2019 Human Performance, Root Cause, & Trending (HPRCT) Conference
June 17-21, 2019
Cheyenne Mountain Resort
Colorado Springs, Colorado
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Thursday, June 20 • 3:00pm - 3:50pm
RCA of a Business Loss due to Contaiminated Raw Material

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Contaminated raw materials in a manufacturing process will often result in significant financial loss.  Off-specification finished products cannot meet the needs of customers, and in some cases, inadvertent reactivity between materials may ultimately lead to loss of containment.    In this case study, contaminated bulk raw material arrives at a manufacturing plant and is introduced to a storage tank and processing equipment.  Upon discovery, a flawed original investigation points to unspecified sources of cross-contamination at a loading terminal.  After a recurrence, the root causes are much deeper within the supply chain.  Multiple “touch points” for the raw material, blending procedures, non-dedicated equipment, and analytical procedures are all found to be causal factors in this complex problem.  After using  a cause and effect methodology to identify and chart all activities, behaviors, and conditions for a series of causal events, the manufacturing team generated a list of solutions to recommend new administrative and engineering controls.  In the end, the controls needed to assure a supply of material within the needed specification range were too onerous for the supplier, and the manufacturing customer chose to replace the supplier.

avatar for Dana Walker Blair

Dana Walker Blair

Manager of EHSS, W.R.Grace
Dana is a Manager of Environmental, Health, Safety and Security for W.R. Grace.  She holds a BS in Chemical Engineering from N.C. State University, and a certificate in Process Safety Practice from Texas A&M.  With over 25 years of experience in chemicals manufacturing, Dana has... Read More →

Thursday June 20, 2019 3:00pm - 3:50pm MDT
White River II

Attendees (2)