Anyone who has been through an in-depth PSM/RMP audit realizes that a single finding can have far-reaching impacts and causes. This means that the finding may need more than “fixing”; it may need to be investigated. What do I mean? Here is an excellent example…
One finding that we see regularly is what I learned to call “short threading.” This is the case where someone used to short a bolt, such that the bolt does not thread fully through the nut or the closure was not tightened/torqued appropriately. This is an ASME Section VIII and ASME B31 issue, as BOTH of these RAGAGEPs call for full engagement of the bolt and nut.
During a 2016 audit, we encountered a flange on an unloading line that did not meet ASME B31 as it was not flush, about half the bolts did not provide full engagement, and others were merely hand tight/loose. This finding was corrected immediately by the facility, and at the audit close-out meeting, the facility requested the item be removed from the report.
This led to a great discussion about how PSM/RMP audit findings should be addressed. Merely having a maintenance person go out and correct this flange issue is NOT a “system fix.” As we discussed the finding, it was evident a couple of managers took issue with the finding (more so that we found it – not that it was present in the process). As we debated the finding’s legitimacy, more information told us (the auditors) that this was more serious than a “flange issue.”
The maintenance manager admitted knowing when that gasket was changed and who changed it due to a minor leak of the HHC during a recent unload. No maintenance personnel were available then, and the truck needed to be unloaded ASAP. So, a gasket was given to the two workers who “unload trucks” to replace the gasket and continue with the unloading. They did their best, and the result was a single audit finding… until our closeout discussion.
In essence, this single finding was found to have been caused by several other process safety failures:
- personnel doing the work were not trained in the skills to do the work (e.g., neither worker knew even how to tighten a flange, or that a torque wrench was required, etc.)
- personnel doing the work were not trained on the maintenance procedure or the line break procedure necessary to do this work safely
- the same personnel who did the inadequate work were those who walked down the line before each “truck unload” and could not recognize their work as sub-standard, even though the flange leaked on almost every unload since they replaced the gasket. Their solution is to keep tightening the bolts to stop the leak (another severe training deficiency)
- not to mention that they got the gasket from the maintenance manager, who knew these two were not trained to do the work.
So, as you can see, a simple PSM/RMP audit finding needs to be investigated so that a proper closure plan can be developed and managed to ensure that everyone follows the procedures!
NOTE: Some will blame the maintenance manager for providing the gasket and “suggesting” the two untrained workers do the work. Yet both workers knew they were not trained or equipped to do the work but chose to use the maintenance manager as their “get out of jail free card.” Everyone was focused on unloading the truck so as not to impact production, so what would you claim as the root cause and contributing factors?
I told you that some PSM/RMP findings may entail an investigation. All of this is from a simple (yet profound) finding.