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Root Cause Failure Analysis Report

K-23252 blower trip on 7th June 2016

2014 PETROLIAM NASIONAL BERHAD (PETRONAS)


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Petroliam Nasional Berhad (PETRONAS) 2014

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

Petroliam Nasional Berhad (PETRONAS) 2014

Investigation Team Members


Investigation Team Members

Internal

M Fadzlee B Samsubaha

Leader

Rotary

M Khairol Anuar B Ramli

Member

Rotary

Nur Anis Bt Ramle

Member

AMT2 Elect.

M Izzudin B Zainal Rosli

Member

OPR

Baharom B A Hadi

Member

OPR

Noraziana Bt A Hamid

Member

TSD

Aimi Yusri B A Kudus

Resource Person

Principal Eng. Elect


(Generation)

Mukhriz B Badarudin

Resource Person

AMT2 Mech Supervisor

M Naqiuddin B M Azizuddin

Resource Person

OPR

M Emran B Ismail

Resource Person

OPR

Petroliam Nasional Berhad (PETRONAS) 2014

Background
Problem Statement

K-23252 tripped due motor overload on 7th June 2016 during


start up activity after verify motor solo run.

Due to unavailability of K-23252, this had resulted in U23 reduce


throughput to 30MB for 3 days.

Internal

Estimated ULPO : USD 270k

Petroliam Nasional Berhad (PETRONAS) 2014

Equipment Description -1

Internal

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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

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P&ID

Internal

Petroliam Nasional Berhad (PETRONAS) 2014

Cross Sectional Drawing


Input shaft
Upper ball
bearing
(Polyamide Cage)

Gear
Box

Intermediat
e shaft

Lower ball
bearing (Steel
Cage)

Output shaft

Blower

Internal

Petroliam Nasional Berhad (PETRONAS) 2014

Sequence of Event
30 May

7 June
0900hrs

7 June
1000hrs

7 June
2300hrs

7 June
2350hrs

Internal

Blower reported abnormal sound.


CBM verified and abnormal sound was observed at motor side(minor). Highest vibration at M2A=2.6mm/sec.
CBM recommend blower to continue running and AMT to do greasing at motor.

AMT done greasing at motor


Abnormal sound disappear and no abnormalities observed at motor.

Blower reported abnormal sound.


CBM verified and abnormal sound was observed at motor side(minor). Coupling condition i.e membrane observed in good
condition (using strobe light). Highest vibration at M2V = 3.9 mm/sec RMS, M2A = 3.8 mm/sec RMS.
CBM recommended to do motor solo run.

Motor solo run


CBM & AMT2 tech found one of coupling spacers bolt missing during uncouple activity.
Motor solo run was proceed. CBM verified and no abnormalities found. Highest vibration at M1V = 1.82 mm/sec RMS.
Running amp = 4 vs 19.3 (FLC). Both blower and motor hand rotate okay
AMT reinstate the missing bolt and couple back for blower test run.

Blower test run


Blower in line up condition and FO start priming lube oil system until lube oil pressure establish then blower
started.
Blower trip after test run (15 second) due to motor overload. Motor solo run done and no abnormalities.
Blower gear box shaft found jammed.
CBM recommended to do gear box internal inspection.

Petroliam Nasional Berhad (PETRONAS) 2014

Facts & Finding Internal inspection

Upper intermediate shaft bearing


damage
Bearing cage broken. Breakage
pattern indicated fatigue crack.

Upper intermediate
shaft gear teeth
damage
Ball bearing stuck at
gear teeth
Internal

Petroliam Nasional Berhad (PETRONAS) 2014

10

Bearing Temperature Trend


Bearing temperature at normal condition before trip.
Nov-Dec
TA 2016

Internal

Petroliam Nasional Berhad (PETRONAS) 2014

7th June
Trip

11

Vibration Monitoring Trend


Vibration monitoring was last taken on 9th May 2016 (monthly
basis for ECA 2 equip.).
Overall vibration at good condition (<4.5mm/s).
No detected symptom of bearing and gear defect.

Highest vibration at gear box vertical, G3V = 1.297 mm/s RMS

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

Main work center

11/25/2015

PSR-2 TA15/16 KM-23252 : Motor overhaul

CONTR

11/23/2015

PSR-2 TA15/16 K-23252 : PM and lube oil


change out

CONTR

7/1/2011

TA2:PM on lube oil (auxiliary) system

CONTR

11/9/2010

To check for suspicious reading PZ-937

6/18/2008

SD/JUNE08:K23252 PPM & lube oil change


out

MECH2

4/1/2008

PSR2 TA2009 K-23252 Insp & service

CRG-M

3/6/2006

BOC-lube oil level low-to top up

MECH2

1/1/2006

Rectify Seal leak

MECH2

1/24/2005

To check blower casing hot

MECH2

Petroliam Nasional Berhad (PETRONAS) 2014

INST2

13

6-monthly PM (C2 equip.)

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

Petroliam Nasional Berhad (PETRONAS) 2014

14

Root Cause Failure Analysis


(5 WHYs-summary)

Top
Even
t

CONTRIBUTORY
CAUSES

Lack of lubrication due


to wrong sequence
steps in line up of
suction & discharge
valve and AOP
High torque &
accelerated shaft
movement during
blower start up
accelerated bearing
damage

Internal

ULPO RM XXX
ULPO RM XXX
K-23252 Blower trip due to motor overload
K-23252 Blower trip due to motor overload

Blowers gear box jammed


Blowers gear box jammed

FAILURE
CONSEQUENCE
FAILURE
MODE

FAILURE
MECHANISM

Gear boxs bearing damage


Gear boxs bearing damage

TAC

Irregular shaft movement


Irregular shaft movement

TAC

Unbalance
Unbalance

TAC

Inadequate coupling installation


Inadequate coupling installation

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

Isolating Dominant Cause(s) from Contributory Cause(s)


Kepner Tregoe approach
Underlying Cause

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)

Sequence steps not in


order for line up of
suction/discharge
valve & AOP
Internal

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.

Lubrication will be adequate to


The sequence step is in
the bearing. Hence, the blower
order to start AOP first
bearing will not experience
before lining up the
damage.
Petroliam
Nasional Berhad (PETRONAS) 2014
suction/discharge
valve
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

To enhance QAQC handover certificate for


coupling and motor reinstallation.

Ineffective
condition
monitoring
program on
sundyne blowers
gear box

Ineffective blower
PM execution
program (single
running & window
bases)

To comply with PM program.

Internal

Action
Party

Deadline

TP
Electrical

Aug 2016

1) To upgrade upper intermediate bearing from


polyamide cage to steel cage as per OEM
recommendation (Refer to Field Engineering
Bulletin) & to comply with PTS 12.11.02

TP Rotating

PSR-2 TA
2019

2) To install magnetic base on gearbox casing


for accurate vibration reading.

TP Rotating

Aug 2016

Petroliam Nasional Berhad (PETRONAS) 2014

AMT 2
manager

Immediatel
y

21

Recommendations-2
Action Party

Deadline

To develop specific OPP (for Sundyne Blower)


together with engineering discipline / vendor
to ensure comprehensive review to avoid
potential equipment failure in the future.

SM Area 2 &
TP
Engineering
Discipline

Aug 2016

To provide Sundyne Blower operation


awareness sign board at site (Visual
management).

TP Rotating

Aug 2016

To do ECA review based on current impact on


unavailability of the equipment.

SM Area 2

Aug 2016

To replace the passing inlet isolation valve

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

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22

Thank you

Internal

Petroliam Nasional Berhad (PETRONAS) 2014

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