Terminated because:

Example RCA - Pump Seal Leak

Chart Key
N Pump handles regulated
T Transitory chemical Other causal paths more productive
N Non-Transitory END
T Transitory Omission

N Non-Transitory Omission

Undefined

Chart Quality Alert

Focal Point

Evidence Notes
Terminated because:
Solutions Tasks N Desire to be in
compliance with all Desired State
environmental regulations END

N Choose not to run with T Decision not to exceed

leaking seal allowable emissions

Terminated because:
N Desire to be good
environmental stewards Desired State
END

AND
OR

Terminated because:
N Leaking seal is safety N Pumped fluid is skin
hazard irritant Other causal paths more productive
END

N Single seal is relatively

inexpensive
Terminated because:
T Pump was running
Desired State
END
T Design choice by capital
project team

Terminated because:
T Project team needed to T Project team over-ran
Solutions save money budget New RCA needed
Terminated because: Modify capital project steps to have END
T Decision to repair pump N System under pressure reliability engineer provide list of key
P-105 Desired State design critieria for new equipment
END
Criteria Pass Status Identified

Terminated because: Terminated because:

N Fast track Project N Inexperienced project
Other causal paths more productive team Other causal paths more productive
END END
T Single seal ordered with
new pump

Terminated because:
N New pump did not receive T No one recognized the T Reliability group never

om
reliability review need provided feedback Other causal paths more productive
END

.c
Solutions
N Single mechanical seal on AND

ic
pump Modify capital project steps to include OR
R&M review

og
Criteria Pass Status Identified
N No information or N No reliability personnel T Capital projects group
knowledge to spec assigned to project team never asked
Solutions b anything different
?

ol
Replace single seal with double
mechanical seal a

.s
Criteria Pass Status Identified

w
Install seal-less pump
T Pump P-105 seal leaking

w
excessively Criteria Status Identified
Connects to: Terminated because:
Not confident that seal-less pump would T Pump not upgraded after N No design standards for N Reliability input not
installation this application required in project Other causal paths more productive

w
be able to handle the large solids

20 hours of production
present
c No one recognized the need
? guiidelines END

outage (Pump seal

replacement)

Terminated because:
N Production can't run
without P-105 Other causal paths more productive
END Connects to:
N Conventional stuffing box
installed
a No information or knowledge to spec anything different
Terminated because:
T Seal Improperly
installed? Other causal paths more productive
END
Solutions
Replace conventional stuffing box with
N 1 hour to LOTO taper bore stuffing box

Criteria Pass Status Selected

T Solids not flushed away

N 1 hr for LEO and Terminated because:

N Conventional stuffing
disconnection boxes unable to Other causal paths more productive
AND
OR effectively purge solids END

N 12 hours to replace seal Connects to: Terminated because: Terminated because:

T No clean, external seal T Small amount of pumped T One face rotates
in shop flush fluid leaks across seal Other causal paths more productive Other causal paths more productive
b No information or knowledge to spec anything different
faces END END

N Total turnaround time =

20 hours N Single seal design unable
to handle pumped fluid

N 3 hours to reinstall Terminated because: Terminated because:

N Pumped fluid contains T Liquid vaporizes T Heat generated by seal N One face is stationary
solids Other causal paths more productive face friction Other causal paths more productive
END END

N 2 hours to de-LEO and Terminated because:

T Solids in fluid N Seal faces run hotter N High friction coefficient N Face materials are the
recommission accumulate on seal faces than liquid boiling point same Other causal paths more productive
END

N Single mechnical seals

unable to tolerate solids

N 1 hour to flush and drain Terminated because: Terminated because:

N Accumulated solids opens N Solids stick to faces N Inability to cool faces
faces Other causal paths more productive Other causal paths more productive
END END