IsYourBusinessFiringonAllCylinders?

HowRootCauseAnalysison BigDiesels l Reveals l Radical d l Solutions

Abayomi Carmichael&PieterWessels BermudaElectricLightCo.Ltd

Reliability 2.0 Conference RCA Symposium 2010 April 20 - 22 Fort Lauderdale, Florida

TableofContents
BermudaandBELCO MaintenanceStrategyDevelopment RootCause(s) C ( )Philosophy hil h DefectEliminationTriggers TypicalCaseWorkflow RCAinPractice Conclusion

TheislandofBermuda
KeyinformationfromtheCIAWorldFactbook
Population: Totalarea: Highestpoint: Economicoverview: Electricity yuse: 67,837(July ( 2009estimate) ) 54km2 (13000acre) TownHillat76m(250ft) Bermudaenjoysthethirdhighestpercapita incomeintheworld. 628.3millionkWh

BermudaElectricLightCompany
MissionStatement
Toprovideasecure,reliableandsustainable electricpowersystemforthepeopleofBermuda

MajorAssets
Gasturbines(Peaking)
Unit GT3E GT3F GT4 GT5 OEM ALLISON ALLISON SOLAR ABB Type 501KB 501KB JUPITER GT35 Year installed 1995 1995 1989 1995 Rating (kW) ( ) 2,500 2,500 15,000 15,000 Speed (RPM) ( ) 1,200 1,200 3,600 3,600

BermudaElectricLightCompany
DieselEngines(baseload)
Unit D3 D8 D10 D14 D15 E1 E2 E3 E4 E5 E6 E7 E8 OEM Sulzer(Wrtsil) Sulzer(Wrtsil) Sulzer(Wrtsil) FairbanksMorse FairbanksMorse B&W(MANDiesel) B&W(MANDiesel) Sulzer (Wrtsil) (Wrtsil) ) Sulzer( MANDiesel MANDiesel MANDiesel MANDiesel Type ZV40/48 ZV40/48 ZV40/48 PC2V PC2V 8K67GSCA 8K67GSCA ZAV40S ZAV40S 48/60A 48/60A 48/60B 48/60B Year installed 1982 1979 1980 1995 1995 1984 1985 1989 1989 2000 2000 2005 2005 Rating Speed (kW) (RPM) 8,000 8,000 8,000 5,525 5 525 5,525 12,493 12,493 10,500 10,500 , 14,300 14,300 14,300 14,300 514 514 514 514 514 150 150 514 514 514 514 514 514 Stroke Cylinders 4 4 4 4 4 2 2 4 4 4 4 4 4 16 16 16 16 16 8 8 16 16 14 14 14 14

M i t Maintenance St Strategy t D Development l t

RCMbasedassessmentandoptimizationon+3500tasksdetailing: FailureModes AppropriateMitigatingTasks AppropriateIntervals OptimalTradetoexecute

Singlelineofresponsibility AllStrategiesCataloguedandManagedfromaSingleLocation PrioritizedDefectElimination

N Not tall lld deviations i ti canbe b investigated i ti t d BasedonParetoAnalysis,whereperformancedeviates,determine whyandfixit DefectEliminationlistreviewedannually

MaintenanceStrategyDevelopment ResultstoDate
CorrectiveWork

40 35 Sep09 30 25 20 15 Date Jul07 Dec07 Jun08 Jan09 Jun09

RootCause(s)Philosophy
Therearemany yRCAapproaches pp Thesignaturefeaturesembeddedinourchoiceare
Goalcentered CauseandEffect Visual Problem,Analysis,Solutionsteps Alwayslookatmultiplecauses Currentprocessisperfectforcurrentresults!

AgreedsolutionsbecomepartofMaintenance/Business Strategy

DefectEliminationTriggers2010
E1/2 JCWLeak C linderHeadLeak Cylinder ExhaustTemperature ExhaustBellows ExhaustValve Exhaust austLeak ea FuelLeaks BlowDownPipe Injectorissues E5/6 JCWIngresstoCyl CACooler Fuelsystemleaks SplashOil RockerGear LubeOilCooler FuelPump FuelRailClamps p Nutshelllines E3/4 Linerissues MainTransformer HTCWpressure FuelLeaks EngineDrivenLOPump Protective otect eRelay e ayTrip p Governor Nutshelllines EngineDrivenFOPump E7/8 BrokenHeadStud CylWaterLeak FuelPumps Nutshellpipe FuelInjector LubeOilPressure Transformertaps CACooler LubeOilSuctionFilter

TypicalCaseWorkFlow
ForcedOutage g onDElist FirstResponse/Oncallfitterfilloutbasicform/map REinvestigatesandaddsdetailassistedby
Fitter Foreman Engineer Planner Operator Buyer

Afterseveraliterations iterations,finalmapisagreed, agreed presentedto groupandagreedsolutionsendorsedbyVP SolutionimplementationmanagedviaIncidentManagement System

RCAinPractice
CauseMapping SolutionsProvided
FuelPumpSupplyPipeFailure ChargeAirCooler(CAC)TubeLeaks FuelPumpDriveDamage

DetailedCauseMap
TurbochargerFailure

CauseMapping
Startwiththeimpactoncompanygoals
SafetyGoal Impacted Availability GoalImpacted Materialand LaborGoal Impacted

Whatcausedit?
Solution Effect Cause

Heat AND Fuel

Fire

Evidence

AND

Continuetodigdeeper

Oxygen

E5FuelPumpSupplyPipeFailure

CauseMap
SafetyGoal Potentially Impacted d Unplanned emergency work required Cyclicload Availability Goal Impacted Engine unavailable for16 hours Forced outage g to repaira fuelleak Failureofa FOsupply pipeonthe engine Fatigue crackingof thesupply pipe Fracture surfaceand agradual failure mechanism Severeoil spillage AND Physical inspectionof allbrackets. Vibration Vibration Alargediesel engine. AND Ineffective pipesupport Poor conditionof thebrackets Alargediesel engine.

