PRODUCTION DELAYED - Apollo Root Cause Analysis

1 PRODUCTION DELAYED . Purpose: To prevent recurrence, not place blame. Report Date: 24-06-2015. Start Date: 01-07-2015. Report Number: 98-362B. I. Problem Definition What: PRODUCTION DELAYED When: Current Where: Granulation plant Significance: High Safety: Increased risk during purging process Environment: Occasional spillage of small volumes but contained Revenue: Est. $ pa Cost: $30k pa - labour and maintenance equipment hire Frequency: Continuous since installation in 2012. II. Report Summary The plant has been experiencing frequent delays in start up because of the ongoing seizure of the current motors in the plant. The decision was made to determine the causes of the problem by conducting an RCA process and to ensure 100% availability of the motors in future The Analysis revealed that PRODUCTION has been DELAYED frequently because of excessive maintenance time which requires the whole plant to be stopped.

2 The excessive maintenance is caused by the high frequency of drive failures when the pneumatic motors seize and fail to restart. They fail to restart because of corrosion which inhibits the movement of motor parts. This corrosion is caused by the entry of water and air which reacts with the motor component materials over time when the motors are idle. The water entry into the motors is caused by carryover from the receiver which has insufficient capacity and is both infrequently and incompletely purged. The purge duration and frequency have not been specified and the precise volume of water received and removed has not been determined. The following solutions have been proposed for immediate improvements but there will be more recommendations as the investigations continue and a higher level investigation is undertaken of the reasons why the purging process has never been specified.

3 This will necessitate the formation of a different team with appropriate expertise and authority. Page 1 of 3. III. Solutions Causes Solutions Solution Owner Due Date Install control instruments to measure Insufficient capacity of and allow purging to occur automatically Trevor Reeks 14-07-2015. receiver when reached a specified water volume Size of receiver Confirm the right size of receiver Roy Theboy 06-07-2015. Size of receiver Contact supplier for Technical Expertise Roy Theboy 06-07-2015. No standard pm checks done Create MSTs and standard daily PM daily Roy Theboy 10-07-2015. Minimal purging checks in Engineer to create and schedule PM. Ross Ebbels 12-07-2015. schedule checks IV. Team Members Name Email Member Info Roy Theboy Mechanical/Reliability Engineer Trevor Reeks Instrument Tech Vin Daloo Team Leader Instruments Ross Ebbels Team Leader Maintenance Mike Hunt Maintenance Fitter Angela Diamond Chemical Engineer V.

4 Notes 1. Realitychart Status: The Realitychart is in draft form and the Incident Report for the first stage of the investigation has been finalized. 2. Check the size and capacity of Motor and if applicable recommend change motor to hydraulic system 3. Some supposed causes have been purposefully left off the chart because there was contrary evidence. 4. Rules Check Status: Missing Causes Resolved. 5. Rules Check Status: Conjunctions Resolved. VI. References 1. RCA Team at 25-06-2015. 2. Occurring every time motor stops 3. Found when opening up of Motor 4. From pipe and pneumatic hose connected to motor 5. Occurs every time motors stops 6. Electricians and operators confirmIn time corrosion develops due to presence of water/air Page 2 of 3. Action BUILT TO.

5 PROVIDE Desired C. SUFFICIENT. Root Cause (C) CAPACITY TO. HOLD MOISTURE. SIZE OF. RECEIVER Condition PLANT AIR. PRESSURE Desired C. BUFFER. Root Cause (C). REQUIREMENT. INSUFFICIENT. CAPACITY OF Action RECEIVER New Prim PURGE STOPPED. TOO SOON. Action Condition RECEIVER NOT PURGE New Prim Action COMPLETELY REQUIREMENT. PURGED UNSPECIFIED. Condition WATER CARRY. CORROSION OVER EX. Condition INCREASES Desired Condition RECEIVER. VOL OF H2O NOT Investiga RESISTANCE/FRIC KNOWN. TION. Action Root Cause (A). WATER AIR NO STANDARD PM New Primary Effect MIXTURE ENTERS Action CHECKS DONE. Action PIPE LINE. RECEIVER. PNEUMATIC. PURGED Root Cause (C). MOTORS SEIZE. INFREQUENTLY MINIMAL PURGING. Condition CHECKS IN New Primary Effect PIPELINE SCHEDULE. Desired Condition Action CONNECTED TO.

6 Action DRIVES FAIL RECEIVER. CORROSION. Condition PRODUCT. ENTERS MOTOR PIPE CONNECTED Desired Condition TO MOTOR. Condition Action Desired Condition MOTORS PROVIDE Action EXCESSIVE DRIVE. WATER REACTS. MAINTENANCE New Primary Effect WITH MATERIALS. DONE Condition Other Cause Paths More Condition OF. HIGH FREQUENCY Productive CONSTRUCTION. CONTAMINANTS. Primary Effect IN WATER Condition Condition PRODUCTION MULTIPLE Lack Of Control DELAYED REGULAR Other Cause Paths More MATERIAL TYPES. MAINTENANCE Productive EXPOSED. LEVEL EXISTS. Condition MAINTENANCE Lack Of Control REQUIRES PLANT. STOPPAGE. Page 3 of 3.