SIX SIGMA

Project Title: Failures of HCN monitor cards in ACN.

Champion Name: Mr. Newand Harpalani

Project Leader(s): Mr. MC Chokshi (G.B.)
Mr. SB Mehta (G.B.)
RCBB: Mr. JK Shah
Team Members: Mr. AV Shah/Mr NK Patel/Mr. Sachin/

Mr. DV Solanki/Mr. Atalia

Process Owner(s): Mr. AV Shah

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 SIX SIGMA
PREFACE

Hydrogen cyanide (HCN) is byproduct of

ACN.HCN is highly toxic in nature .HCN
monitoring system is used to detect any
leakage of HCN in plant area and to take
immediate corrective action. Also, it activates
the water spray system automatically. Hence
the HCN monitoring system should work
without any unrevealed failure and is
expected to detect the leakage positively
whenever it occurs.

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 SIX SIGMA
Understanding the VOC

S I P O C R
Process Output Customer Requirements
Supplier Input Not Met

CES/ACN plant Specifications Procurement of HCN monitoring system Receipt of HCN ACN plant, RIL- 6 Nos. of HCN
monitoring system VMD monitor card
complying to specs. failures in 18
months since
ACN plant, Vendor, Utility (Power supply), Installation of HCN monitoring system Installation as per OEM ACN plant, RIL- installation
contractor. barrier, cables, JB’s etc guidelines and good VMD
and vendor/contractor engineering practice
services

M/s. Dragger (OEM) Calibration ampoules, Commissioning of HCN monitoring system To achieve required ACN plant, RIL-
calibration setup, OEM functionality of HCN VMD
service personnel. monitoring system.

M/s. Dragger (OEM) Awareness/Training to Maintenance of HCN monitoring system To maintain reliable ACN plant, RIL-
maintenance crew. system operation VMD

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 SIX SIGMA
Project Charter D M A I C
Business Case Financial Impact (SOFT Project)
In view of better Process Safety Management, the Annualized
obsolete HCN monitoring system was replaced. After Type of Benefits
Savings (Rs. Lacs)
installation, within 18 months, 6 times card failures were
Top line Growth (Revenue) NA
observed for 18 installed monitors. Inspite of putting all
efforts problem persisted. Hence, the project was taken Net Bottom-line Growth (Hard Savings) NA
as six sigma project in Dec’08. Cost Avoidance NA

Customer Total
External: NA
Internal: HOD(ACN Plan)/HOS (Inst-ACN) Milestones/Timeline: Scheduled Actual
Define Tollgate Review: Jan, 2009 Jan’09
Defects & Metrics Measure Tollgate Review: Mar, 2009 Mar’09
Business: Reliable HCN monitoring for PSM Analyze Tollgate Review: Apr , 2009 Apr’09
Improve Tollgate Review: Apr, 2009 Apr’09
Defect(s): High no. of HCN monitor card failures. Control Tollgate Review: May, 2009 June’09
Primary: No. of HCN monitor card failures per quarter.
Consequential: Periodical replacement of card/complete unit.
Project Scope/Boundaries:
Process Start: Procurement
Problem Statement Process Stop: Maintenance
Failure of HCN monitor cards in ACN plant from Oct'07 In Scope: Installation & Maintenance
to Dec'08 6 times against expected failures NIL. Out of Scope: Procurement & Calibration

Project Leader(s): Mr. MC Chokshi /Mr. Snehal Mehta

Objective Statement Champion/Sponsor: Mr N.V. Harpalani
RCBB : Mr. J.K. Shah
Reduce failures of HCN monitor cards from an average of
Team: Mr AV Shah/Mr NK Patel/Mr. Sachin/ Mr. DV Solanki/
4/year to zero by April’09. Mr.Atalia
Process Owner(s): Mr. AV Shah

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 SIX SIGMA
Project Scoping D M A I C

HCN MONITORING SYSTEM IN ACN PLANT

PRE CIRCULAR AQUEOUS WASTE STREAM FOR TREATMENT

LP STEAM TREATMENT POND
SYSTEM

SULPHURIC PROCESS VENT TO

PROCESS AIR
ATMOSHPERE FROM ABSORBER
COMPRESSOR ACID
CHEMICAL AND CRUDE
INHIBITOR ACRYLO TANK
OXYGEN FROM HM28
  PP4 HM29

