LOST PRODUCTION

Purpose: To prevent recurrence, not place blame.

Report Date: 12-12-2013

Start Date: 03-12-2013
Report Number: NC23-0351

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.

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III. Solutions
Causes Solutions Solution Owner Due Date

Water pressure fell Install uprated pump to

Phil Sager 03-02-2014
below 25 psi ensure supply

Increase inspections of
Blockage not identified Stirling Maus 25-12-2013
screens to weekly

Lubricant supply Double capacity of lube

Nando Alonso 14-02-2014
exhausted supply

Lubricant supply Schedule weekly

Stirling Mice 25-12-2013
exhausted inspections of supply

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

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 Condition

LUBRICANT Desired Condition

PREVENTS WEAR
Action
Condition
EXCESSIVE WEAR
OCCURRED IN SINGLE POINT ORIGINAL DESIGN
END COVER LUBE INJECTION
SYSTEM
Root Cause (A) Root Cause (A)
Condition
WET END LUBRICANT
HIGH INJECTION Desired Condition
LABYRINTH WORN SUPPLY
EXHAUSTED FREQUENCY
Condition Action
Action
COVER PROVIDES Desired Condition SUPPLY NOT New Primary Effect
GLAND WATER
PROTECTION REPLENISHED
ENTERED

Action Condition

BEARING GREASE LABYRINTH SEAL Desired Condition

WASHED OUT PREVENTS Condition
WATER ENTRY 25 PSI IS MINIMUM Desired Condition
Root Cause (A)
REQUIREMENT
Condition

SYSTEM Desired Condition WATER

PRESSURISED PRESSURE FELL Action
BELOW 25 PSI OTHER
Action Action New Primary Effect
PRODUCTION
Condition
METAL TO METAL SELF-CLEANING REQUIREMENTS
CONTACT SYSTEM FAILED PREVAILED
FEED PUMP Desired Condition
REQUIRED FOR Action Condition
PROCESS Lack Of Control
LUBRICANT MIN PRESSURE IS
Primary Effect
Action CONTAMINATED 25 PSI
WET END Condition
LOST
BEARING SEIZED Condition
Other Cause Paths More
PRODUCTION CLEANING
LUBRICANT INHIBITS Productive
FAILURE CONTAMINATION
Action
Condition
COARSE FEED
Condition
PUMP STOPPED Desired Condition CONTAMINANTS Other Cause Paths More
PUMP ROTATING COMPROMISE Productive
Condition PERFORMANCE

BEARING Desired Condition

PERMITS
ROTATION

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