Assignment - The Hub Oil LI
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School
University of Alberta *
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Course
406
Subject
Industrial Engineering
Date
Feb 20, 2024
Type
Pages
35
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Started on
Tuesday, 14 November 2023, 10:54 AM
State
Finished
Completed on
Friday, 24 November 2023, 11:55 PM
Time taken
10 days 13 hours
Marks
47.54/64.00
Grade
74.27
out of 100.00
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Question 1
Correct
Mark 6.00 out of
6.00
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"
and "Second Intermediate" only to aid in your selection and scoring. There is no significance to the "First"
or "Second" except as it relates to the automatic scoring function on eClass quizzes.)
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Petrol released
from pump casing
resulting in a
petroleum fire
Pump casing
corroded (failed)
Casing material
was incompatible
Improper material
was used
Pump design was
incorrect
The refinery design
program did not
include a standard
to design pumps
for this process
service.
Incident description (abbreviated)
Immediate Cause: Sub-standard condition
Intermediate Cause
Intermediate Cause
Basic Cause: Engr&Design – inadequate technical design
Latent Cause - Inadequate Performance Standards: relates to RME#7 DC&SU
Your answer is correct.
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The correct answer is: Petrol released from pump casing resulting in a petroleum fire → Incident
description (abbreviated), Pump casing corroded (failed) → Immediate Cause: Sub-standard condition,
Casing material was incompatible → Intermediate Cause, Improper material was used → Intermediate
Cause, Pump design was incorrect → Basic Cause: Engr&Design – inadequate technical design, The
refinery design program did not include a standard to design pumps for this process service. → Latent
Cause - Inadequate Performance Standards: relates to RME#7 DC&SU
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Question 2
Correct
Mark 5.00 out of
5.00
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:
Two (2) fatalities, and six (6) people struck by shrapnel at the Hub Oil
Plant
Large noxious plume of black smoke over several days; volume of
hydrocarbons released through surface run-off.
Entire facility destroyed; loss of personal and company vehicles.
Facility permanently shut down - can no longer process used oil for
recycling at rate of 15 million litres per year.
Wide residential areas were evacuated, with exposure to potentially
harmful emissions.
People - Workers
Environment
Assets
Production
People - General Public
Your answer is correct.
People - Workers: Two (2) fatalities, and six (6) people struck by shrapnel at the Hub Oil Plant
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.
Assets: Entire facility destroyed; loss of personal and company vehicles.
Production: Facility permanently shut down - can no longer process used oil for recycling at rate of 15
million litres per year.
Distractor: The light-rail commuter line running just north of the plant was temporarily shut-down as a
precautionary measure.
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The correct answer is: Two (2) fatalities, and six (6) people struck by shrapnel at the Hub Oil Plant →
People - Workers, Large noxious plume of black smoke over several days; volume of hydrocarbons
released through surface run-off. → Environment, Entire facility destroyed; loss of personal and
company vehicles. → Assets, Facility permanently shut down - can no longer process used oil for
recycling at rate of 15 million litres per year. → Production, Wide residential areas were evacuated, with
exposure to potentially harmful emissions. → People - General Public
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Question 3
Partially correct
Mark 2.00 out of
5.00
Still #2, a reclaimed pressure vessel, was central to this loss incident and its causes. Match the
immediate cause category and sub-category with the appropriate immediate cause.
IC-SP = substandard practice
IC-SC = substandard condition
The over-pressure safety relief
valve was removed from Still #2.
The water for cleaning the feed
pipes to/from Still #2 was not
drained and dried during the
maintenance turn-around.
Still #2 was not rated for the
actual operating pressure.
The contents of Still #2 were
above auto-ignition
temperature and flash-point
temperature.
The pressure in Still #2 system
was not monitored and
controlled below the critical
operating conditions.
SP - Not following proper operating procedures or methods
SP - Not following proper maintenance procedures or methods
SP - Safety devices were made inoperable
SC - Fire and explosion hazard
SC - Inadequate protective equipment
Your answer is partially correct.
You have correctly selected 2.