HM21
HM19 HM16
PROPYLENE HM11
PURIFICATION
RECOVERY
REACTOR SECTION QUENCH SYSTEM SECTION
SYSTEM HM18

AMMONIA HM14

BOILER FEED INHIBITORS

CONDENSATE
WATER
TREATMENT
DM WATER SLOP
SEGREGATED
PROCESS SEWER WATER HM12 HM13

BFW TANK
HCN
CHEMICAL STEAM SECTION
ADDITION B/D
HM23
HM17 HM15
HM22
HM24
CATALYST PRODUCT
CATALYST HM25
STORAGE & INCINERATOR RUNDOWN
SETTLING
HANDLING WASTE WATER TANK HM26

SEWER

ACETONITRILE
PURIFICATION
HM27
ACN TO PRODUCT STORAGE
POND
ACN PRODUCT HCN PRODUCT

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 SIX SIGMA
Target Setting D M A I C

Baseline  4 failures/yr

Entitlement  NA

Target  0 failures/yr

Result  0 failures since

April’09

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 SIX SIGMA
Measure Phase Overview D M A I C

Measure
 Process Mapping
 Fishbone Analysis
 List of Quick Wins
 Key Shortlisted Xs

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 D

SIX SIGMA
D M A I C
STEAM
B/D

BARRIER DCS I/O

CARD
POWER
SUPPLY
CARD
110VAC/24V
SIGNAL DC P/S
SENSOR OUTPUT
CONDITION MEMORY MODULE
ER
UPS POWER
WA
S
TRANSMITTER UNIT T
E

W
HCN MONITORING SYSTEM A
T
E
R

Procurement SEWER Commissioning Maintenance

Installation

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 SIX SIGMA
Fishbone Analysis D M A I C

Improper Fluctuation in power supply Improper Earthing/ Shielding RF interference

handling

Improper regulation
High resistance of earthpit
Defective PS board
Loose connection incompatible barrier Earthpit dry nearby walkie-talkie / mobile
defective barrier Improper MOC
Human Salt level low
improper crimping
Faulty/rusted TB
Deliberate touch No connection/continuity
nearby welding work
Interference/Noise in Human error
power supply SOP not followed
Shield
Poor installation High voltage cable connected to
running parallel both ends

Improper On/Off switching of

location heavy equipment
Improper Failure of HCN monitor
support cards

Nearby steam or other Surrounding steam/water

hot source Water spray
steam leakage
steam leakage No SMP process drains
Poor quality of Periodical area
component cleaning
Nearbyhot Fire hydrant
Component failure
work testing
Poor mounting Sunlight exporsure SMP not followed
Dry solder Poor supervision Poor Tx. Protection
improper support Improper fixing of PCB's Canopy not provided
Ambient mounting on beam High voltage to Tx. Card Canopy damaged
condition Technical ability Improper mounting of canopy
Skill
Knowledge
Nearby heavy machines Experience Humidity high
Lack of training
Heavy rain

High temperature Vibration Defective hardware Poor maintenance Water ingress

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 SIX SIGMA
List of Quick wins D M A I C

• During Measure phase brainstorming and interaction with the OEM, it

emerged that output voltage from existing barrier (MTL 5042) was 17.3 V
which was very near to minimum acceptable limit of 16 V for reliable
operation of HCN monitoring system. After testing, alternate barrier
MTL 5041 was found supplying 23 V to the transmitter and hence
was more suitable to take care of voltage fluctuation on lower side.
Subsequently, barriers in 2 loops were replaced with alternate barrier
MTL 5041 in Feb’09 and since then no card failures were observed.
Based upon above test, barriers in all the remaining 16 loops have been
replaced with MTL 5041.

• During field checks, grounding of shields in 6 nos. of loops was

found not connected. Out of the 6 loops, failures of HCN monitor cards
was observed in 2 loops which might be attributed to improper shielding.
Shielding for all the 18 loops was ensured as per standard engineering
practice.

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 SIX SIGMA
List of Xs Shortlisted from CE Matrix D M A I C

Sl. No. Name of ‘X’

X1 Power supply characteristics

X2 Enclosure

X3 Noise immunity

X4 Barrier compatibility with Tx.

X5 OEM recommendation for installation

X6 Grounding / Earthing

X7 Skill / Knowledge of maintenance personnel

X8 Health check / LLF of HCN monitoring system

X9 Quality inspection for workmanship of Tx. modules

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 SIX SIGMA
Analyze Phase Overview D M A I C

Analyze
 FMEA Form

 FMEA Action Details

 Data Collection Plan

 MAIC Funnel

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 SIX SIGMA
FMEA Form D M A I C

Potential Effects S Potential Cause(s)/ O Current D R

Characteristic of Potential Failure Mode (What is
of Failure (Y or E Mechanism(s) of C Process E P
Input (KPIV / X) wrong with the X / How the X fails?)
Mini-Y) V Failure (Sub X's) C Controls T N

Power supply supply>30V component failure of Malfunctioning of COSEL regulated supply & 180

10

6
characteristics PS board voltage regulatory barrier
system of COSEL PS.

