NAROGONG ROOT CAUSE ANALYSIS – JULY 2012

NAR1
1. Kiln stopped due to BBS pump Leakage
(Stop date 17.07.2012 10:20:00, Duration : 15.82 hours)
 Symptom
- 16 July, replace the leakage diaphragm at flange area when PM stop
- After reparation, circulation BBS has been tested by BBS and mechanical teams
in 15 minutes and no leakage found.
- BBS rate to Kiln Burner was 1.2 – 1.5 tph
- Found leakage pump which BBS liquid flew from pump room to rest room
drainage.
- From TIS data identified BBS liquid level dropped very fast about 23% in 2.5
hours (78% to 55%) then Kiln stopped (see graphic at page. 8)
- 18 July, During checking bolt loose before start up, all flange membrane bolts
loose but the bolts were not worn out.
 Root Cause
- BBS Pump leakage due to ball valve bolt loose

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 Action
- Stop Kiln to reduce impact from dilute water PIC : Safrin Done
- Cleaning overflow in pump room area, ditch,
and settling pond PIC : Agung G Done
- Isolated rest room drainage to stop BBS going to
the ditch PIC : Agung G Done
- Purchase oil skimmer PIC : Agung G Done
- Conduct water analysis (pH, COD, TDS, and TSS) at
settling pond before and after every 2 hours
(for next 48 hrs) PIC : Lab Done
- Review and repair the water leakages source from
all unit area to ditch PIC : Muhamad D Done
- Install CCTV for BBS Pump room PIC : Helmi Aziz Nov
- Install higher dam to avoid overflow to control
room and shower room PIC : Kodari Nov
- Perform routine inspection and improve awareness PIC : Sofyan Sept

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 NAROGONG ROOT CAUSE ANALYSIS – JULY 2012

- Improve Emergency Response in Oil Spillage

Procedure & Responsibility PIC : Very N Nov
- Conduct training of emergency Response in
Oil Leakage PIC : Lilik Rendra Nov
- Reposition shower room drainage and relocate
rest room to outside BBS facility building PIC : Kodari Sept
- Install three permanent water gates equipped
with ladders ( 2 at settling pond and 1
beside of truck lift) PIC : Kodari Nov
- Install material level sensor in the BBS Pump room PIC : ruslan Nov
- Add level reducing rate alarm (set level > 4 tph) PIC : Mukhlas A. Aug

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 NAROGONG ROOT CAUSE ANALYSIS – JULY 2012

Replaced
diaphragm
in 16 July
Leakage
position
before repair
16 July

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 NAROGONG ROOT CAUSE ANALYSIS – JULY 2012

Leakage
position at 17
July morning
due to this bolt
was loose

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 NAROGONG ROOT CAUSE ANALYSIS – JULY 2012

Location
of leakage

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Overflow via
rest room
drainage

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 BBS Liquid Flow Graphic
Leakage
Leakage found, BBS
90 happen 3directly be
stopped
85
Start 2.5
80 BBS
Tank 1 Level, ton

BBS rate, tph

2
75
70 1.5
65
1
Unloading
60
BBS delivery
0.5
55
50 0
8:00
9:00

0:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
10:00
11:00
12:00
13:00
14:00
15:00
16:00
17:00
18:00
19:00
20:00
21:00
22:00
23:00
LA3-3B1.L1:PV_AVG Level indicator tanki 1 %
LA3-VA3.F1:PV_AVG BBS rate to kiln (new log) t/h

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