The correct answer is:
The over-pressure safety relief valve was removed from Still #2. → SP - Safety devices were made
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inoperable,
The water for cleaning the feed pipes to/from Still #2 was not drained and dried during the
maintenance turn-around. → SP - Not following proper maintenance procedures or methods,
Still #2 was not rated for the actual operating pressure. → SC - Inadequate protective equipment,
The contents of Still #2 were above auto-ignition temperature and flash-point temperature. → SC - Fire
and explosion hazard,
The pressure in Still #2 system was not monitored and controlled below the critical operating
conditions. → SP - Not following proper operating procedures or methods
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Question 4
Correct
Mark 7.00 out of
7.00
Match the basic cause category and sub-category with the most appropriate basic cause description.
BC-EDF - Basic Cause - Engineering and Design Factor
BC-JF = Basic Cause - Job Factor
BC-PF = Basic Cause - Personal Factor
Standard Procedures were not accessible i.e. were
locked away in manager’s office
There was no qualification or refresher training for
employees at Hub Oil
Pressure gauges on Still #2 System were not
maintained
The skills for cleaning pipes were not thoroughly
acquired from the original contractor
Reclaimed pressure vessel was not registered with
ABSA, nor met ABSA regulations
Reclaimed pressure vessel was readily available
and "would do the job"
Potential PEAP impacts were not identified in any
aspect of the operation
JF: Inadequate job procedure
JF - Inadequate training
JF - Inadequate maintenance of equipment
PF - Lack of knowledge or skill
EDF - Inadequate engineering standards
PF - Improper motivation
EDF - Inadequate assessment of risks
Your answer is correct.
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
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Inadequate maintenance (Job factor) - Pressure gauges 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
Inadequate engineering standards, specifications, or design criteria (E&D factor) - Reclaimed pressure
vessel not registered with ABSA and did not meet ABSA regulations
Improper motivation (Personal factor) - Reclaimed pressure vessel was readily available and "would do
the job without detailed engineering"
Inadequate assessment of loss exposures / risk assessment / hazard identification (E&D factor) -
Potential PEAP impacts were not identified in any aspect of the operation
The correct answer is:
Standard Procedures were not accessible i.e. were locked away in manager’s office
→ JF: Inadequate job
procedure,
There was no qualification or refresher training for employees at Hub Oil → JF - Inadequate training,
Pressure gauges on Still #2 System were not maintained → JF - Inadequate maintenance of equipment,
The skills for cleaning pipes were not thoroughly acquired from the original contractor → PF - Lack of
knowledge or skill,
Reclaimed pressure vessel was not registered with ABSA, nor met ABSA regulations → EDF - Inadequate
engineering standards,
Reclaimed pressure vessel was readily available and "would do the job" → PF - Improper motivation,
Potential PEAP impacts were not identified in any aspect of the operation → EDF - Inadequate
assessment of risks
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Question 5
Partially correct
Mark 0.25 out of
1.00
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 conceived nor planned for.
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.
There was a complete absence of a risk
management system and program at Hub Oil.
Maintenance was done on an "as needed” basis,
and "if it ain't broke, don't fix it”.
Your answer is partially correct.
The correct response is "There was a complete absence of a risk management program at Hub Oil."
There is a difference between a "risk management program", (the overall "umbrella" as discussed in
Topic #15 Chapter 3.1 The Risk Management Program, Chapter 3.2 The Risk Management Work Process,
and Chapter 3.3 The Risk Management System and Elements), and RM Element #2 Risk Assessment and
Management of Risks, which is but one of 11 elements of the risk management program. The scope of
Element #2 includes Hazard Identification (FLRA, SQRA, JSA, Checklists, Reporting & Correcting
Substandard Conditions & Practices, 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.
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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 system and program at Hub
Oil.
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Question 6
Correct
Mark 2.00 out of
2.00
For the latent cause as stated below for RME #1, to which category of a latent cause does it most
strongly belong?
Latent Cause: There was a complete absence of a risk management system and the element
programs at Hub Oil.
Reminder, alignment is defined as
"P” = Inadequate Program,
"S” = Inadequate Performance Standards,
"C” = Inadequate Compliance with Performance Standards
Select one:
P
S
C
Your answer is correct.
Latent Cause: There was a complete absence of a risk management system and element programs at
Hub Oil.
The correct response is P:
Explanation: Management neither held nor had stated a set of safety values, and had minimal, if any,
concept of engineering safety and risk management. Hub Oil had not created a set of corporate safety
values, lacked a comprehensive Risk Management System, and their leadership lacked knowledge to
understand engineering safety and risk management, and to commit resources to develop an
acceptable safety culture and risk management program. Other objectives, such as production, costs,
marketing, and employee welfare and satisfaction were managed instead of safety.
