (high Cost value) are not investigated through RCA.4. 56% of the RCAs recommendations had exceeded their target dates.Item Desc. Main reason Action required Assigned to1. 79% of the RCAs studies Lack of Sponsor Complete the RCA Teamhad exceeded the follow-up RCA Leadersallowable duration forcompleting the study2. Many incidents initiated in Lack of IMRS 15 Initiate RCAs for Safety Eng./SAP-EHSM were closed compliance event with high Plantwithout RCA investigation. consequence Managers(Incompliance to IMRS 15) (Cost , Duration) refer to Company Matrix3. Many Production Loss Lack of PLA Initiate RCAs for ProductionAccounting (PLA) events Procedure event with high Engineerare not investigated by compliance consequence /PlantRCA. (Cost , Duration) Managers refer to Company Matrix4. 56% of the RCAs Lack of department Expedite Concernedrecommendations had tracking of RCA execution and departmentexceeded their target date recommendation better planning manager Table 1 Major findings and Action itemsRCA Monthly Report Page 9 of 11

9. AppendixAppendix 1 RCA overdue (C4and above ) as 19Aug15.xlsRCA Monthly Report Page 10 of 11

Appendix 2RCA for Team leader A ction. x lsAppendix 3 Page 11 of 11SAP- EHSM incident report Accidnet IncidnetSAP EHSM as of 30 Aug.mhtAppendix 4Production Loss Accounting for July 2015 Copy of PLA Report of YTD (JUL 2015).xlsxRCA Monthly Report