Case Studies details
“Peeling Away the Onion” to Determine Root Cause
Arbitration, United States
October 1, 2014
As part of our investigations into hydrocarbon fires and explosions, Baker & O’Brien is often asked to assist in establishing the “root cause” of an incident. Root cause has variously been described as “the most basic and fundamental cause,” or more specifically, “The cause that can be reasonably identified and which management has the ability to fix—and when fixed, will significantly reduce the likelihood of a recurrence.”
A large domestic refinery experienced a hydrocarbon release and subsequent fire. Baker & O’Brien was engaged to conduct a detailed review of the incident and provide opinions as to the root cause and the party (or parties) whose actions may have contributed to the event.
A preliminary investigation indicated the apparent cause of the hydrocarbon release as a piece of equipment that had been inactive for many years, but which, unbeknownst to plant personnel, had been improperly modified. The release occurred when this equipment was again placed in service. Complicating the investigation into who may have been responsible for the modification, was the fact that significant work had been performed in and around this equipment—turnarounds, capital expansions, and maintenance repairs—by various entities over a period of more than 15 years prior to the incident.
In addressing this matter, Baker & O’Brien used a technique often referred to as “peeling away the onion,” or in common parlance, looking beyond just the surface by removing the layers that may obscure a particular topic. In this case, through exhaustive collection and analysis of all data and records, we began to systematically eliminate improbable scenarios in order to identify which organization(s) most likely performed the improper modification–and when.
Among other things, our work included: (1) analyzing the work performed and the tools that would have been needed for the modification; (2) identifying the location of the modification and the companies that had worked in that area in the past; (3) estimating the likely time frame during which the modification was made; and (4) systematically eliminating candidates that did not fall into these criteria. At the conclusion of our investigative process, we were left with one highly-probable scenario pointing to the likely responsible party. Identifying such party enables management to develop mitigating actions to prevent a recurrence.
Our report was submitted into evidence and our lead consultant testified in the arbitration.