Root Cause Failure Analysis Report (Bad Actor)

P-1809B V3SS Pump Mechanical seal leak on Jun

2015

AUGUST 2016

Prepared by:
Noorulhuda Binti Ismail

2015 PETROLIAM NASIONAL BERHAD (PETRONAS)

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Table of Content
1. Investigation Team Members
2. Problem Statement
3. Sequence of Events
4. Process Sequence of Event
5. Facts and Findings
6. Root Cause Failure Analysis (5 WHYs)
7. Recommendation Actions

Investigation Team Members

Investigation Team Members
Noorulhuda Binti Ismail

Team Leader

Engineer Area 2 & MG3

Nooratikah Bt Shaari

Facilitator

RMU Representative

M Khairol Anuar B Ramli

Team Member

Engineer Area 3

M Safwan B Atan

Team Member

Assistance Operation
Engineer Area 6

Kng Seng Kiat

Team Member

Assistance Operation
Engineer Area 6

M Fadzlee B Samsubaha

Resource Person

TP Rotating Area 2 & 6

Bazurim B Ibrahim

Resource Person

TTS

Nurulain Bt Baharuddin

Resource Person

Jawatan penuh

Isma'il B A Halim

Resource Person

Assistance Operation
Engineer Area 6

Naimah Bt Azizan

Resource Person

Inspection Area 6

Problem Statement
P-1809B V3SS Pump reported mechanical seal leak badly leaked
externally at 60 drops/minute and pressure at accumulator also
dropped on Jun 2015. Replace mechanical seal and maintenance
cost incurred USD 20,000.00 in 2015.
Last maintenance in August 2014

Sequences of Event (SOE)

Motor
overhaul &
alignment
by Elect
vendor

7.9.14

Rpt m/seal
leak(after
m/seal
flushing)
leak 60
m/seal
D/min.
leak 30
sealpot
D/min.
pressure= sealpot
10.77 vs pressure=
13
12.15 vs
kg/cm2 13 kg/cm2

20.5.15 21.5.15
Mech6
to do
seal
flushin
g

Leak 60
d/min
(100N)
Opr
topup
1x/shift.

26.5.1
5

M/seal badly
leak 60 d/m
and coupling
membrane
damage.
Sealpot
pressure
9.85 kg/cm2
Highest vib
at P2H =
15.14
mm/sec
RMS.

28.5.15

Motor
solo
run

Internal
inspection
, replace
m.seal,
coupling
membranc
e

8.6.15
2.6.15
Switch to A
and CRG to
replace
coupling
membrane
and replace
m/seal

Running
with
good
conditio
n.
Highest
vib at
P1H =
1.41
mm/sec
RMS

Motor
Overha
ul

9.6.15

16.6.15

No changes in
flow and pump
vibration

Mechanical Seal Drawing P-1809B

P-1809B fact & findings

No

Fact

Findings

References

Detail P-1809B parameter

Info

Detail

Detail M.seal drawing P-1809B

(Flowserve)

Info

Detail

Acceptable vibration below

4.5mm/s

Motor trending spectrum

High vibration at P2H = 15.14
mm/sec on 28.5.15

CBM

Mechanical seal inspection report

1. Inner SilCarb Face (rotate)

chipped OD and chipped at pin
slot
2. Outer bellow assy (static)
chipped at ID & OD
3. Setting plate dented at edge
4. Particle (coking) found at OD
outer seal
5. Secondary seal normal wear

Flowserve re
port

Central Repair Group (CRG)

inspection report

1. As found alignment out of

tolerance
2. Membrane coupling broken

CRG report

Flow trend from PI system

Flow trending from May-Jun 2015

Vs
Pump curve

PI system

M.Seal pressure trending

Info

PI system
8

Root Cause Failure Analysis (5 WHY)

Top Event

P1809B
m.seal
leak

Failure
Mechanis
m

High
vibration
at P2H =
15.14
mm/sec

Transactio
nal Active
Cause

Membrane
broken

Transactional
Active Cause

Misalignment

Transactio
nal Active
Cause

piping stress at
suction piping
(offset: +20mm; Gap: +16mm)
Inadequate
coupling
installation
after motor
maintenance

Underlying
Cause

Lack of
QA/QC during
construction

Lack of final
QC/QC after
motor
maintenance

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

Kepner Tregoe approach
Underlying
Cause
Lack of QA/QC
during
construction

Lack of final
QC/QC after
motor
maintenance

What will
happen if.

Potential outcome

Adequate QAQC program on piping

installation was performed and
verified prior handover to
commissioning

Piping stress will not occur will

not impact equipment alignment
Incident may or not happen
if piping stress has been
taken into account during
alignment correction

Motor vendors final alignment

result were verified by PP(M)SB final
acceptance criteria

Inadequate coupling installation

will not happen & misalignment
can be detected & corrected.
Hence, mech seal & membrane
coupling will not failed due to
misalignment.

Conclusion

Contributory
(Root
Cause)

Dominant
Cause
(Root
Cause)

Recommendations
N
o
1

Underlying cause
Lack of QA/QC
during
construction
Lack of final
QC/QC after
motor
maintenance

Recommendation Action

Action By

Date line

To verify all registered punch list

(piping to equipment) that yet to
be rectified & rectified in the
next TA

PESD

Next TA

Motor vendor should provide

final alignment result and
checklist during maintenance for
PP(M)SB final acceptance criteria

Electrical
/Rotary

Immediate

11

Thank You

12

V3SS Pump P-1809B

Equipment Details
ECA
:2
Service
: V3SS
Equipment type : Centrifugal Pump
Running Philosophy
: N+1
Equipment Mfg : SULZER PUMPS INDIA
LTD
Equipment Model : ZF150-4400
BEP Flow
: 344.9 m3/hr
Min flow (rated) : 79.7 m3/hr
Pumping temp
: 317.8 degreeC
Product
: Vacuum Distilate
Temperature : 385 degreeC
Shaft speed : 2970rpm
Specific gravity : 0.871
Running amp/FLC : 156A vs x (FLC)

M.Seal Plan
API Plan 02
API Plan 53M

13

Datasheet P-1809A/B

14

Detail Mechanical Seal P-1809A/B

15

To add trend after motor overhaul 17.9.2014!

Vibration trending at PM-1809B

14.5.1
5

22.5.15 pump & motor low

vibration

28.5.15 pump failed

1. Spectrum show bearing defect compress to low frequency earlier that 06 Feb 2015 (0.2mm/s) and 14.5.15
(1.1mm/s) until coupling membrane broken on 28 May 2015
2. On 2.6.15 Symptom of bearing defect found at motor side although overall vibration still low(stage 2).
Waveform shows sign of beating with truncated and rubbing of bearing impact. Gs amplitude is still

16

Flow trendingP-1809B

17

Performance curve P-1809B

Min flow
=79.9m3/h
r

Running
flow=170
m3/hr

BEP =
344.9
m3/hr

70-120% from
BEP

18

M.Seal pressure P-1809B

19