The correct answer is: P
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Question 7
Correct
Mark 1.00 out of
1.00
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 operations
The risk assessment program did not include
standards to conduct formal risk assessments
on critical plant operations.
Safety performance objectives and targets were
not established.
No qualification process for selecting contractor
companies or contractor employees
Your answer is correct.
The correct answer is: The risk assessment program did not include standards to conduct formal risk
assessments on critical plant operations.
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Question 8
Correct
Mark 2.00 out of
2.00
For the latent cause as stated below for RME #2, to which category of a latent cause does it most
strongly belong?
Latent Cause: The risk assessment program did not include standards to conduct formal risk
assessments on critical plant operations.
Reminder, alignment is defined as
"P” = Inadequate Program,
"S” = Inadequate Performance Standards,
"C” = Inadequate Compliance with Performance Standards
Select one:
P
S
C
Your answer is correct.
Latent Cause: The risk assessment program did not include standards to conduct formal risk
assessments on critical plant operations.
The correct response is S:
Explanation: The risk assessment program did not include process safety reviews, ABSA pressure vessel
data / specification sheets, processes for ensuring compliance with ABSA regulations, and OH&S legal
requirements. Although Hub Oil had a very basic risk management program that addressed the most
simple of hazards (hot surfaces, ignition sources, and the like), the program completely overlooked all
regulatory requirements (ABSA Reg'ns and OH&S Code), and the hazards and risks associated with
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Question 9
Correct
Mark 1.00 out of
1.00
refining and recycling spent oils (process safety). Employees had minimal understanding of occupational
safety hazards, and requirements of the Alberta Occupational Health and Safety Act, Regulations, and
Code.
The correct answer is: S
Which of the following latent causes most strongly relates to RME #4 Management of Change?
Select one:
There was no MOC program to effectively
manage changes to plant operations over time
in order to prevent degradation of plant
operations.
No monitoring of safety performance
There was a complete absence of a risk
management program at Hub Oil.
No process for effectively learning contractor
skills.
Your answer is correct.
The correct answer is: There was no MOC program to effectively manage changes to plant operations
over time in order to prevent degradation of plant operations.
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Question 10
Correct
Mark 2.00 out of
2.00
For the latent cause as stated below for RME #4, to which category of a latent cause does it most
strongly belong?
Latent Cause: There was no MOC program to effectively manage changes to plant operations
over time in order to prevent degradation of plant operations.
Select one:
P
S
C
Your answer is correct.
Latent Cause: There was no MOC program to effectively ensure plant operations did not degrade over
time
The correct response is P:
Explanation: There was no program, process, procedure, or any documented administrative control to
manage changes relating to the process unit operations at Hub Oil. Management did not consider that
changes in operations or equipment needed to be closely managed and documented; management
assumed that these changes would be managed by the workers. Management did not implement an
MOC Program and MOC Work Process.
The correct answer is: P
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Question 11
Correct
Mark 1.00 out of
1.00
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 the company nor with local
authorities.
Safety not a value. Other objectives such as
production, costs, employee satisfaction were
managed instead of safety
The engineering and design program did not
abide by rigorous industry and regulatory
standards for specifying,
procuring, fabricating, or modifying the
process equipment and pressure vessels in the
plant. (Recall that the plant was built based on
trial and error of legacy knowledge, and not
properly designed nor engineered.)
Complete lack of understanding of process
safety hazards.
Your answer is correct.
The correct answer is: The engineering and design program did not abide by rigorous industry and
regulatory standards for specifying, procuring, fabricating, or modifying the process equipment and
pressure vessels in the plant. (Recall that the plant was built based on trial and error of legacy
knowledge, and not properly designed nor engineered.)
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Question 12
Incorrect
Mark 0.00 out of
2.00
For the latent cause as stated below for RME #7, to which category of a latent cause does it most
strongly belong?
Latent Cause: The engineering and design program did not abide by rigorous industry and
regulatory standards for specifying, procuring, fabricating, or modifying the process equipment
and pressure vessels in the plant.
Select one:
P
S
C
Your answer is incorrect.
Latent Cause: The engineering and design program did not integrate and follow rigorous industry and
regulatory standards for specifying, procuring, fabricating, or modifying the process equipment and
pressure vessels in the plant.
