某煉油廠在2016年進行大修時，除了例行檢修保養之外，還必須汰換一項特殊巨型關鍵性設備，使得當年工作規模及工作複雜度均創下歷年之冠，然而因為該廠擔負國內台中以北油料供應責任，工廠大修工作仍然必須控制在72天內完成，俾能如期恢復煉油生產，滿足國內各項油品消費需求。
石化產業之特殊設備一般都是由國外擁有專利的知名廠商設計製造，並委託給具經驗之合作廠商施工、安裝，可是該煉油廠在尋求國外原廠提供專利製程技術訪價時並不順利，因此陷入一個兩難的僵局：一是繼續接洽原廠，可能會耽誤原已排定的大修計畫，導致停工時間過長，影響國內油料供應及公司績效。二是找國內優質廠商按原設計圖製造及安裝，除了要考慮技術上是否能勝任外，也必須在期限內取得原廠專利授權，才可找原廠以外的第三家廠商施工，否則可能會面臨侵權問題及法律訴訟，嚴重損害公司財務及國際形象。因此本個案運用情境規劃列舉所有可能決策情境，並以決策樹分析得出找國內優質廠商按圖製造及安裝的決策。
回顧過去該工廠的大修，從來沒有完成過更新類似特殊設備的經驗，而且國內也沒有曾獨立完成製造及安裝的承攬商，萬一大修過程中發生技術或管理能力不足，導致工安意外，造成人員或設備損傷，或是在大修時漏掉該維修的項目沒把設備修好，造成開工延誤、公安及環保事故，將會有龐大的財物損失。因此個案運用階層任務分析，列舉出完成大修專案所需進行的步驟，並借助失效模式與影響分析一一檢視每一個步驟的功能、失效模式、可能影響、發生失效可能根本原因、當前控制措施，再決定行動措施，可降低或避免維修的風險。最後運用第五項修練的系統分析模式，重新檢視本次大修過程維修的決策與執行過程，以幫助煉油廠結合理論與實務，發展日後進行重大決策選出並順利完成任務的典範，建立持續改善、精益求精的學習型組織文化。

An oil refinery had a turnaround in 2016, because in addition to routine maintenance, but also must be replaced by a special giant key equipment, making the scale and complexity of work were the highest than before, but the factory overhaul work must still be controlled within 72 days to complete, in order to be able to resume production of oil refining to meet the domestic consumption of oil demand.
The special equipment of the petrochemical industry is generally designed and manufactured by foreign manufacturers then constructed and installed in collaboration with experienced global companies. However, the process of contacting the original manufacturer for helping with factory overhaul was not smooth. Thus, the refinery was trapped in a dilemma either to continue contacting the original manufacturer but may delay the scheduled overhaul plan, resulting in longer than expected downtime; or on the other hand, the refinery may find domestic manufacturers to perform installation according to the original design. Then obtaining the original patent license from the original manufacturer must proceed before seeking domestic manufacturer with technical competence to avoid technical infringement and other legal issues which may result in possible loss of corporate property and international reputation. The use of scenario planning and decision tree analysis can lead to a reasonable decision outcome of seeking domestic manufacturer.
In the past, the factory had never accomplished similar special equipment renewal project, and no domestic contractor had any experience in this overhaul project. Without appropriate technical and management capacity, accidents could happen and result in personnel or equipment damage, or the equipment may not be repaired completely and caused serious delays, public security, environmental crisis, or possible huge loss of property. The use of hierarchical task analysis which illustrated necessary steps to perform overhaul projects followed by failure mode and impact analysis to illustrate function, potential failure mode, severity and possible causes associated with each perform step can reduce the risk in performing the overhaul task. Finally, the overhaul decision making and execution process was examined by the systems thinking approach to help the refinery develop best practice for the future refinery operations as part of continuous improvement to organizational learning.

1. 范振誠等(2016)，2016石化產業年鑑，工研院產業經濟與趨勢研究中心
2. 郭進隆、齊若蘭譯(2010)，第五項修練，天下文化，譯自Peter M. Senge(2006),” The Fifth Discipline: The Art & Practice of The Learning Organization “,Random House ,Inc
3. 陳信宏譯(2015)，雙贏談判術，天下文化，譯自Lawrence Susskind (2014),” Good for You, Great for Me: Finding the Trading Zone and Winning at Win-Win Negotiation”,Publicaffairs,
4. 張順教(2016)，賽局與談判，財經傳訊
5. 李國光(2015)，策略知識管理教材，online,avilable：http://www.gwoguang.byethost6.com/SKMWEB/01策略知識管理_展開.html?i=1
6. MBA智庫百科，FMEA管理模式，online,avilable：http://wiki.mbalib.com/zh-tw/FMEA
7. 維基百科，失效模式與影響分析，online,avilable：https://zh.wikipedia.org/wiki/失效模式與影響分析
8. MBA智庫百科，決策樹，online,avilable：http://wiki.mbalib.com/zh-tw/決策樹
9. Chi, C.-F., Tseng, L.-K., Jang, Y. ,2012. Prune a decision tree of selecting computer-related assistive devices for the disable user, IEEE Transactions on Neural Systems & Rehabilitation Engineering ,20(4),564-573.
10. John Annett (2005),” Hierarchical Task Analysis(HTA)”, Handbook of Human Factors and Ergonomics Methods, Chapter 33, CRC Press LLC
11. Neville A. Stanton (2006),” Hierarchical Task Analysis: Developments, Applications and Extensions”, Applied Ergonomics, Volume 37, Issue 1, Elsevier Ltd, pp.1-110.
12. D.H. Stamatis (2003)” Failure Mode and Effect Analysis-FMEA from Theory to Execution”, Second Edition, ASQ QUALITY PRESS
13. Paul J. Schoemaker(1995),”Scenario Planning: A Tool for Strategic Thinking”, MIT Sloan Management Review, Winter 1995,Volume 36,Issue 2, online,avilable：http://sloanreview.mit.edu/article/scenario-planning-a-tool-for-strategic-thinking/
14. John F. Magee(1964),“Decision Trees for Decision Making”, Harvard Business Review, The July 1964 Issue , online,avilable：https://hbr.org/1964/07/decision-trees-for-decision-making
15. James Manktelow(2017),Decision Trees :Choosing by Projecting "Expected Outcomes” , online,avilable：https://mindtools.com
16. Ross Dawson(2012), Scenario Planning in Action,online,available：http://rossdawson.com/frameworks/scenario-planning-in-action
17. Department of The Army (2006) Technical Manual 5-698-4 Failure Modes, Effects and Criticality Analysis (FMECA) For Command, Control, communications, computer, intelligence, surveillance, and reconnaissance (C4ISR) facility.