Safety & Asset Integrity Excellence - A Study of Three Mile Island
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The document discusses an innovative approach to integrating safety and asset integrity through data and prescriptive analytics, arguing that these elements are interconnected and should not be treated separately. It highlights the case of the Three Mile Island incident to illustrate how a combination of mechanical failures, human errors, and inadequate data management can culminate in catastrophic events. The proposed system aims to mitigate composite risks by leveraging robust data collection and analytics, promoting a culture of safety and operational excellence that transitions organizations from reactive to proactive risk management.
Safety & Asset Integrity Excellence - A Study of Three Mile Island
- 1. Kienbaum Management Consultants CaseStudy Safety and Asset Integrity Excellence – Using data and analytics to control risk and add operating value Conventional wisdom sees process safety and machine integrity and maintenance as two separate areas of operating practice. We believe, however, that these are one and the same. Viewing safety and equipment maintenance as elements of the same system is an innovative approach that not only manages composite risk but also adds significant operating value. However, these components are both being addressed separately already by many companies without success. To change that, an unconventional approach is required: data and prescriptive analytics, applied specifically to safety and maintenance. Presented here is a case in which an incident occurred as a result of a number of factors working together to culminate in a catastrophic failure. This example illustrates the interconnected nature of many incidents, as well as the inadequacies in processes, systems, and organizational understanding that plague current safety and asset integrity cultures. To solve these issues, an innovative system of Safety and Asset Integrity Excellence is presented. This system addresses composite risk associated with operations using prescriptive analytics. Using risk mitigation strategies, robust data and analytics, key performance indicators, personnel trainings, workplace design elements, and asset management, organizations have the ability to shift risk mitigation to value creation. Three Mile Island was a nuclear meltdown in Pennsylvania in 1979. This accident was the most serious commercial nuclear power plant incident in U.S. history. This case is an example of how incidents are rarely the result of a single mistake, and how a comprehensive, data based risk strategy can address the network of safety and maintenance factors that affect the operations of a site. After a thorough investigation of the Three Mile Island event, authorities identified no single action or inaction as the cause. Rather, a complex and interlinked series of mechanical failures, human actions, engineering designs, operational implementations, and team interfaces occurred. The Three Mile Island site did not have an adequate system to process the amount of data and recognize the inconsistencies that led to the meltdown. In addition to this deficiency, an effective risk mitigation strategy was severely lacking. The failures and errors that occurred could have been avoided prior to the incident, eliminating the possibility of escalation to the meltdown point. Critical Events: » Asset integrity failure: Faulty pumps and valves prevent proper cooling water from being delivered to the reactor » Inadequate data management: Gauges and controls read incorrect data, and were not correctly installed to display the current state of the entire system » Key metric absence: Operators were not able to clearly and rapidly make judgements based on the massive amount of data being delivered » Operator error: Due to a lack of training and incorrect safety culture, the operators did not properly handle the escalation The incident was the result of a combination of errors, along with a misaligned safety and asset integrity culture. This incident and others can be avoided by correctly utilizing data and prescriptive analytics. When applied effectively, today’s technologies give the ability to gather massive amounts of actionable data, providing the information needed to mitigate this composite risk. Three Mile Island Overview A New Approach
- 2. Composite Risk: People & Machines Overall composite risk is a combination of risk from people and risk from equipment. Humans will be a significant risk contributor to any risk profile. The case of Three Mile Island exemplifies this: no blatant mistake occurred, but action was taken without an accurate understanding of the situation. The risk of human intervention based on the situation is always present. Equipment malfunctions and breakdowns are another source of risk. Preventive maintenance and reaction plans should be established to ensure that the human equipment interaction is handled correctly. The fact of operation is that humans interact with equipment, both of which present inherent risk. As seen in the Three Mile Island case, the operators reaction to equipment was a critical piece of the puzzle. A safety and asset integrity culture that does not recognize the interaction between these elements limits the effectiveness of risk mitigation. Data Collection: Understanding the Connection For operators and equipment to interact effectively, data must accurately depict the current situation. Given the technologies available for data management, prescriptive analytics offer an innovative and invaluable tool for safety and equipment. Data needs to be collected from all sources and aggregated before it can be used for any analytics. When robust data is aggregated, a model can be created that predicts adverse events and prescribes early interventions. This model allows organizations to progress from descriptive analytics, where data reports what happened in previous events, to prescriptive analytics. Based on the incoming data, the model is able to monitor real time incident risk levels and provide correct signals and intervention. DADA Cycle: From Risk to Value Data is the start of a closed feedback loop, the DADA cycle, that results in a proactive system and triggers continuous performance improvement through analytics. This approach allows an organization to move from reactive safety procedures to a proactive mentality. Rather than focusing on adverse events that have occurred previously, the goal is to understand the conditions and factors that lead to successful safe operations. This culture facilitates an organizational shift from value protection to value creation. This shift is where organizations are able to create value, delivering operational improvements from employees and equipment Prescriptive Analytics: Incident Mitigation Strategy Prescriptive analytic models offer the intervention strategies, but operators are still required to take action. Based on the model, key performance indicators to focus the data, trainings on how to read signals, and standard operating procedures can be developed to mitigate the risks through behavior. These components not only encourage safe behavior and limit equipment failure, but also add significant operating value. The improved performance due to less downtime and fewer costs associated with adverse events makes Safety and Asset Integrity Excellence a valuable component of operations. With proper application, a pervasive culture is instilled in the organization. Employees see increased efficiency when working with well-maintained equipment in safe environments. Kienbaum Consultants Inc. 2300 Lakeview Parkway, Suite 700 Alpharetta, GA 30009 USA www.kienbaum.com Excellence Applied: Three Mile Island » Preventative maintenance: Equipment upkeep as a piece of the risk mitigation strategy eliminates issues such as the initial failure in Three Mile Island » Workplace design: Proper implementation and design of the gauges and controls would ensure an accurate depiction of the system’s current state and eliminate false readings » Key performance indicators: Critical metrics that are used to evaluate the performance of the system would disallow an unsafe situation to arise if monitored correctly » Data utilization: Prescriptive analytics based on a robust data management system can aid in risk assessment, and would have provided the appropriate intervention strategy in this case » Training & Development: Operators require proper training to monitor all risk factors and properly handle escalating situations similar to Three Mile Island, thus limiting harm to the system following a single adverse event » Organizational Culture: An under- standing of and an alignment between all of these components is necessary in order to control risk and add operating value The interaction between humans and equipment is a complicated one, but is critical to organizational success. Viewing these as separate elements allows for cost avoidance but stops there, without holistically addressing the system. The Safety and Asset Integrity Excellence system is an innovative approach that effectively mitigates composite risk using prescriptive analytics, allowing organizations to create value in safety and asset management. For more information, contact Eric Lavelle at [email protected]. Data Analysis Decision Action