Another significant event was the power outage in 2003, which blacked out parts of New York, Ohio, and Pennsylvania. The congressional investigation focused heavily on the system failures from the overloading of the grid. They talked about weak infrastructure and an aging power grid.
However, the root cause of the system wide failure was not discussed. According to the investigation, deferred maintenance was the initial cause.
Several trees scheduled for trimming contacted power lines in Ohio, tripping the first substation. Why this occurred is not discussed, but new regulations were introduced just as fast as Congress could write them. Among them was a new requirement for tree trimming to a specific distance from the power line.
In March 2005, the Texas City, TX BP refinery experienced an explosion that was felt for miles. This particular event was responsible for the deaths of 15 people and injuries to another 180 people.
The explosion occurred during the startup of a raffinate tower after a maintenance shutdown. There were many factors in this case which contributed to the resulting explosion. Among them, operator fatigue, outdated standard instructions, and malfunctioning instruments among others.
This event also had a more obvious management connection. BP’s drive toward cost cutting had reduced head counts and forced the plant to rely heavily on contract labor. There had also been a halt put on any work efforts to update the process equipment. Much of the Texas City equipment had outlived its planned life cycle. This series of decisions and equipment health created the potential for a large disaster, and the worst-case scenario was realized.
The Reliability Connection
Maintenance is not a passive player in the events listed above. It was an integral part of each incident and contributed significantly to the outcome. A holistic reliability approach to the maintenance programs in each of these cases could have prevented their occurrence and outcomes.
The link lies in understanding the Codes of Federal Regulation (CFR). There are several common themes in CFR’s that a comprehensive reliability program will address and/or exceed.
21 CFR Part 211.67; FDA
Equipment cleaning and maintenance.
- (a) Equipment and utensils shall be cleaned, maintained, and sanitized at appropriate intervals to prevent malfunctions or contamination that would alter the safety, identity, strength, quality, or purity of the drug product beyond the official or other established requirements.
- (b) Written procedures shall be established and followed for cleaning and maintenance of equipment, including utensils, used in the manufacture, processing, packing, or holding of a drug product. These procedures shall include, but are not necessarily limited to, the following:
- (1) Assignment of responsibility for cleaning and maintaining equipment;
- (2) Maintenance and cleaning schedules, including, where appropriate, sanitizing schedules;
- (3) A description in sufficient detail of the methods, equipment, and materials used in cleaning and maintenance operations, and the methods of disassembling and reassembling equipment as necessary to assure proper cleaning and maintenance;
- (4) Removal or obliteration of previous batch identification;
- (5) Protection of clean equipment from contamination prior to use;
- (6) Inspection of equipment for cleanliness immediately before use.
- (c) Records shall be kept of maintenance, cleaning, sanitizing, and inspection as specified in 211.180 and 211.182
The example contained in the FDA code illustrates this reliability connection. Section (a) and (b) specifically instruct the company to identify responsibilities for maintenance and draft standard work procedures.
40 CFR Part 68.73; vessel mechanical integrity
- Written Procedures
- Training For Process Maintenance Activities
- Inspection and Testing
- Equipment Deficiencies (“Operator shall correct deficiencies…”)
- Quality Assurance (“Correct Materials, Correct Design, Proper installation.)
This EPA Regulation is specifically for vessel integrity. This is an example where industry specific codes are addressed through a comprehensive reliability program. Note, there are statements in the code requiring written procedures, training and corrective actions for equipment deficiencies.
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