Incident Investigation:Process to Identify Root Causes of Mechanical Failures

摘要

This paper describes an actual incident investigation into unexpected premature failure of sealed diaphragm pressure transmitters in a chemical process.Some nontypical investigation tools from the CCPS Guidelines for Investigating Chemical Process Incidents(2nd edition)were used.A typical failure allowed a release of a corrosive process fluid with potential injury to personnel.The failures also required a shutdown of the process with loss of production.The cause of the problem was elusive;pressure transmitters from the same manufacturer had no problems in a similar process unit,although component designs differed between the two units.The investigation included confirmation of materials of construction,photographic and visual analyses of failed components,simulation of assembly of the pressure transmitter in the process and measurement of torque values,and brainstorming of possible failure mechanisms.Several hypotheses were tested using a fact-hypothesis matrix to determine most likely cause scenarios.Similarly,a matrix was used to illustrate which scenarios could be prevented by which corrective actions.The investigation included a root cause analysis tree to confirm cause scenarios.The paper discusses the incident investigation process,including diversity of skills on the investigation team,and how each of the tools was used.The paper also discusses the communication of the findings to operations.