Root Cause Analysis (RCA) Example: Pipeline Leak Incident - Occupational safety, health, environment, case studies, food safety, research journals, and e-books

Root Cause Analysis (RCA) Example: Pipeline Leak Incident

Pipeline Leak Incident
Pipeline Leak Incident
Incident Description

A pipeline leak occurred , in a chemical processing plant, leading to the release of hazardous materials. The leak was detected in Section 3 of the plant's main chemical processing line, which is responsible for transporting corrosive chemicals. Although the spill was contained, it caused significant environmental damage to the surrounding area and resulted in a 12-hour shutdown of operations. Fortunately, no personnel were injured, and the plant's emergency response team quickly controlled the situation.
The leak was traced to a crack in the pipeline, which had developed near a weld joint. Upon inspection, it was discovered that corrosion had weakened the pipeline over time, particularly around the welded section, leading to the failure. The pipeline, made of stainless steel, had been in service for 10 years, and while routine inspections were conducted, they did not include detailed checks of the protective coating or weld joints, both of which showed signs of wear and degradation.
As a result of the incident, the plant initiated an investigation to determine the root cause of the failure and develop corrective measures. The immediate shutdown minimized the impact on plant personnel and the environment, but it underscored the importance of more thorough maintenance protocols, particularly for aging infrastructure in harsh operational environments.

Step 1: Problem Identification

  • Issue: Pipeline leak detected in the plant.
  • Impact: Environmental contamination, production halted for 12 hours, minor spill of hazardous chemicals.
  • Location: Section 3 of the chemical processing line.
  • Date: -

Step 2: Data Collection

  • Pipeline material: Stainless steel.
  • Operating pressure: 120 psi.
  • Age of pipeline: 10 years.
  • Last inspection: 8 months ago.
  • Weather conditions: High humidity, temperature 30°C.
  • Operational logs: No unusual activity before the incident.

Eyewitness Reports

  • Operators noticed a slight drop in pressure before the leak.
  • Maintenance team reports no recent repairs or modifications to the affected section.

Physical Evidence

  • Small crack visible in the pipeline near a weld joint.
  • Evidence of corrosion around the affected area.

Step 3: Event Mapping

Sequence of Events:

  • Pressure in the pipeline drops.
  • Leak detected by operators; safety systems activated.
  • Hazardous material spills into the containment area.
  • Maintenance team investigates the leak and shuts down the system.
  • Inspection reveals corrosion at the weld joint, leading to a crack in the pipe.

Step 4: Root Cause Identification

Using the Five Whys technique:

A. Why did the pipeline leak?
  • The pipeline cracked at a weld joint.
B. Why did the weld joint crack?
  • Corrosion weakened the material at the joint.
C. Why was there corrosion?
  • The protective coating around the weld joint had deteriorated.
D. Why did the protective coating deteriorate?
  • Regular inspections didn’t detect coating degradation.
E. Why wasn’t the degradation detected?
  • Inspection protocols did not include specific checks for coating integrity at weld joints.
Step 5: Contributing Factors

  • Environmental conditions: High humidity contributed to accelerated corrosion.
  • Age of the pipeline: After 10 years of use, wear and tear became more significant.
  • Inadequate inspection protocol: Routine inspections focused on pipeline pressure and integrity but didn’t account for specific weld joint vulnerabilities.
  • Failure in protective coating: The coating applied at the joint was not adequately monitored for degradation.

Step 6: Corrective Actions

  • Revise inspection protocols: Include detailed checks on protective coatings, especially around weld joints.
  • Regular coating reapplication: Implement a schedule to reapply protective coatings every 2 years.
  • Upgrade materials: Consider using corrosion-resistant alloys for critical pipeline sections.
  • Environmental monitoring: Install humidity control systems in the affected areas to reduce corrosion risks.
  • Staff training: Provide additional training for maintenance teams on identifying early signs of coating degradation.

Step 7: Preventative Actions

  • Schedule a full inspection of all weld joints in similar pipelines.
  • Implement continuous pressure monitoring systems that can detect minor drops earlier.
  • Adopt a more robust maintenance protocol for aging infrastructure.

Step 8: Conclusion

The pipeline leak was caused by corrosion at a weld joint, which was not detected due to gaps in the inspection protocols. The combination of environmental factors and the aging infrastructure contributed to the failure. By improving inspection protocols, upgrading materials, and addressing environmental conditions, the risk of similar incidents can be reduced in the future.

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