Incident investigation with root cause analyse

In this study, work related incident investigation of work related incident with Root Cause Analyze Method by gathering evidences, interview with related personnel and finding the root causes of incident was analyzed. Root Causes Analyze Method was applied to an process incident at pump station of Botas International Limited, the authorized operator of Baku Tbilisi Ceyhan Crude Oil Pipeline, Turkey Section, in Erzurum. At the end of the analyze, recommendations were produced for the company management to avoid recurrences of same or similar incidents. Root Cause Analyse is not known so much in our country and not used due to this reason. As a result of investigation of the incident with this technique, the malfunction of UPS cart system and shutdown of communication system was found as the critical factor. As immediate cause the system was not redundant and was not foreseen in HAZOP study. Also the operation unit was not informed about the HAZOP. It was emphasized that the planning, construction and operation of these kind of plants shall be considered in total and communication to be provided between all units. Root Cause Analyze shall be used in the training of safety personnel in order to provide a different approach and technique. This study was planed and executed as there was no similar study in our country.