AND QC check sheets for PMto t inspectall brackets. Ineffective maintenance Outstanding workrequest andPMto inspect(4 timesinthe 15months).

Material andLabor Goal Impacted

Extensive repairsand cleanup

Environ E i mental Goal Impacted

Prolonged g exposure

Outsidethe scopeof fthi this presentation

Outstanding workrequest from15 monthsprior toincident.

CheckSheet BracketInspection

E8CACTubeLeak

CauseMap
SafetyGoal Potentially Impacted Metal ? Improve accessto procedure. QC new checksheet. Oxygen concentration cell Permissible ChloridesinCW <50ppm AND ActualChlorides inCW> 50ppm Tubesarenot brushed d i during refurbishment Observed during overhaul. NewRO plant. Chlorides in makeupwater >50ppm AND Forcedoutage toreplacea leakingCAC AND Material land d LaborGoal Impacted Morefrequent f CAC refurbishment Inadequate information availabletothe Fitter AND Supplierunable toprovide correctspares OEMspares referencesonly theentire assembly

Availability G lI Goal Impacted d

Excessivetube corrosion i

Electronflow

AND

Electrolyte (corrosive environment)

AND Incorrect materialsissued for refurbishment Observed during overhaul.

Electronic spares manual. Cooler manufactureis subcontracted

ElectronicSparesManual

DamagetoFuelOilPumpDrive

CauseMap
Thedesign ofthefuel pump p p Safety Goal Potentially Impacted Unplanned emergency work required Existing problems withFO pumps Various sources (known problem) Availability Goal Impacted RTS delayedby 7hours Pumpdrive was damaged OR Destructive test done withlow viscosity MDO. Specificto the inspection ofthedrive Actual:well below 12cSt Online viscosity measure ment and trending. Cavitation damageto pump elements OEM designnew pump elements. AND LowFO viscosity ? Permissible operating condition: 1214cSt Design inputFO: 120cSt(at 50C) Modifythe FOsupply systemto allowfor cooling. Systemis unableto reduceFO temp. Original power plantspec.

AND

AND

Material andLabor Goal Impacted

FOpump drive replaced

Oversight ofthe contractor Procedure not followed.

ActualFO procured: 60cSt(at 50C) Sample analysis reports.

TurbochargerFailure

CauseMap TurbochargerFailure
SafetyGoal I Impacted t d IncreasedRisk t Staff to St ff Onlinetip clearance monitor Onlinevibration Increase periodicvibration readings trendRPMon DCS oiltemp monitoring

ProductionGoal Impacted

Availability Target

Turbocharger SystemFailure Smoke,fire detector, noise, physical evidence

RHSTC failure inservice ABB inspection:

Bearingsfailure ABB inspection:

Bearingwear ABB inspection:

Matls/Labor Goal Impacted

Materials& Labourbudget

CauseMap TurbochargerFailure
BladeFouling OR nonstickcoated rings Nozzlering fouling OR

Bearingwear ABB inspection:

Bearingload increased Nutshellingnotdone

Restrictedgas flowthrough turbo

Airflow turbineside

Casingfouling

CauseMap TurbochargerFailure
upgradetononstick coatedblades Particulate buildupon blades Particulate buildup operationsforeman toformallyverifythis isdone educateoperations onimportanceofthis work

Redesign (Venturi suggested) Nutshelling system unreliable Operatorreports

uselower volumeover longertime Nutshelling pipesblock Operatorreports

OR upgradetonon stickcoatedcasing Particulate buildupon casing

Nutshellingnot done Systemoutofservice

CauseMap TurbochargerFailure
Amountin

AND

Redesigna systemthat doesntusedCA Compressed Airused Nushellsclump together observation Compressed AirQuality AND Designrequires compressedair

Amountout

Compressed AirQualitylow observation

Compressed AirWater moisturelevel

CauseMap TurbochargerFailure
ReviewMaintenance Strategy,failure modes PM effectiveness AutoDrainnot performing

Comp.Air BottleDrainage

AND Reviewsupervision, documentationof workperformed Manual l drainingnot performing

ServiceInterval

Design

CauseMap TurbochargerFailure
Installpilotline ReviewSpecification Procedures

Design

Willnotdryair sufficiently

Pilotline missing

Pilotlinenever installed

CauseMap TurbochargerFailure

Summary
MaintenanceStrategyDevelopment RootCause(s)Philosophy Defect f Elimination li i i Triggers i TypicalCaseWorkflow RCAinPractice