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292089 rca report---mining-lost-production
- 1. Page 1 of 3 I. Problem Definition What: Lost Production When: December 18, 2013 Where: USA Facility: Central 3 System: Processor Significance: High Safety: Minimal impact – increased exposure to lifted loads and slippery conditions Environment: No Impact Revenue: Downtime 44 Hours Cost: $2.4M Frequency: First 1 II. Report Summary Lost production was caused by the CHP having to be shut down when the wet end bearing failed. This bearing failed because of metal-to-metal contact due to the bearing lubrication becoming ineffective because the grease was washed and contamination was present. The grease was washed out because the wet end labyrinth seal failed and allowed the entry of gland water. Excessive wear occurred in the end cover and the labyrinth seal because the lubricant supply ran out. The contamination was caused by the failure of the screen filtration system due to the self- cleaning system not operating and the subsequent blockage not being identified. The self- cleaning system failure was caused by the water pressure falling below the minimum because of demands on the water supply elsewhere on the site. This, in turn, was caused by new planned production arrangements and the limited capacity of the water storage. LOST PRODUCTION Purpose: To prevent recurrence, not place blame. Report Date: 12-12-2013 Start Date: 03-12-2013 Report Number: NC23-0351
- 2. Page 2 of 3 III. Solutions Causes Solutions Solution Owner Due Date Water pressure fell below 25 psi Install uprated pump to ensure supply Phil Sager 03-02-2014 Blockage not identified Increase inspections of screens to weekly Stirling Maus 25-12-2013 Lubricant supply exhausted Double capacity of lube supply Nando Alonso 14-02-2014 Lubricant supply exhausted Schedule weekly inspections of supply Stirling Mice 25-12-2013 IV. Team Members Name Email Member Info Phil Sager psage@somewhere.com Reliability Superintendent Roy Davies rdavies@somewhere.com Defect Elimination Officer Nando Alonso nalonso@somewhere.com Plant Mechanical Engineer Stirling Maus smaus@somewhere.com Plant Maintenance Supervisor Bryson Fittipaldi bfittipaldi@somewhere.com Condition Monitoring Co-ordinator Merv Shews mshews@somewhere.com Condition Monitoring Technician Les Gibston lgibson@everywhere.com Facilitator Reliability Engineer V. Notes 1. Realitychart Status: The Realitychart and Incident Report have been finalized. 2. Rules Check Status: Missing Causes Resolved. 3. Rules Check Status: Conjunctions Resolved. VI. References 1. Photo # 17 2. mining development plan at 23.01.2014 3. photo # 13
- 3. Page 3 of 3 Action METAL TO METAL CONTACT Condition HIGH INJECTION FREQUENCY Root Cause (A) LUBRICANT SUPPLY EXHAUSTED Action SELF-CLEANING SYSTEM FAILED Action METAL TO METAL CONTACT Primary Effect LOST PRODUCTION Action SELF-CLEANING SYSTEM FAILED Condition MIN PRESSURE IS 25 PSI Other Cause Paths More Productive ORIGINAL DESIGN Condition PUMP ROTATING Desired Condition Action BEARING GREASE WASHED OUT Desired Condition Root Cause (A) WATER PRESSURE FELL BELOW 25 PSI Desired Condition Condition MIN PRESSURE IS 25 PSI Condition FEED PUMP REQUIRED FOR PROCESS Other Cause Paths More Productive Condition CONTAMINANTS COMPROMISE PERFORMANCE Condition SINGLE POINT LUBE INJECTION SYSTEM Condition SYSTEM PRESSURISED Action BEARING GREASE WASHED OUT Action GLAND WATER ENTERED Action SUPPLY NOT REPLENISHED New Primary Effect Action WET END BEARING SEIZED Condition 25 PSI IS MINIMUM REQUIREMENT Condition BEARING PERMITS ROTATION Desired Condition Condition LUBRICANT PREVENTS WEAR Condition HIGH INJECTION FREQUENCY Root Cause (A) WET END LABYRINTH WORN Condition COVER PROVIDES PROTECTION Condition PUMP ROTATING Condition COVER PROVIDES PROTECTION Desired Condition New Primary Effect Action GLAND WATER ENTERED Condition CLEANING INHIBITS CONTAMINATION Action OTHER PRODUCTION REQUIREMENTS PREVAILED Action EXCESSIVE WEAR OCCURRED IN END COVER Lack Of Control Action SUPPLY NOT REPLENISHED Root Cause (A) WET END LABYRINTH WORN Condition LUBRICANT FAILURE Action LUBRICANT CONTAMINATED Action COARSE FEED PUMP STOPPED Desired Condition Desired Condition Condition LUBRICANT PREVENTS WEAR Action EXCESSIVE WEAR OCCURRED IN END COVER Root Cause (A) LUBRICANT SUPPLY EXHAUSTED Desired Condition Action OTHER PRODUCTION REQUIREMENTS PREVAILED Action WET END BEARING SEIZED Condition LABYRINTH SEAL PREVENTS WATER ENTRY Desired Condition Condition SINGLE POINT LUBE INJECTION SYSTEM Action LUBRICANT CONTAMINATEDPrimary Effect LOST PRODUCTION Condition LABYRINTH SEAL PREVENTS WATER ENTRY Condition FEED PUMP REQUIRED FOR PROCESS Condition CLEANING INHIBITS CONTAMINATION Condition 25 PSI IS MINIMUM REQUIREMENT Condition SYSTEM PRESSURISED Action COARSE FEED PUMP STOPPED Condition CONTAMINANTS COMPROMISE PERFORMANCE Condition LUBRICANT FAILURE Condition BEARING PERMITS ROTATION Root Cause (A) WATER PRESSURE FELL BELOW 25 PSI