The correct response is C
Explanation: "At the very least, the professional engineers and operating engineers at Hub Oil should
have known to access the ABSA Regulations and comply with those regulations." Anyone doing any
kind of design work at Hub Oil was not aware that they needed to comply with the ABSA Regulations
(legal requirements). The plant was built based on trial and error of legacy knowledge, and not properly
designed or engineered. ABSA Regulations for pressure vessels, pressure safety relief valves, and other
plant safety systems were not followed or tracked as they should have been. In other words, the ABSA
regulations ARE the engineering and design program complete with standards for pressure vessels for
ALL facilities operating pressure vessels in Alberta; thus the "C" and not "P" or "S".
The correct answer is: C
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Question 13
Correct
Mark 1.00 out of
1.00
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, and other plant safety
systems were not considered, not tracked, not
followed.
Employees had minimal understanding of
occupational safety hazards and requirement of
Alberta Occupational Health and Safety Act,
Regulations, and Code; ABSA requirements.
The Maintenance Program did not include
standards to plan, schedule, and coordinate
jobs and resources in any sustainable manner;
it was executed on an "as needed" basis
Management did not fully value the contractor's
knowledge and expertise. Management
marginalized the contractors i.e. "they can do the
dirty work”.
Your answer is correct.
The correct answer is: The Maintenance Program did not include standards to plan, schedule, and
coordinate jobs and resources in any sustainable manner; it was executed on an "as needed" basis
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Question 14
Correct
Mark 2.00 out of
2.00
For the latent cause given below for RME #8, to which category of a latent cause does it most strongly
belong?
Latent Cause: The Maintenance Program did not include standards to plan, schedule, and
coordinate jobs and resources in any sustainable manner; it was executed on an "as needed"
basis.
Select one:
P
S
C
Your answer is correct.
Latent Cause: The Maintenance Program did not include standards to plan, schedule, and coordinate
jobs and resources in any sustainable manner; it was executed on an "as needed" basis.
The correct response is S.
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 or
no 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.
The correct answer is: S
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Question 15
Correct
Mark 1.00 out of
1.00
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 requirement of Alberta
Occupational Health and Safety Act,
Regulations, and Code; ABSA requirements;
and other Alberta Codes.
b.
The training
program
did not
include
standards
to train,
qualify,
certify, and
confirm that
the workers
were
competent
on the
process unit
operations.
(Recall that
training was
done "on-
the-job"
and without
Knowledge was 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.
There was no formal documentation to train, qualify, certify, and
confirm that the workers were competent on the process unit
operations.
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the benefit
of any
training
documents.)
c.
No monitoring of safety performance
d.
Plant was built based on trial and error of
legacy knowledge, and not properly designed
or engineered.
Your answer is correct.
The correct answer is: The training program did not include standards to train, qualify, certify, and
confirm that the workers were competent on the process unit operations. (Recall that training was done
"on-the-job" and without the benefit of any training documents.)
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Question 16
Correct
Mark 2.00 out of
2.00
For the latent cause given below for RME #9, to which category of latent cause does it most strongly
belong?
Latent Cause: The training program did not include standards to train, certify, and confirm that
the workers were competent on the process unit operations.
Select one:
P
S
C
Your answer is correct.
The correct response is S.
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.
The correct answer is: S
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Question 17
Correct
Mark 1.00 out of
1.00
Which of the following latent causes most strongly relates to RME #11 Operations and Facilities
Information and Documentation?
Select one:
The D&I Program did not include standards to
allow restricted access to the operations
standards and maintenance standards. (Recall
that the "manual" was locked away, which
prevented employees from following and
complying with those standards.)
Maintenance was done on an "as needed” basis,
and "if it ain't broke, don't fix it”.
Although changes were made and
acknowledged as changes, the changes were not
effectively and formally managed.
There was a complete absence of a risk
management program at Hub Oil.
Your answer is correct.
The correct answer is: The D&I Program did not include standards to allow restricted access to the
operations standards and maintenance standards. (Recall that the "manual" was locked away, which
prevented employees from following and complying with those standards.)
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Question 18
Incorrect
Mark 0.00 out of
2.00
For the latent cause as stated below for RME #11, to which category 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.
Select one:
P
S
C
Your answer is incorrect.
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.
The correct response is C.
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.
The correct answer is: C
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Question 19
Partially correct
Mark 4.29 out of
6.00
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.
