Let's Be Frank: What Went Wrong?

By Inspector Frank. June 27, 2019

Editor’s Note:  This is the first article in a new column entitled Let’s Be Frank. In each article, the author will share technical, thought-provoking, and sometimes humorous or emotional experiences garnered in a career that spans over 20 years inside the gates of facilities. Writing under the pseudonym Inspector Frank, the author will offer a first-hand, candid view of what he has witnessed throughout his career. His purpose in sharing these experiences and opinions is to encourage readers to think deeper about what they do, why they do it, and the possible impact of their decisions.

Inspectioneering is committed to protecting the anonymity of pseudonymous authors. We do, however, hold these contributors to the same editorial standards as those writing under their own name. In this, we know the author’s identity and maintain communications regarding the author’s published works. If you have and questions, feedback, or concerns stemming from this article, please send an email to and we will forward your correspondence to the appropriate party.

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What Went Wrong?

Watching a fireball rising above your facility is the worst thing an asset integrity professional can witness. Is there anything that screams failure more? If your one job is to keep the process in the pipe, then you obviously just failed at your one job. The question of “what went wrong?” will be asked.

In the coming months, there will be a plethora of opportunities to fully appreciate the breakdowns that occurred; meetings with various regulators, insurance companies, investigators looking at everything, your own command structure’s response, the public outrage, etc. Fingers will be pointed. This can and will be very demoralizing. The very thing you are tasked to prevent has occurred.

In hindsight, the steps that would have avoided the accident may seem so obvious and so easy. Maybe the original fabricators made a mistake. Maybe maintenance work was not executed as per the company specification. Maybe a process change that had an effect on damage mechanisms occurred without an MOC. Maybe somebody missed an opportunity to follow up on a low UT reading.

I found it hard to not take it personally.

But significant incidents can also hone. They allow for clarity of focus that may not be achievable by individuals or teams who have not been forced to deal with their own fallibility. So what lessons have I learned? Lots and I am still learning.

Be honest with yourself and your team about what contributed to the incident and what could have prevented it if done properly. Have a healthy, productive process for identifying the causes. When you look for the breakdowns in the layers of protection, don’t sugar coat – at least not internally. That’s the Company’s PR problem; unless there’s a new API standard I’m unaware of.

Use this as an opportunity to take a good hard look at what you are actually doing. Or, preferably, use an incident in a related industry to be the focal point for self-evaluation. If you have been fortunate enough to not have an incident on your watch, these are the important questions to answer and address proactively:

  1. Does your team understand the facility processes well enough to make sound decisions about applying the right inspection technique to the right area? If not, then what steps can be done to develop this knowledge (i.e., working through a detailed RBI/corrosion study with a corrosion specialist familiar with the unit type)? Can you spare your personnel to spend time in the control rooms learning how the units they are responsible for operate? Unit operations manuals are great sources of information that, unfortunately, read like my tax submission, but they too can be utilized. At the end of the day, whatever education you can finagle will add to the team’s effectiveness.
  2. As with any profession, competing non-essential work is always present. That eats up time. Are your staffing levels enabling you to deal with everything that is on your plate? Are you out chasing rainbows to keep corporate happy? Have the team do some brainstorming around what it is you are doing day to day and verify that it goes with your mandate. Do you have an effective prioritization method? This leads directly into:
  3. Does your integrity department have a clear charter or mandate? What are you doing and how should things be prioritized within the group? Where are you trying to go? If you don’t know the destination it’s hard to plan an effective route. While the perfect destination may never be achieved, are those that are driving the program, at least, all headed in the same direction?
  4. Without an overarching vision of what your desired program looks like, it’s hard to ensure your various integrity initiatives are aligned to produce maximum process safety. Do your programs complement each other and add multiple layers of protection? I have read (and heard) from multiple sources that “good layers of protection are like spinning disks with holes in them; the more disks that are spinning the less likely the holes will ever line up to allow something through.” Do you have the disks, are they spinning, and do you have the resources to keep them spinning?
  5. Look at where you are spending your money. Dealing with issues 1 through 4 above should help you spend your hard-fought inspection budget wisely.
  6. Does your facility have a robust management of change program? Are any changes that vary from the original design or original operating parameters thoroughly reviewed prior to the change? Do people take the time to understand what effect the work they are proposing may have? Does the equipment integrity department, at least, get notified of proposed changes as part of the process? If not, this creates a large gap that can and will bite you. It is not a matter of “IF” – it’s “WHEN” and “WHERE”?
  7. Speaking of managing change; does your group have a formalized process to manage change of critical personnel? They may be mechanical integrity personnel themselves or those from other departments that help integrity out by providing their knowledge and experience. For example, losing that key person out of a control room can mean the difference between understanding that the water injection system is critical to corrosion protection vs. thinking it’s just there to help desalt the condensers.
  8. Are high risk areas identified? Are operations personnel aware of any process changes they can make that will alter the risk level in those areas? A key part of really effective integrity programs is having integrity operating windows (IOWs) in place for the front line operations personnel. Operators need to know that if they raise the temperature at ‘that heater’, the downstream piping’s corrosion rate will go through the roof. In a perfect world, automatic notifications would go out from the control system if an IOW was violated. But a good stop gap measure is educating operations personnel on potential risks to changing critical process parameters. Also, effective links to the complimentary response systems must be established for the appropriate action to take place. Some examples include: a review by a qualified person who can evaluate the effects of the change on the mechanical integrity of the affected equipment, or an automated system that shuts down the system, or evaluation by an RBI or Inspection analyst for consideration, etc.

A man wiser than me once said, “if you don’t have a fire or explosion every once in a while, no one takes equipment integrity seriously.” In a tight economy, it’s very easy for a company to stop seeing the need to spend money on something that doesn’t readily and quantifiably help the bottom line.

However, a fireball rising over your facility does, with brutal effectiveness, have an impact on the bottom line. It’s the kind of PR you and your company will wish you never had.

In summary, what I have learned is that EDUCATION IS CRITICAL. Maintenance, reliability, process, and integrity personnel have to become knowledgeable on what the process is and what effect changing parameters can have on equipment integrity. Some people say a little knowledge can be dangerous. I say a little knowledge is better than none, especially if it leads to someone asking the important question “is this going to go wrong?” It’s much better than the question “what went wrong?”

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Comments and Discussion

Posted by William Oliphant on June 28, 2019
Great article! I highly recommend Drift into... Log in or register to read the rest of this comment.

Posted by Dave Maguire on August 26, 2019
Great idea for a series of articles. Good points... Log in or register to read the rest of this comment.

Posted by Andy Gysbers on August 29, 2019
Good article. Brings to mind another quote that... Log in or register to read the rest of this comment.

Posted by John Reynolds on September 3, 2019
Enjoyed the article, but I take issue with the... Log in or register to read the rest of this comment.

Posted by Akash Vala on September 15, 2019
Great things, In Blog subject "Lets Be Frank" its... Log in or register to read the rest of this comment.

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