Fault/Event Analysis

FAULT TREE ANALYSIS

Graphically displays a sequence of faults and causes leading to a hazardous event Uses Boolean logic with basic AND and OR gates

LOGIC symbols OR gate AND gate EVENT symbols Basic Event Combination Event Fault Event not required to be developed further

Reactor quench system example

QUENCH TANK L1 V-2

V-1 close button V-2 open button Temperature Alarm

Inlet

L2

T1

V-1

T2

REACTOR L3 Outlet

Reactor quench system

Highly unstable reaction carried out in Reactor is sensitive to small increases in temp. Hence quench system to control reaction. Reactor temp monitored by 2 independent sensors T1 and T2 Quench tank outlet valve V-2 activates automatically when T1 detects a certain increase in temp. Independently T2 activates alarm to alert operator for loss of control of reaction Operator should then press a button to close valve V-1 to stop reactor feed. On hearing alarm the operator is also instructed to press a button that opens V-2 in case T1 sensor failed to operate If either V2 opens or V1 closes the reactor enters a stable shut-down condition without damage to the system. Top event = Reactor damage due to high temp Analysis limited to equipment in diagram i.e. upstream and downstream of reactor not considered. Power failure, wiring or push button failures not taken into account. The normal state of V-1 is open and V-2 is closed.

Damage to Reactor due to High Temperature

No Flow in L1

Valve V-1 Remains open

Quench Tank Empty

Valve V-2 does Not Open

Valve V-1 Fails to Close

Operator Fails to Close Valve V-1

Valve V-2 Not Initiated

Valve V-2 Fails to Open

Operator Fails to Obey Alarm and Close V-1

Alarm Fails To Alert Operator

Operator Fails To initiate V-2

T1Fails to Initiate V-2 T1 Fails to detect Temp Rise

Alarm Fails off

Operator Fails to obey Alarm and Open V-2

Alarm Fails to Alert Operator

T2 Fails To detect Temp Rise

Alarm fails off

T2 Fails To detect Temp Rise

Fault tree analysis advantages

Graphical - Easy to follow Simple and logical overview of causes and initiating events - Particularly useful when you are considering a small number of major outcomes Extremely powerful tool that is capable of handling most combinations of events concentrates on multiple causes Good basis for quantification

Fault tree analysis limitations

Trees can grow rapidly Needs experience It is not a model of the causes of all possible system failures Can be time consuming It is not suitable for analysing time sequences of events such as batch processing

Developing a Fault Tree 1

Determine the Top Event, the occurrence which triggered the incident or accident, or might do so. Identify all the possible faults which might contribute to creating the Top Event Write the faults on cards or sticky notes Sort them into connected groups Arrange in logical sequences

Building fire Central London

Developing a Fault Tree 2

Example. Top Event is - Fire Sprinkler System did not operate Faults might be:
Water supply to system failed Heat detection system did not work Water pump did not start Sprinkler nozzles were blocked Smoke detectors did not function

Typical sprinkler nozzle

Typical smoke detector

Developing a Fault Tree 3

Group items together.
Water supply group contains:
Water supply to system failed Water pump did not start Sprinkler nozzles were blocked

Detection failure group contains:

Heat detection system did not work Smoke detectors did not function

Developing a Fault Tree 4

Fire Sprinkler system failed to operate Fire detection system failure Water supply to system failed

Smoke detectors failed

Heat detectors failed

Water pump did not start

Sprinkler nozzles blocked

Developing a Fault Tree 5

Fire Sprinkler system failed to operate Fire detection system failure Water supply to system failed

Smoke detectors failed

Heat detectors failed

Water pump did not start

Sprinkler nozzles blocked

Pump filter missing

Dirt in water

Developing a Fault Tree 6

Fire Sprinkler system failed to operate Fire detection system failure Water supply to system failed

Smoke detectors failed

Heat detectors failed

Water pump did not start

Sprinkler nozzles blocked

POSSIBLE MAINTENANCE FAILURES?

Pump filter missing

Dirt in water

Minimal Cut Sets

Cut Sets: A list of those failure events which will cause the top event to occur Minimal Cut Sets: A list of minimal, necessary and sufficient conditions for the occurrence of the top event.

Set Cuts example

Set cuts are 1,2,3 and 1,2,4, and 1,2,3&4. Minimal set cuts are 1,2,3 and 1,2,4.

EVENT TREE ANALYSIS

Graphically displays a sequence of possible consequences resulting from an undesirable event Uses Boolean logic but in opposite direction to Fault Trees, which usually work backwards to define the causes.

Event Tree example

Fire detection fails Gas detector fails Deluge fails Immediate ignition Delayed ignition Explosion? No No No No No Yes No Yes No No ESD fails

Yes Yes No Yes No Yes No Yes No Yes No No Yes No

Yes No Yes No

Release of flammable gas

Event Tree construction

Start with the initiating event Consider the impact of every credible operation and the positive or negative outcome Each outcome must be taken to its ultimate completion It may be possible to reduce the number of branches by combining those with the same outcome.

Event tree analysis advantages

Graphical - Easy to follow Simple and logical overview of events and consequences Extremely powerful tool that is capable of handling most combinations of events Good basis for quantification Potential single point failures and system weaknesses can be identified

Event tree analysis limitations

Trees can grow rapidly Partial outcomes are not modelled. Yes or No only Initiating events are considered singly Multiple trees are needed for multiple events It is not suitable for analysing time sequences of events such as batch processing

Event Tree example

ComparativeGasReleaseEvent Tree (courtesyCBISS)
GasRelease Immediate Ignition? Yes Vapour Cloud forms and ignites? Liquid rainout and ignition? Explosion occurs? Toxic Chemical? Jet Fire Yes Yes No No Yes No Yes No No Possible environmental impact ToxicExposure Pool Fire FlashFire Vapour Cloud Explosion Result

Terminal fire Australia