Limitations of 439 SS in HP Feedwater Heater Application

2010 ◽  
Author(s):  
Silvia Khurrum ◽  
Michael Catapano
Keyword(s):  
Technical Specification ◽  
Primary Objective ◽  
Lessons Learned ◽  
Tube Material ◽  
Cause Analysis ◽  
Root Cause ◽  
Stainless Steel Tubing ◽  
Steel Tubing ◽  
History Of ◽  
The Subject

This paper presents a case history of problems experienced with a replacement HP feedwater heater that was manufactured with Type 439 stainless steel tubing. The subject heater was installed after numerous problems during manufacturing and was commissioned for service in February 2007. The first failures were experienced after only 2 years of operation. Reports indicate that after the discovery of the first leaks, maintenance groups servicing the heater were never able to get the heater completely leak-tight. Ultimately, the frequency and magnitude of subsequent leak incidents that followed caused the power generating company to fully bypass the heater in September 2009. The paper offers a full chronology of events that ultimately led to the demise of subject heater. The primary objective of the paper is to share the lessons learned during the root cause analysis of the problem, including the inherent limitations related to subject tube material. Specific steps identified herein were taken by the power generating company to ensure that the technical specification for the next replacement heater would preclude any similar problems from occurring.

Enhancing the Drilling Performance Management on a Large Drilling Operation

2021 ◽  
Author(s):  
Alvin Ivan Handoko ◽  
Henry Edward Khella ◽  
Erwan Couzigou ◽  
Adel Abdulrahman Al-Marzouqi
Keyword(s):  
Performance Management ◽  
Performance Indicator ◽  
Root Cause Analysis ◽  
Systematic Investigation ◽  
Lessons Learned ◽  
Company Performance ◽  
Cause Analysis ◽  
Large Organization ◽  
Root Cause ◽  
Drilling Performance

Abstract Since the implementation of the Drilling Performance Department in late 2017, ADNOC Offshore has been able to develop a company performance-oriented culture among the drilling teams. This performance culture is reflected in 25% ILT reduction in 2018 and 12% in 2019. Furthermore, 37 NPT RCA cases were investigated and concluded in 2019, which resulted in 57 actions for tracking and closure. With 5 (five) concessions, 9 (nine) different shareholders, and 39 (thirty-nine) rigs, drilling performance management is challenging. ADNOC Offshore created a centralized Drilling Performance Team to capitalize on this diversity as an opportunity to improve the traditional drilling performance role. This paper describes the team's approach on Drilling Performance and the consecutive result. The team enhances the typical drilling performance role of Key Performance Indicator (KPI) management and reporting by adopting the Performance Opportunity Time (POT) and Root Cause Analysis (RCA) Process. At the same time, the Drilling Performance Team facilitates the flow of information between teams to ensure effective knowledge transfer within such a large organization. The POT concept tackles the well duration reduction through the reduction of Invisible Lost Time (ILT) and Non-Productive Time (NPT). To reduce the ILT, the team took advantage of the extensive technical background in the various drilling teams. Performance improvement initiatives were proposed by taking references from different teams within ADNOC Offshore and evaluating the application in other concession. Other approach is to compare with out-of-company references. For NPT reduction, the innovative approach was to use the HSE Root Cause Analysis (RCA) concept. This RCA process led by the Drilling Performance Team was implemented to standardize the approach and have a systematic investigation analysis. This process resulted in identifying root causes and effective corrective action plans. As per HSE, addressing the root causes of incidents would result in the most significant impact in NPT. This approach also allows an independent and more detailed look on the subjects, where commonly these tasks are done in a limited manner by drilling teams alone with their ongoing operational workload. Finally, results are communicated to the drilling organization through lessons learned portal and technical bulletins.

