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API RP 585 Pressure

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Equipment Integrity

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Incident Investigation

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AFPM Maintenance and Reliability Conference

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A u s t i n , Te x a s
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©

May 19, 2015

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PROPRIETARY INFORMATION 1
 Overview

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 What is a Pressure Equipment Incident (PEI)?

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 Equipment Included/Excluded

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 PEI Incident Types

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 Consequences to Incidences

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 Level of Incidences
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 Gathering Data
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 Investigation Methods
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 Causes of Incidences
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 Reports and Action Items

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2
 What is a Pressure Equipment Integrity
Incident?

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 The termination of the ability of a pressure

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equipment system, structure, or component to

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perform its function of containment of the process

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fluid. Loss of containment due to miss operation of

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equipment and not involving material damage

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mechanisms is not considered PEI failure.

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3
 Types of Pressure Equipment Covered

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 Pressure Vessels and Piping

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 Storage Tanks (atmospheric, pressurized)

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Rotating Equipment (pumps, excluding seals)

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

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 Boilers and Heaters (pressurized components)

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Heat Exchanger Components

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

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 Pressure Relief Devices uity
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 Structural Systems (integral to supporting pressure-

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containing systems, skirts)

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 Cooling Water Towers

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 Stacks and Flares

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4
 Equipment Excluded

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 Instruments and Control Systems

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 Electrical Systems

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Machinery Components (except casing)

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 Structural Equipment (not pressure supporting)

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Movable Pressure Systems (barges, trucks, skids)

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5
 Purpose of Incident Investigation

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 Rarely the result of one, isolated issue

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– Almost always less severe precursors to a major failure

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– Precursors are frequently near misses

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 Value of recognizing precursors to identify causes

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 If near miss causes can be resolved, then major

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catastrophic failures of pressure equipment could be
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minimized or prevented
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 Continuous improvement process

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6
 PEI Incident Types

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 Near Misses

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– Damage not passing FFS (non leak)

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– Operating outside of IOW

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– Failure of a pressure-relief device (closed valve in path)

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Wrong alloy in circuit (PMI errors)

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– Incorrect fitting or piping (Sch. 40 instead Sch. XS)
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– Wrong gasket or bolting for piping class
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7
 PEI Incident Types

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 Failures

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– Flange leak (not fugitive emissions leak)

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– Corrosion thinning to a leak

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– Through wall cracking

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– Rupture

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– Leak to atmosphere
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– Structural failure that causes derate or alters operation
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(e.g., support rings)

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20
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8
 Documenting PEI Incidents

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“Even low-consequence incidents, provide

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opportunities to learn through investigation in order to

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identify the causes and implement improvements to

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prevent a potential major failure... The tracking of PEI

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incident data provides opportunity to identify trends

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and improve PEI.”

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20
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9
 PEI Investigation Levels

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 It is impractical/unnecessary to investigate every PEI

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to a high level or detail.

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 Levels of investigation exist for different

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consequences.

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 The more serious or potentially serious an incident,

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the greater the scope and depth of investigation.
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10
 Determining Consequence

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 Consider both actual and potential consequences to

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determine the level of the investigation.

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 Potential consequences should be only the most likely

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scenarios that might have occurred if one or possibly

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two other events had happened. Not more than two.

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 Consequences should be clearly documented and
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agreed upon with the investigation sponsor.
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11
 Examples of Consequence

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 “If a leak occurs and releases gasoline that forms a vapor

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cloud but does not cause a fire...because an operator

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immediately saw the leak and turned on fire monitors,

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then it is reasonable to consider fire…as a potential

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consequence and investigate based on that.”

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 “If a leak releases diesel and a small pool fire results that
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is contained by the emergency response, it might not be
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reasonable to say that the potential consequence would

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have been major equipment damage if the fire monitors

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were not working and the emergency shutdown valves

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©

had not been activated.”

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12
 Level 1 - Low Consequence Events

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 Incorrect gasket installed – leak without fire

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

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

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 Schedule 40 nipple installed where Schedule 80 required in

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piping specification

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 Inspector discovers wrong weld rod being used by welder for

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Cr-Mo piping replacement

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 Inspector discovers utility hose being used for process drain

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 Goal is to document data and look at trends to prevent a

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larger incident or promote a larger investigation or

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repeat “level 1” events

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20

 Serves as a leading indicator

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13
 Level 2 - Medium Consequence Events

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 Grouping/repeat of Level 1 events

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 Boiler tube rupture

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Tank bottom leak

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 UT findings below T min

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Flange leak on start up (small fire)

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 Relief valve opens prematurely uity
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 Relief valve found plugged

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 Heat exchanger tube rupture

