PT Notes
Amendments to EPA's RMP Rule - Root Cause Analysis
PT Notes is a series of topical technical notes on process safety provided periodically by Primatech for your benefit. Please feel free to provide feedback.
EPA has proposed several amendments relating to prevention program provisions. This PT Note addresses:
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EPA’s proposed requirement for all facilities with Program 2 and 3 processes to conduct a root cause analysis as part of an incident investigation for an RMP-reportable accident This includes requiring the root cause analysis to include specific elements, requiring the use of a recognized investigation method, and requiring that investigations are completed within 12 months.
Further details are provided below.
EPA notes that among facilities reporting accidents, facilities who reported one often have multiple accidents, indicating a failure to properly address circumstances leading to subsequent accidents. EPA believes these accidents may have been preventable if root cause analyses had been required. EPA believes multiple accidents result, in part, from a failure to thoroughly investigate and learn from prior accidents.
Although EPA cannot be certain that, in all cases, subsequent accidents are due to a failure to conduct a root cause analysis of an earlier incident, EPA found that 60 percent (42 out of 70) of the facilities with multiple accidents between 2016 and 2020 reported repeat causal factors within the same process. While this could be a failure to implement incident investigation findings or could be unrelated to the earlier incident, multiple accidents within the same process with the same causal factors indicate a likely failure to rectify prior failures and root causes of these incidents. EPA believes the occurrence of such subsequent incidents indicates an overall failure to identify and implement controls that may have prevented future incidents.
EPA notes that CSB investigations have found that root causes of prior, similar incidents were not identified and their omission contributed to subsequent incidents. EPA also notes that incident investigations following an accident often reveal multiple causal factors related to prevention program elements.
Root cause analysis identifies the underlying reasons an event was allowed to occur so that workable corrective actions can be implemented to help prevent recurrence of the event (or occurrence of similar events). Causes of incidents are commonly referred to as ''causal factors'', which are also known as contributing causes, contributory causes, contributing factors, or critical factors. Causal or contributing factors usually have underlying reasons for why they occurred, which are known as ''root causes.'' EPA is proposing to define ''root cause'' as a fundamental, underlying, system-related reason why an incident occurred.
EPA is proposing that Incident investigation reports must include factors that contributed to the incident including the initiating event, direct and indirect contributing factors, and root causes. Root causes must be determined by conducting an analysis for each incident using a recognized method (such as those documented by CCPS)
EPA has discovered situations where owners or operators of regulated facilities indefinitely delayed completing incident investigations. Thus, EPA is proposing to require that facility owners or operators complete an incident investigation report as soon as reasonably practicable, but no later than 12 months after an RMP-reportable accident. For very complex incident investigations that cannot be completed within 12 months, EPA is allowing an extension of time if the implementing agency (i.e., EPA and delegated authorities) approves the extension in writing. EPA believes that 12 months is long enough to complete most complex accident investigations but will allow facilities more time if they consult with their implementing agency and receive approval for an extension.
EPA expects that the proposed requirement to conduct a formal root cause analysis after an RMP-reportable accident will be helpful to ensure deficient prevention program areas are thoroughly investigated for the specific covered processes involved in the accident.
In the 2017 amendments rule, EPA considered, but elected not to finalize, a regulatory definition of ‘‘near miss’’ to identify incidents that require investigation to clarify incident investigation requirements. Adding the term ''near miss'' was not intended to expand the types of incidents required to be investigated, but rather, was intended as a clarification of incidents that may have reasonably resulted in a catastrophic release and were already required to be investigated.
EPA is not proposing a definition of ''near miss'' as part of this rulemaking. Nevertheless, it is soliciting comments on a potential definition of ''near miss'' that would address difficulties in identifying the variety of incidents that may occur at RMP facilities that could be near misses that should be investigated. Based on these comments, EPA may propose a definition of ''near miss” in a future rulemaking.
EPA is soliciting comments on the proposed amendments and has posed questions regarding them.
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