Complex Systems and Approaches to Quality Improvement

2016 ◽  
Author(s):  
Loren Riskin ◽  
Alex Macario
Keyword(s):  
Quality Improvement ◽  
Complex Systems ◽  
Research Study ◽  
Systems Management ◽  
Improvement Science ◽  
Cause Analysis ◽  
Root Cause ◽  
Traditional Research ◽  
Current Thinking ◽  
History Of

This chapter, “Complex Systems and Approaches to Quality Improvement,” serves as an introduction to complex systems management and current thinking in improvement science. It explains the context behind quality improvement (QI) initiatives, beginning with a discussion of the ultimate goals of this movement. It then briefly reviews the history of QI development and early leaders in the field. The universal elements of a successful QI or patient safety project are discussed, followed by the exploration of commonly encountered barriers to systems and individual improvement. The chapter also highlights the differences between QI work and traditional research study. Selected tools to examine and prevent risk are explored, including informal approaches, Deming’s model for improvement, Six Sigma, healthcare failure mode and effects analysis (HFMEA), and root cause analysis (RCA).

scholarly journals China's social moral empirical research based on situational simulations

2020 ◽  
Author(s):  
Yitian Shao ◽  
Yiping Wang ◽  
Rong-Jie Li
Keyword(s):  
Social Ethics ◽  
Living Environment ◽  
Cause Analysis ◽  
Root Cause ◽  
Coastal Cities ◽  
Profound Influence ◽  
The Social ◽  
History Of ◽  
Improvement Measures ◽  
Survey Results

<p>China has a long history of more than 5000 years, which inheriting many excellent moral traditions. China’s moral level and civilization degree once led the world, and had a profound influence on other countries. However, <a>a series of social </a><a>problems</a> merging<a> in China in recent years </a>because of the social morals, these problems limit the progress of social civilization seriously and<a> influence people's living environment</a> adversely. In order to analyze the changes of social morals and the<a> root causes</a>, the research team designed four different situational <a>simulation</a>s<a> in the main developed coastal cities in China</a>. <a></a><a></a><a>The survey results indicated that China's present social ethics is not ideal, </a><a>it is </a><a>necessary</a> to make root cause analysis and <a>implement</a> improvement measures to recreate<a> good moral civilization</a><a></a> in the whole society.</p>

Root Cause Analysis of an Industrial Boiler Explosion (and How Hazard Analysis Could Have Prevented It)

2010 ◽  
Author(s):  
Juan C. Ramirez ◽  
Mark Fecke ◽  
Delmar Trey Morrison ◽  
John D. Martens
Keyword(s):  
Hazard Analysis ◽  
Multiple Root ◽  
Root Cause Analysis ◽  
Lessons Learned ◽  
Processing Plant ◽  
Similar System ◽  
Cause Analysis ◽  
Root Cause ◽  
Industrial Boiler ◽  
Secondary Air

An explosion occurred in the firebox of an industrial boiler with a nominal fuel input rate of 100 MW (340 million Btu/hr), in a processing plant during final commissioning of the burner systems. This paper describes the investigation of the incident, root cause analysis, and lessons learned from the incident. The original burners in the boiler had recently been replaced with low NOx burners, and the facility was in the process of commissioning the new burner system. The boiler was running only on natural gas igniters at the time of the incident. While firing on igniters, an undetected stoppage of the control equipment occurred, which led to a restriction of airflow through the secondary air dampers. The boiler controls included programmable logic controllers (PLCs) for both the combustion control system (CCS) for regulation and the burner management system (BMS) for safety functions. The BMS was intended to detect a loss of control such as this and immediately stop fuel to the boiler; however, it did not. The BMS PLC was not configured to detect the dangerous states and allowed the igniters to continue to fire. An explosion subsequently occurred within the boiler firebox that caused extensive damages to the facility and equipment. This paper will describe the incident investigation and determination of multiple root causes for failure of the BMS to prevent the explosion. The inadequate configuration of the control systems was likely present for some time prior to the incident, and the explosion was eventually caused when the right conditions occurred during this commissioning. We found through the investigation that the BMS deficiencies could have been detected and prevented (and almost were) through standard hazard analysis techniques common in the chemical processing industries. This paper will also discuss how hazard analysis can be applied to detect and prevent similar system failures.