Recall these acronyms:
MLCA = RME#1: Management Leadership, Commitment, and Accountability
RAMR = RME#2: Risk Assessment and Management of Risk
CAEP = RME #3: Community Awareness and Emergency Preparedness
MOC = RME#4: Management of Change
IRIAA = RME #5: Incident Reporting, Investigation, Analysis, and Actions
PECI = RME #6: Program Evaluation and Continuous Improvement
DCSU = RME#7: Design, Construction, and Start Up
O&M = RME#8: Operations and Maintenance
ECT = RME#9: Employee Competency and Training
CCI = RME #10: Contractor Competency and Integration
OFID = RME #11: Operations and Facilities Information and Documentatio
n
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.
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.
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.
RAMR
OFID
ECT
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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.
Implement a program to include management approval prior to employees
undertaking tasks and executing procedures that are outside of normal operating
parameters.
Implement a program to include process safety reviews.
Implement a program with a comprehensive set of maintenance and repair
procedures / manuals.
MLCA
MOC
MOC
O&M
Your answer is partially correct.
You have correctly selected 5.
Latent causes should be exclusive to or pertain to only one risk management system element.
A latent cause can and should only be related to one risk management system element. Consider the
following latent cause statement from the selections in this question, "Implement a program for
management to create a set of safety values, communicate the values of safety within the organization,
and commit resources
to developing and implementing a comprehensive risk management program."
The key phrase is commit resources
which pertains to RME #1 MLCA.
So, the latent cause statement should be correctly stated to include the element name e.g. "Implement
a leadership and commitment program
for management to create a set of safety values,
communicate the values of safety within the organization, and commit resources to developing and
implementing a comprehensive risk management program".
It does not relate to #2 Risk Assessment and Management of Risks; a latent cause statement would start
with or relate to "the risk assessment program". Also recall that a synonymous phrase for this element is
"#2 Risk Assessment and Control of Risks".
RME #1 MLCA: "Implement a leadership and commitment program for management to create a set of
safety values, and communicate the values of safety within the organization."
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RME #2: "Develop and implement a comprehensive risk assessment program for the recycle oil refining
process systems."
The correct answer is: 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. → DCSU, 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. → OFID, 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. → ECT, 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. →
MLCA, Implement a program to include management approval prior to employees undertaking tasks
and executing procedures that are outside of normal operating parameters. → MOC, Implement a
program to include process safety reviews. → RAMR, Implement a program with a comprehensive set of
maintenance and repair procedures / manuals. → O&M
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Question 20
Partially correct
Mark 3.00 out of
7.00
Chapters 4.5: The Swiss Cheese Model and The Relationship Between Latent Causes &
Incidents:
A Risk Management System consists of different components as depicted by the slices in the
Swiss Cheese Model. The model as shown in this graphic depicts a Risk Management System
with failure outcomes
. Match the most appropriate description for each of the slices: (7 marks
total; 1 mark for each correct response; no penalty for incorrect response or no response)
Ineffective implementation at this slice
sets the latency for causing loss
incidents.
Slice D
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Ineffective equipment and software as
managed within the system are
depicted at this slice.
Ineffective documentation of the
organization as managed within the
system is depicted at this slice.
Action that reflects "the culture of the
organization” is depicted at this slice.
Ineffective implementation of PDCA is
depicted at this slice.
Robust risk management system
elements are depicted at this slice of
this graphic.
Effective implementation at this slice
sustainably prevents loss incidents.
Slice B
Slice C
Slice A
Slice D
Slice A
This is not a slice in the model with failure outcomes.
Your answer is partially correct.
You have correctly selected 3.
The letters in the depicted model in the assignment and the numbers on the model in the course
content (PPTs) are in the same order. The graphic depicts a failure outcome; thus "adequacies" are not
valid responses for this question.
Slice A / 1 = Risk Management System. Recall that the ineffective implementation at this slice sets the
latency for causing loss incidents.
Slice B / 2 = Engineering Controls. Recall that ineffective equipment and software as managed within
the system are depicted at this slice.,
Slice C / 3 = Administrative Controls. Recall that ineffective documentation of the organization as
managed within the system is depicted at this slice.
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Slice D / 4 = Work Practices = Action that reflects "the culture of the organization” is depicted at this
slice. Recall, culture is defined as the "way we do work around here". This applies and is true whether
the outcome is a success or a failure.
