Root Cause Analysis and Counter Measures

SBU/Dept
Leaching
Date and time of Occurance:
15/6/16 9.30pm
Date and time of restorance:
15/6/15 11.30pm
Problem Statement: NL01V003 motor to gearbox coupling pinbush failure

Section/Equipment
Total Equipment downtime (Hrs)
Total Plant downtime(Hrs)
Team Involved in Investigation: ( Strictly cross functional team )
Praveen,naveen
Name of contract employee involved:

Observation From Site: Nl3 agitator Pin bush found broken

Leaching/NL01V003
2hr

Company:SS

Action Taken for restoration: New pin bush provided

Why-Why Analysis

Problem

Why-1

Why-2

NL3 gearbox not running

NL3 motor gearbox coupling pin bush broken

Agitator running in high load

Why-2
Reactor online flushing not done
Root Cause: 1) Schedule online flushing of reactor not done

NL3 motor gearbox coupling pin bush broken

Why-1

Agitator running in high load

Why-2

Reactor online flushing not done

Why-3

Standby reactor was under maintenance

Root cause

Root cause identified? If yes, Tick the relevant cell

Man

Machine

Lack of operating skills

Lack of Maintenance skills
Negligence

Corrective action

Sl No
1

Preventive action

Due

Status

Reactor flushing to be schedule

PSIC

SMP

Drg

Horizontal Deployment Opportunities

To be check for NL2 and NL4 agitator

Done

By
PSIC

Relevent Document updated:( Tick wherever applicable) SOP

Horizontal Deployment Opportunity Exists ? If YES, pl mention the detail

Improper operation
Improper Adjustment

Shift Incharge

Tried to do online removing of solid through drain but not success

Sl No

Method

By

Pin bush replaced

Sl No
1

Material

Lack / Inadequate PMI schedule

Input material not meeting spec
Lack/ Inadequate CBM schedule
Poor Quality of spare
Design weakness
Aging of spares
Rusting/pitting
Rusting/pitting
Leakage
Corrective & Preventive Action Plan

Due

Status
Done

Shutdown/require standby tank

PMI checklist

Pending

MOC

By

Due

Status

Varun

25/7/2016

pending

ZR Notification No.: ( Mandetory )

Sign HOD

SBU Head

Sign Engg/Oprn Head

Sign AO Head

Root Cause Ana

SBU/Dept
Date and time of Occurance:
Date and time of restorance:
Problem Statement: NL01V003 motor to gearbox coupling pinbush failure

Observation From Site: Nl3 agitator Pin bush found broken

Problem

Why-1

NL3 gearbox not running

NL3 motor gearbox coupling pin bush broken

Why-2
Coupling gap was 4mm, instead of 2mm
Root Cause: 1) MOC of line

Root cause identi

Man

Lack of operating skills

Lack of Maintenance skills
Negligence

Lack / Inadequate PMI schedule

Lack/ Inadequate CBM schedule
Design weakness
Rusting/pitting
Leakage
Corrective

Corrective action

Sl No
1

Machine

Pin bush replaced

Preventive action

Sl No
1

Pin bush coupling gap to be maintainance training

Relevent Document updated:( Tick wherever applicable) SOP

Horizontal Deployment Opportunity Exists ? If YES, pl mention the detail

Sl No

Horizontal Deployment Opportunities

ZR Notification No.: ( Mandetory )

Sign HOD

SBU Head

SMP

Root Cause Analysis and Counter Measures

Leaching

gearbox coupling pinbush failure

bush found broken

Why-Why Analysis

pin bush broken

ad of 2mm

Root cause identified? If yes, Tick the relevant cell

Machine

Material

Lack / Inadequate PMI schedule

Input material not meeting spec
Lack/ Inadequate CBM schedule
Poor Quality of spare
Design weakness
Aging of spares
Rusting/pitting
Rusting/pitting
Leakage
Corrective & Preventive Action Plan

Corrective action

By
Shift Incharge

Preventive action

By

aintainance training

rever applicable) SOP

ists ? If YES, pl mention the detail

Varun.D

SMP

Drg

l Deployment Opportunities

PMI chec

By

Sign Engg/Oprn Head

Analysis and Counter Measures

Section/Equipment
Total Equipment downtime (Hrs)
Total Plant downtime(Hrs)
Team Involved in Investigation: ( Strictly cross functional team )
Varun.D
Name of contract employee involved:

Company:SS

Action Taken for restoration: New pin bush provided

Why-Why Analysis

NL3 motor gearbox coupling pin bush broken

Coupling gap was 4mm, instead of 2mm

Technician while installing coupling has not maintained proper gap

entified? If yes, Tick the relevant cell

Material

Input material not meeting spec

Poor Quality of spare
Aging of spares
Rusting/pitting

Method

Improper operation
Improper Adjustment

ctive & Preventive Action Plan

By
Shift Incharge

Due

By

Due

Varun.D

1/7/2016

Drg

gn Engg/Oprn Head

PMI checklist

By

MOC

Due

Sign AO Head

Leaching/NL01V003

Why-1

Why-2

Root cause

Status
Done

Status
Pending

Status

Sign AO Head