SOP for RCA Quality Review

Function: TSD Dept.: Engineering Section/Area: Reliability

Doc. No.: P07-TSD-REL Rev: 01 Date: June 13, 2021 Page 1 of 7
Preparation: Said Ahmed Al-Habsi, Review: Abdulaziz AL Hamdi Approval: Shakthisena THIRU,
Reliability Engineer PSM lead Engineering lead

Review: Menno HOFSTRA,

Reliability Team Lead

Review: Talal Al-Rawahi,

PES lead

1. Purpose
The purpose of this document is to describe/detail the process used for incident investigation report
quality review and shall be treated as a supplementary/complementary document to the Incident
Investigation Procedure (05.04.01-Incident Investigation). The intent is to ensure that the root-cause of the
issue is well captured, and the recommendations given will result in the highest value and the minimum
cost.

2. Scope:
This document covers the meeting agenda, the quality review team, meeting frequency, the roles &
responsibilities as well as the process KPIs.
The objective is to improve the quality of RCAs and prevent the incident from reoccurrence by ensuring the
root-cause and contributary factors are well captured, and the recommendations given are SMART
(Specific, Measurable, Achievable, Relevant and Time-bound) & will offer the highest value with the lowest
cost (Suitable minimum technical solution). The process aims to encourage leaders & facilitators for a
better outcome and to show appreciation & recognition, and not to discourage & hold people accountable.

3. Definitions:
Refer 05.04.01-Incident Investigation: Incident investigation procedure

4. Activities/Description:

4.1. Meeting frequency & duration:

The frequency of the meeting is based on incident investigations. Each incident investigation report is
required to go through this quality review. Just before report signing, the RCA facilitator will set up a
meeting with the review team in order to review the quality of the RCA report. With the current data, this
meeting will occur once every 2 weeks. The duration of the meeting is 30-45 minutes for each RCA, 10-15
minutes is for the RCA leader to present the RCA report and 20-30 minutes is for the review team to
challenge the quality.

4.2. Meeting agenda:

The meeting is split into 2 main parts:

A. RCA leader (10-15 minutes):

presents the RCA report to the quality review team going through:
- Incident summary & process description
- Major findings, root-cause of the incident and contributing factors
- The recommendations given to prevent the incident from reoccurring
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B. Quality review team (20-30 Mins):

Challenge the quality of the RCA report focusing on:
- Ensure the root-cause & contributary factors are well captured, to prevent the incident from
reoccurring
- Review the quality of the recommendations (being SMART), and support on selecting the most
suitable solutions (highest value with the lowest cost)
- Discuss if the recommendations can be applied anywhere else in the plant as lessons learned,
and keep the recommendations number as low as possible (ideally 3-6 recommendations)
- Give the decision for the RCA leader whether to proceed to signing, or adjust the RCA report

4.3. Quality review team:

The selection of the quality review team is dependent on the impact of the incident whether it is black, red,
PSM Tier-1, Product Quality Tier-1, or yellow, PSM Tier-2, Hipo Tier-3, Product Quality, Tier-2, Tier-3.
- The participants for the review will be selected after the RCA quality review request is sent by the
RCA Facilitator.
- The review team shall be a maximum of 5 people
- For low impact incidents, TA-2 is selected from another team to keep the process transparent and
eliminate any conflict of interest, e.g. if an incident is led by AP PES focal point, the review team
shall include a TA-2 from SR, PP, MAF or LPIC etc.
- Based on the nature of the incident, the respective lead to be involved, engineering lead /asset
integrity lead for reliability incidents, PSM lead for process safety incidents, PES lead for quality
incidents.
 SOP for RCA Quality Review

Doc. No.: P07-TSD-REL Rev: 01 Date: June 13, 2021 Page 3 of 7

5. Meeting Key Performance Indicators (KPIs):

KPI Unit Frequency Tracking/Display Target

Quality review team decision (accepted/ -
rejected) 1. Reliability/PSM RCA
RCA based, every tracking sheet in ECM
RCA to go
Review Team attendance % through this 75% (3
meeting 2. Reliability/PSM monthly out of 4)
report
The time from quality review request Days 5 Days
until the review team decision

