12 Steps to Investigate and Learn from Any FEMI Incident

Executive Summary

As the title implies, this article outlines the twelve steps for implementing a work process to learn valuable lessons after a fixed equipment mechanical integrity (FEMI) incident of any magnitude (minor to major) occurs. As such, this is basically a step-by-step guide to implementing the FEMI investigation process for learning from incidents (LFI). When a FEMI event occurs, or a FEMI problem is noticed that could have or did release some amount of hazardous fluids, or even just a near-miss without a release or a discovery of something improper or unexpected has been made, it’s important for all sites to know how to expeditiously understand and learn from these incidents. Knowledge of the twelve steps proposed in this article ensures that your site/company can learn the what, how, and why aspects of an incident/issue that has occurred, in order to improve existing procedures/practices and avoid future FEMI incidents, especially catastrophic losses.

Introduction

All hydrocarbon and chemical processing sites have had leaks, releases, and incidents associated with equipment failure and/or any other FEMI issue that is noticed, which demonstrates a less-than-excellent FEMI work process. From the 125+ FEMI audits in which I have participated over the last 50+ years, I can definitively say that many sites need to have a better work process for LFI, and in our case, specifically LFI that involves FEMI issues. Though most sites have a work process that can be implemented when a major release occurs, causing significant process safety incidents involving potential fires, explosions, injuries, etc., not many also have a structured LFI work process for less than major process safety incidents or for learning from near-misses or even after discovery of incorrect FEMI issues before they cause a release of hazardous substances. These smaller incidents are the ones we really need to learn from to prevent smaller FEMI incidents, eventually resulting in the big process safety events. There’s an old adage that goes like this: “Investigate all the little incidents, then implement corrective actions and you will likely avoid the big one in the future.” Figure 1 illustrates the twelve-step process for LFI, which involves FEMI failures, near-misses, and unexpected discovery items that I will expand upon in this article.

This LFI process for FEMI issues is documented in great detail in API RP 585, Pressure Equipment Integrity Incident Investigation [1]. If you aren’t familiar with API 585, I encourage you to obtain a copy and review it to increase your understanding of investigating FEMI incidents. If you can understand the FEMI LFI process beforehand, you will be ready to act when the next occasion arises where you may be involved in an investigation of a FEMI event, near-miss, or unexpected discovery of something that just isn’t right.

API RP 585 is an excellent reference for how to go about investigating FEMI failures of any size, from minor discoveries that are not in accordance with industry or company standards on up to minor leaks/operating incidents and even major loss of primary containment (LOPC) events that may include extensive damage, injuries, negative media attention and possibly legal implications and/or regulatory actions. FEMI incidents, including low-consequence incidents, near-misses, and unexpected discoveries, provide opportunities to learn through structured investigations, identify causes, and implement improvements to prevent potentially larger failures. The investigation process described herein also expands upon how to implement the last two parts of the four-step PERI Work Process Model for FEMI, which consists of Plan-Execute-Review-Improve [2].