The other responses are distractors / incorrect responses, and although they are true statements, they
are not "slices" in this model with a failure outcome.
Ineffective implementation of PDCA is depicted at this slice. (PDCA is not depicted in the model.)
Robust risk management system elements are depicted at this slice of this graphic. (These are not
depicted in the failure model.)
Effective implementation at this slice sustainably prevents loss incidents. (Although it is true that the
effective implementation of a risk management system does sustainably prevent loss incidents, it does
not apply for this graphic of the model with a successful outcome.)
The correct answer is: Ineffective implementation at this slice sets the latency for causing loss
incidents.
→ Slice A, Ineffective equipment and software as managed within the system are
depicted at this slice.
→ Slice B, Ineffective documentation of the organization as managed within
the system is depicted at this slice.
→ Slice C, Action that reflects "the culture of the organization”
is depicted at this slice.
→ Slice D,
Ineffective implementation of PDCA is depicted at this slice.
→ This is not a slice in the model with
failure outcomes.,
Robust risk management system elements are depicted at this slice of this graphic.
→ This is not
a slice in the model with failure outcomes.,
Effective implementation at this slice sustainably prevents loss incidents.
→ This is not a slice in
the model with failure outcomes.
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Question 21
Partially correct
Mark 4.00 out of
7.00
Chapters 4.5: The Swiss Cheese Model and The Relationship Between Latent Causes &
Incidents:
A Risk Management System consists of different components as depicted by the slices in the
Swiss Cheese Model. The model as shown in this graphic depicts a Risk Management System
with successful outcomes
in this graphic
. Match the most appropriate description for each of
the slices for the graphic shown: (7 marks total; 1 mark for each correct response; no penalty for
incorrect response or no response)
Action that reflects "the culture of
the organization” is depicted at this
slice.
Documentation of the organization
as managed within the system is
depicted at this slice.
Slice D
Slice B
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Installed equipment and software as
managed within the system are
depicted at this slice.
Effective implementation at this
slice sustainably prevents loss
incidents.
Effective implementation of PDCA is
depicted at this slice.
Latent causes are depicted at this
slice of this graphic.
Ineffective implementation at this
slice sets the latency for causing
loss incidents.
Slice C
Slice D
Slice A
Slice A
This is not a slice in the Model with successful outcomes
Your answer is partially correct.
You have correctly selected 4.
The letters in the depicted model in the assignment are reverse-ordered from the numbers on the
model in the course content (PPTs). This was done so as to make the question a bit of a thinking /
analysing exercise. The graphic also depicts a successful
outcome; thus "deficiencies" are not valid
responses for this question.
Slice D / 1 = Risk Management System. Recall that the effective implementation of a risk management
system i.e. no latent causes, sustainably prevents loss incidents.
Slice C / 2 = Engineering Controls. Recall that engineered systems or engineering controls are "Installed
equipment and software as managed within the system".
Slice B / 3 = Administrative Controls. Recall that administrative controls consist of the "documentation
of the organization as managed within the system".
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Slice A / 4 = Work Practices = Action that reflects "the culture of the organization” is depicted at this
slice. Recall, culture is defined as the "way we do work around here". This applies and is true whether
the outcome is a success or a failure.
The other responses are distractors / incorrect responses, and although they are true statements, they
are not "slices" in this model with a successful outcome.
Effective implementation of PDCA is depicted at this slice. (PDCA is not depicted in the model.)
Latent causes are depicted at this slice of this graphic. (Latent causes are not depicted in the successful
model.)
Ineffective implementation at this slice sets the latency for causing loss incidents. (Although it is true
that the ineffective implementation of a risk management system does set the latency for causing loss
incidents, it does not apply for this graphic of the model with a successful outcome.)
The correct answer is: Action that reflects "the culture of the organization” is depicted at this slice.
→ Slice A, Documentation of the organization as managed within the system is depicted at this
slice.
→ Slice B, Installed equipment and software as managed within the system are depicted at
this slice.
→ Slice C, Effective implementation at this slice sustainably prevents loss incidents.
→
Slice D,
Effective implementation of PDCA is depicted at this slice.
→ This is not a slice in the Model with
successful outcomes,
Latent causes are depicted at this slice of this graphic.
→ This is not a slice in the Model with
successful outcomes,
Ineffective implementation at this slice sets the latency for causing loss incidents.
→ This is not a
slice in the Model with successful outcomes
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