Surgical site infection related to use of elastomeric pumps in pectus excavatum repair. Lessons learned from root cause analysis

2017 ◽  
Vol 52 (8) ◽  
pp. 1292-1295 ◽  
Author(s):  
Nadja Apelt ◽  
Joshua Schaffzin ◽  
Christina Bates ◽  
Rebeccah L. Brown ◽  
Marc Mecoli ◽  
...  
Keyword(s):  
Surgical Site Infection ◽  
Pectus Excavatum ◽  
Root Cause Analysis ◽  
Lessons Learned ◽  
Site Infection ◽  
Cause Analysis ◽  
Root Cause

Root Cause Analysis of the Unexpected Behaviour of a Flaked Material Under Irradiation and Transferability to the Doel 3/Tihange 2 Reactor Pressure Vessels

2016 ◽  
Author(s):  
Evy De Bruycker ◽  
Séverine De Vroey ◽  
Xavier Hallet ◽  
Jacqueline Stubbe ◽  
Steve Nardone
Keyword(s):  
Nuclear Power ◽  
Power Plants ◽  
Root Cause Analysis ◽  
Pressure Vessels ◽  
Operating Cycle ◽  
Cause Analysis ◽  
Root Cause ◽  
History Of ◽  
Manufacturing History ◽  
Reactor Pressure

During the 2012 outage at Doel 3 (D3) and Tihange 2 (T2) Nuclear Power Plants (NPP), a large number of nearly-laminar indications were detected mainly in the lower and upper core shells. The D3/T2 shells are made from solid casts that were pierced and forged. Restart authorization in 2013 was accompanied by a number of “mid-term” requirements, to be completed during the first operating cycle after the restart. One of these requirements was the mechanical testing of irradiated specimens containing hydrogen flakes. These tests showed unexpected results regarding the shift in the Reference Temperature for Nil Ductility Transition (RTNDT) of the flaked material VB395 (Steam Generator shell rejected because of flakes) after irradiation. This paper presents the root cause analysis of this unexpected behaviour and its transferability (or not) to the D3/T2 Reactor Pressure Vessels (RPVs). A mechanistic and a manufacturing based approach were used, aiming at identifying the microstructural mechanisms responsible for the atypical embrittlement of VB395 and evaluating the plausibility of these mechanisms in the D3/T2 RPVs. This work was based on expert’s opinions, literature data and test results. Both flaked and unflaked samples have been investigated in irradiated and non-irradiated condition. All hydrogen-related mechanisms were excluded as root cause of the unexpected behaviour of VB395. Two possible mechanisms at the basis of the atypical embrittlement of VB395 were identified, but are still open to discussion. These mechanisms could be linked to the specific manufacturing history of the rejected VB395 shell. Since the larger than predicted shift in transition temperature after irradiation of VB395 is not linked with the hydrogen flaking and since none of the specific manufacturing history features that are possible root causes are reported for the D3/T2 RPVs, the D3/T2 shells should not show the unexpected behaviour observed in VB395.

scholarly journals China's social moral empirical research based on situational simulations

2020 ◽  
Author(s):  
Yitian Shao ◽  
Yiping Wang ◽  
Rong-Jie Li
Keyword(s):  
Social Ethics ◽  
Living Environment ◽  
Cause Analysis ◽  
Root Cause ◽  
Coastal Cities ◽  
Profound Influence ◽  
The Social ◽  
History Of ◽  
Improvement Measures ◽  
Survey Results

<p>China has a long history of more than 5000 years, which inheriting many excellent moral traditions. China’s moral level and civilization degree once led the world, and had a profound influence on other countries. However, <a>a series of social </a><a>problems</a> merging<a> in China in recent years </a>because of the social morals, these problems limit the progress of social civilization seriously and<a> influence people's living environment</a> adversely. In order to analyze the changes of social morals and the<a> root causes</a>, the research team designed four different situational <a>simulation</a>s<a> in the main developed coastal cities in China</a>. <a></a><a></a><a>The survey results indicated that China's present social ethics is not ideal, </a><a>it is </a><a>necessary</a> to make root cause analysis and <a>implement</a> improvement measures to recreate<a> good moral civilization</a><a></a> in the whole society.</p>

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