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Gasket blows on blocked in line

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
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14
 Level 3 - High Consequence Events

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 Repeat events not solved by Level 1 or 2 investigation

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 Anything above “medium” consequence

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 Events causing fire with damage to equipment

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 Production Loss

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Significant safety incident

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Large release (regulator involvement)
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
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 All levels are built on actual or potential

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consequences
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 Investigations started on a lower level can be

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extended if repeat/trend occurs

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15
 Levels of Investigation

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 Besides consequences, levels differ in resources (timing

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and personnel included)

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 Level 1 (Low Consequence)

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– One or two person investigation – 5 Whys technique

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– Experience to determine cause (not 100% certain)

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– Starting point - may not determine root cause

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 Level 2 (Medium Consequence)

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– Small team
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– Casual factor or logic tree decision
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 Level 3 (High Consequence)

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– Team led by trained root cause investigator

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– Substantial evidence gathering

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– Structured RCA methodology, several weeks

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16
 C
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 API Disclaimer

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 “Owners/users may provide guidelines defining the

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different levels of investigations and the

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circumstances under which they are used.”

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 API 585 does not directly call out consequence levels,

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a brief review of API 754 will be included at the end.

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 API 585 is an RP, no Shall statements included.
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18
 Investigation Method

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 Gather Evidence – Conduct Analysis – Determine Cause

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En
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19
 Gathering Evidence

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 Begin collecting evidence as soon as safely possible.

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May occur before repair activity.

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 People – interview eyewitnesses, operators, process

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or design engineers

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 Physical – photograph as-found condition, chemical

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samples, secondary damage, valve positions
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 Records – operating logs, inspection records,
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recorded operating trends, maintenance records,

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emails
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 Collect perishable evidence first (memories)

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20
 People Data

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 Eyewitness reports

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 First Responders (incident reports)

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Operators – on shift and off shift

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 Inspection & Maintenance Personnel

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Metallurgist/Process/Reliability/Design Engineers

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 Manufacturer’s representatives uity
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 Laboratory personnel
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21
 Eyewitness Questions (Examples)

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 Let them tell the story. Do not lead a response with a yes/no

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 Ensure them this is not to place blame but to learn from

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experiences.

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 Start simple and work up, ask for clarification (what do you

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mean when you say…?)

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 Where were you at the time of the incident?

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 Would you describe the incident?

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What did you see, hear, feel, or smell?
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 Did you have any indications before the incident that something was
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about the happen?

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 Was there anything different right before the incident?

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 Has this incident or a very similar event occurred previously? If so,

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when and what happened?

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©
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22
 Physical Evidence

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 Photograph as-found (scale)

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 Secondary damage caused

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Sketches of the scene (location of fragments)

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 Take notes on deformation/color/smell

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Collect deposits

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 Plastic bags/Store indoors

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 Avoid cleaning (grit blasting)

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Label everything!
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
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23
 Analyzing Evidence

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 Collect all evidence first/analyze after

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– Keep separate focus and don’t become biased

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 PEI team members – knowledgeable but unbiased

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 Review each piece of evidence and summarize what

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was learned from each

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 Stay focused on why the loss of containment
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occurred
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– Not events caused by incident (improper drainage or fire

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monitor coverage)
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 Multiple separate field visits may be necessary

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20
©
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24
 Types of Causes

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 Immediate Causes

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– Un-neutralized acid came in contact with CS and rapidly

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corroded to point of failure

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 Contributing Causes

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– Inadequate operating conditions allowing carry over

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– Operators did not recognize or react to carry over

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 Root Causes
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– Lack of retraining of operators
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– Leadership did not address lack of process controls

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15
20
©
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25
 Determining Causes

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 Level 1 may only determine Immediate Cause

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 If Immediate Cause is not determined by evidence

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(Level 1 or 2), Metallurgical Failure Analysis may

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provide more insight

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 Level 3 is typically needed for identifying Root Cause

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 “Root causes are typically related to management
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systems or organizational cultural issues that need to
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be corrected to prevent other incidents from

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occurring.”
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20
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26
 Probable Cause

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 Causes that cannot be verified to a high degree of

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certainty

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 Typically contributing or immediate causes

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 Level 1 may conclude based on probable cause

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 Level 2 or 3 may have multiple causes; however,

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some contributing causes are theorized or probable

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causes. Eq
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27
 Action Items

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 Opportunities for future improvement

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 Items may be related to immediate, root, or

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contributing cause

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 Clearly written (no interpretation), address which

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cause it is linked to and implementation plan

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 Important to follow-up on implementation
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 Implement on-stream NDE

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 Add more process variables to IOW

15
20
©
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28
 Effectiveness of Action Items

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 Continued review of PEI incidents

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 Are common and systematic incidents reduced or

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eliminated?