6. Roles & Responsibilities:

6.2. RCA presenter (RCA leader):

- Ensure the RCA report is ready for the quality review session
- Present the RCA summary, major findings, root-cause & contributing factors and list of
recommendations
- Ensure the meeting outcome/changes are reflected in the report (taking the meeting
outcome back to the team & following up on the changes)
- Seek the approval of the quality review team to the causes & recommendations

6.1. Meeting facilitator (Reliability/PSM engineer):

- Schedule an RCA quality review meeting before RCA report signing (sending the meeting
invitation with the RCA report)
- Record & e-mail the minutes-of-meeting (MOM), for the decision/changes/steer proposed
by the review team
- Update the meeting KPIs in the RCA tracking sheet & escalate if the KPIs targets are not met
- Ensure the meeting outcome/changes are reflected in the report (taking the meeting
outcome back to the team & following up on the changes)

6.3. Quality review team:

- Selection of TA-2 for low impact incidents

- Ensure the root-causes & contributing factures are well captured (nothing missed), and are
supported by sufficient evidence for validation
- Ensure good quality of the proposed recommendations, being SMART (Specific, Measurable,
Achievable, Relevant and Time-bound)
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Doc. No.: P07-TSD-REL Rev: 01 Date: June 13, 2021 Page 4 of 7

- Discuss the lessons learned, where the RCA recommendations can be applied anywhere else
in the plant
- Decide whether to circulate/communicate an LFI for the incident or not
- Ensure the number of recommendations are kept as low as possible

6.4. RACI Matrix: R – Responsible; A – Accountable; C – Consulted; I – Informed

Rel./PSM/Engineering
/PES/AI Team Leaders

Engineering, PES &

Asset integrity lead
Operation lead
RCA Facilitator

Operation VP
RCA Leader

TSD leader
PSM lead
TA-2
Action

Ensure the meeting outcome/changes are reflected in the report C R I I I I A I I

Record/share the MOM, showing the decision/changes/steer R I I A I I I I I
proposed by the review team
Update the meeting KPIs in the RCA tracking sheet & escalate if R I I A I I I I I
the KPIs targets are not met
For low impact incident: Selection of TA-2 I I I I I R R I A
For high impact incident: Ensure the root-causes & contributing I I NA NA C R R C A
factures are well captured
For low impact incident: Ensure the root-causes & contributing I I C R C A A N N
Based Based
factures are well captured A A
on on
Incident Incident

For high impact incident: Ensure good quality of I I NA NA C R R C A

recommendations and lessons learned
For low impact incident: Ensure good quality of I I C R C A A N N
Based Based
recommendations and lessons learned A A
on on
Incident Incident

For high impact incident: Decide whether to publish an LFI or not I I NA NA C R R C A

For low impact incident: Decide whether to publish an LFI or not I I C R C A A N N
Based Based
A A
on on
Incident Incident
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Doc. No.: P07-TSD-REL Rev: 01 Date: June 13, 2021 Page 5 of 7

7. References:

7.1 05.04.01-Incident Investigation: Incident investigation procedure

8. Annexures:
N/A
 SOP for RCA Quality Review

Function: TSD Dept.: Engineering Section/Area: Reliability

Doc. No.: P07-TSD-REL Rev: 01 Date: June 13, 2021 Page 6 of 7

9. KPI sheet:

RCA quality review

No. of calendar
Date RCA Date of
days from
Started RCA
Incident Reliability RCA RCA Facilitation Risk RCA accepted Review team quality review
Site Unit Year Remarks (Kick-off Report
number Engineer Leader Title Status Rating /rejected attendance invitation until
Meeting Submitted
review team
Date) for quality
decision
Review

10. MOM template:

Change/Actions proposed by quality RCA quality review

review team
No. of calendar
1
Review days from quality
RCA
2 team review invitation
decision
attendance until review team
3 decision
accepted
4
/rejected

F01-P07-TSD-REL