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Table of Content
1. Investigation Team Members
2. Background
3. Sequence of Event
4. Facts and Findings
5. Root Cause Failure Analysis (5 WHYs)
6. Recommendation Actions
Internal
Internal
M Fadzlee B Samsubaha
Leader
Rotary
Member
Rotary
Member
AMT2 Elect.
Member
OPR
Baharom B A Hadi
Member
OPR
Noraziana Bt A Hamid
Member
TSD
Resource Person
Mukhriz B Badarudin
Resource Person
M Naqiuddin B M Azizuddin
Resource Person
OPR
M Emran B Ismail
Resource Person
OPR
Background
Problem Statement
Internal
Equipment Description -1
Internal
Equipment Description-2
Equipment Details
ECA
:2
Service
: Lift Gas Blower
Equipment type
: Centrifugal Blower-OH6
Running Philosophy : N+0
Equipment Mfg : Sundyne
Equipment Model
: LMC 311
Seal Details
Seal Type
: Single seal (Gas Seal)
Operating Parameters
Product
: Nitrogen (N2)
Product Temp : 61 degC
Suction Press. : 5.7 kgf/cm2
Discharge Press.
: 6.6 kgf/cm2
Input speed
: 2920 RPM
Output speed
: 18779 RPM
Gear box lube oil
: ATF-D
Internal
P&ID
Internal
Gear
Box
Intermediat
e shaft
Lower ball
bearing (Steel
Cage)
Output shaft
Blower
Internal
Sequence of Event
30 May
7 June
0900hrs
7 June
1000hrs
7 June
2300hrs
7 June
2350hrs
Internal
Upper intermediate
shaft gear teeth
damage
Ball bearing stuck at
gear teeth
Internal
10
Internal
7th June
Trip
11
Internal
GMF
** NOTE:
Polyamide cage failures are almost completely undetectable using
a walk around vibration monitoring program. Polyamide is
relatively soft and acts as cushion and impact between rolling
elements and bits of breaking up cage do not transmit to the
bearing casing.
Once defect initiated, polyamide cage failure accelerated quite
quickly.
Petroliam Nasional Berhad (PETRONAS) 2014
12
Maintenance History
No.
Internal
Date
Description
11/25/2015
CONTR
11/23/2015
CONTR
7/1/2011
CONTR
11/9/2010
6/18/2008
MECH2
4/1/2008
CRG-M
3/6/2006
MECH2
1/1/2006
MECH2
1/24/2005
MECH2
INST2
13
No.
1
2
3
4
5
6
7
8
9
10
Internal
Basic start
date
3/8/2016
9/8/2015
3/8/2015
9/8/2014
3/8/2014
9/26/2013
9/8/2013
3/26/2013
3/8/2013
8/2/2012
Description
6
6
6
6
6
6
6
6
6
6
MONTHLY
MONTHLY
MONTHLY
MONTHLY
MONTHLY
MONTHLY
MONTHLY
MONTHLY
MONTHLY
MONTHLY
PM
PM
PM
PM
PM
PM
PM
PM
PM
PM
FOR
FOR
FOR
FOR
FOR
FOR
FOR
FOR
FOR
FOR
BLOWER
BLOWER
BLOWER
BLOWER
BLOWER
BLOWER
BLOWER
BLOWER
BLOWER
BLOWER
Main work
center
MECH2
MECH2
MECH2
MECH2
MECH2
MECH2
MECH2
MECH2
MECH2
MECH2
14
Top
Even
t
CONTRIBUTORY
CAUSES
Internal
ULPO RM XXX
ULPO RM XXX
K-23252 Blower trip due to motor overload
K-23252 Blower trip due to motor overload
FAILURE
CONSEQUENCE
FAILURE
MODE
FAILURE
MECHANISM
TAC
TAC
Unbalance
Unbalance
TAC
TAC
Inadequate
Ineffective
Ineffective blower
Inadequate
Ineffective
QAQC program
condition
Ineffective
blower
PM execution
QAQC
program
condition
on coupling
and
monitoring
PM
execution
program
(single
on coupling
and
monitoring
motor reprogram
program
(single
running & window
motor
reprogram
UNDERLYING
installation
*Failure
runningbased)
& window
CAUSE
installation
*Failure
*Failure related
related to
based)
*Failure related to
*Failure
related related to
to Maintenance
Maintenance
- *Failure
related toMaintenance
to Maintenance
Maintenance
5
quality quality Maintenance
Inadequate
PPM
quality
quality
assurance
assurance
Petroliam Nasional Berhad
(PETRONAS) 2014
Inadequate PPM
assurance
why
15
Inadequate QAQC
program on coupling
and motor reinstallation
Ineffective condition
monitoring program on
sundyne blowers
gearbox
Ineffective blower PM
execution program
(single running &
window bases)
What will
happen if.
Adequate QAQC program on
coupling and motor
reinstallation was performed
and verified prior handover
to operation.
Effective condition
monitoring program was
performed on blowers
gearbox
Effective blower PM
execution program (single
running & window bases)
was perfomed
Potential outcome
Adequate installation of coupling
(i.e no missing bolt) which will
avoid source of unbalance.
Hence the blower bearing will
not experience damage.
Incident will not occur.
Effective condition monitoring
program result may allow
unbalance induced by the
missing bolt & bearing defect to
be detected earlier. Hence the
blower bearing will not
experience damage.
Incident will not occur.
Missing couplings spacer bolt
can be detected which will avoid
source of unbalance vibration.
Hence the blower bearing will
not experience damage.
Incident will not occur.
Conclusion
Dominant
Cause
(Root
Cause)
Dominant
Cause
(Root
Cause)
Dominant
Cause
(Root
Cause)
Contributing
Cause
(Root Cause
20
)
Recommendations-1
N
o
Underlying Cause
Action
Inadequate QAQC
program on
coupling and
motor reinstallation
Ineffective
condition
monitoring
program on
sundyne blowers
gear box
Ineffective blower
PM execution
program (single
running & window
bases)
Internal
Action
Party
Deadline
TP
Electrical
Aug 2016
TP Rotating
PSR-2 TA
2019
TP Rotating
Aug 2016
AMT 2
manager
Immediatel
y
21
Recommendations-2
Action Party
Deadline
SM Area 2 &
TP
Engineering
Discipline
Aug 2016
TP Rotating
Aug 2016
SM Area 2
Aug 2016
AMT
Manager
PSR-2 TA
2019
N
o
Contributing
Cause
Sequence steps
not in order for
line up of
suction/discharge
valve & AOP
Internal
Action
22
Thank you
Internal
23