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 This may lead to a higher level investigation if action

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item did not create progress

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 Continues improvement cycle
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Image From: “The Role of Continuous Improvement in Achieving Excellence in Pressure Equipment Integrity and Reliability”, John Reynolds, Inspectioneering 2012.
https://inspectioneering.com/journal/2012-07-01/3073/the-role-of-continuous-improve

29
 Final Report and Documentation

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 Summary of the incident (where and what)

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 Investigation effort

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Presentation of the findings (how and why)

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

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 Conclusions on findings (immediate, contributing,

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root causes)

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 Indicate what management systems that may be
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related to the root cause
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 Recommendations to prevent repeat incident (action

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items)
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20
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 Highlight assumptions made along the way

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30
 Level 3 Additions

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 Component Failure Analysis Techniques

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– Visual Examination

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– Physical Measurements

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– Cutting and Extraction

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– Macro and Micro Examination

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– SEM and EDS examination
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– Macro and Micro Hardness Testing
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– Fracture Surface Examination

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– Deposit Analysis
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20

– Mechanical Testing (fracture toughness/tension)

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31
 Training and Information Sharing

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 Training personnel to lead PEI investigation

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– To understand multiple facets, mainly highlighted in this

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presentation

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 Sharing Experiences with different site and the whole

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industry

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En
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Image From: “The Role of Continuous Improvement in Achieving Excellence in Pressure Equipment Integrity and Reliability”, John Reynolds, Inspectioneering 2012.
https://inspectioneering.com/journal/2012-07-01/3073/the-role-of-continuous-improve
32
 Annex (Informative)

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 A – Example Reporting Form for PEI Incidents

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 B – Example Application of the “5 Whys”

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Investigation Methodology

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 C – Example Level 1 PEI Incident Investigation

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Results Form

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 D – Example Lists of Generic Evidence to be

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Gathered Eq
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 E – Examples of Questions to Ask Eyewitnesses
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 F – Request for Failure Analysis Form

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 G – Example Template for Level 2 or Level 3 PEI

15
20

Incident Investigation Report

©
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33
 “5 Whys” Case

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 HE bundle was pulled and cleaned, excessive damage

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lead to need for replacement (>20% plugged)

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 New engineer pulled drawing from main records and

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sent to the fabricator

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 Bundle made it to plant a before end of TA

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 Bundle would not fit into shell
En
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 Shell had been modified in the past
Eq
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 Old bundle was replaced in service and block valves

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were installed for future bundle

15
20
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 Unit load was reduced due to plugged tubes

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34
 “5 Whys” Example

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 What Happened that should not have: bundle fabricated

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incorrectly

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 1 Why - Wrong drawings were used to fabricate

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 2 Why - Drawings were not updated in main equipment file

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 3 Why - Previous engineer did not update the files

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 4 Why - Previous engineer did not trust security, kept his
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own files instead uity
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 5 Why - Equipment file room does not have controlled

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access, documents have been lost in the past

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 6 Why - Keeping up-to-date equipment files is not given a

20
©

high priority by management

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35
 Consequence Guidance from API 754

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 Incidents are rarely caused by a single catastrophic

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failure (Multiple that coincide)

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 Swiss Cheese and Spinning Disk (dynamic)

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 “Barriers” can be active, passive, or procedural

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 “Holes” can be latent, incipient, or actively opened by

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people
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20
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Image From: API RP 754 Process Safety Performance Indicators for the Refining and Petrochemical Industries

36
Consequence Guidance from API 754

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Image From: API RP 754 Process Safety Performance Indicators for the Refining and Petrochemical Industries

37
 Lagging vs. Leading

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 Lagging tends to be outcome-oriented and retrospective

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 Hindsight is always 20:20

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38
 Tiers in API 754

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 1 – most lagging, greater consequences from actual

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39
Comparison of API 754, API 585, Two
Example Companies’ Incident Levels

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API 754 API 585 Company A Company B

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Tier 1 Level 3 Level 5 Level 4

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Company A approximates a large Fortune 100 company, Company B is a
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fictitious small refinery

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40
 Tier 1 Thresholds

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Image From: API RP 754 Process Safety Performance Indicators for the Refining and Petrochemical Industries

41
 Tier 2 Thresholds

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Image From: API RP 754 Process Safety Performance Indicators for the Refining and Petrochemical Industries

42
 .
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QUESTIONS?

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Shaker Heights, OH  Houston, TX  Victoria, TX

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Alberta, Canada  Abu Dhabi, UAE

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