High voltage cable BMP compliance 180

10

6
running parallel
On/Off switching of Good engineering practice 180

10

6
heavy equipment
Faulty barrier procurement of standard 120

10

6
make barriers
Rapid ON/OFF switching of power supply corruption of loose connection skill technician, scheduled 360

10

6
microcontroller audits, standard wiring
memory/ damage to practice
PS board barrier/PS malfunction procurement of standard 180

10

6
make barriers /PS
Compatibility with Tx. Supply to Tx. Out of limits (Current at Failure of 6 Improper current 1 Barrier compatibility check 3 18
Tx > 22 mA, Voltage > 30 VDC) component of P/S regulation by barrier before
Good engineering Enclosure not as per IP54 SC in PCB's due 10 Improper fixing of 3 skill technician, scheduled 3 90
practice to water ingress enclosure audits
10 Improper dimensions 1 specifications, inspections 1 10
of enclosure
Water ingress SC in PCB's 10 Heavy rain 3 scheduled audits for 3 90
monsoon protection/
10 Nearby steam 3 LLF 2 60
leakages
10 process drains 2 LLF 2 40

10 Periodical area 2 LLF 2 40

cleaning with water jet
10 Fire hydrant testing 2 Canopy provision done/ 2 40
Monsoon protection for Tx.
10 Canopy improper 2 LLF 3 60

10 improper glanding 2 skilled technician, LLF 3 60

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 SIX SIGMA
Xs Treatment based on FMEA D M A I C

 # Xs for further scrutiny  17

(Sev > 7 & RPN > 300)
 # Xs for immediate actions 0
(RPN 125 to 300)
 # Xs with no action required  13
(RPN 1 to 125)

Actions have been taken for Xs irrespective of RPN wherever

simple, quick and cost-effective solutions were possible

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 SIX SIGMA
FMEA Action Summary D M A I C

Actions Count Action Type Summary Count

Total
30 Mistake Proofing 1
Recommended

Timely Completion/
28
Ongoing
Occurrence Reduction
23
(w/o Mistake Proofing)
Delayed
0
Completion

Pending Detection Improvement 6

2
Completion

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 SIX SIGMA
Data collection -1 D M A I C

Measurement of voltages in loop at barrier and at sensor head

HM-17 HM-22 HM-24
MRC-302 MRC-303 MRC-302
RZ-6 13/14 RB-1/64 RZ-2 31/32 RB-2/47 RZ-3 15/16 RB-2/42

Barrier Barrier Sensor Barrier Barrier Sensor Barrier Barrier Sensor

Sr. No. Date input (V) output (V) head (V) input (V) output (V) head (V) input (V) output (V) head (V) Remarks
1 31.01.09 23.13 17.78 23.36 17.63 23.13 17.6
2 02.02.09 23.12 17.78 23.36 17.63 23.13 17.6
3 04.02.09 23.12 17.78 17.79 23.36 17.63 17.65 23.13 17.6 17.63
4 06.02.09 23.12 17.78 17.8 23.36 17.63 17.64 23.12 17.6 17.6
5 08.02.09 23.13 17.78 17.79 23.37 17.63 17.64 23.13 17.59 17.63
6 10.02.09 23.13 17.78 17.79 23.37 17.63 17.64 23.12 17.6 17.63
7 12.02.09 23.12 17.78 17.8 23.37 17.63 23.11 17.6
8 12.02.09 23.12 17.78 23.38 23.37 23.3 23.12 23.1 23
After replacing
9 14.02.09 23.12 17.79 17.79 23.38 23.37 23.3 23.12 23.1 23
barrier with
10 16.02.09 23.13 17.8 17.8 23.38 23.37 23.3 23.12 23.1 23
MTL 5041
11 18.02.09 23.13 17.8 17.79 23.38 23.37 23.3 23.13 23.1 23

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 SIX SIGMA
Data collection -2 D M A I C
Audit for grounding of shield for HCN monitors
DCS
Transmitter Junc tion Box marshelling
cabinet
Sr. Shield Branch cable Shields from Shields of
TAG No. JB No.
No. connected to shield multicore cable multicore cable
earth connected to connected to JB connected to
(Y/N) JB shield bus shield bus bar signal earth
bar (Y/N) (Y/N) (Y/N)
1 BACNHM1.1 JB-BA121-11E NO YES YES YES
2 BACNHM1.2 JB-BA611-02E NO YES YES YES
3 BACNHM1.3 JB-BA611-02E NO YES YES YES
4 BACNHM1.4 JB-BA131-01E NO YES YES YES
5 BACNHM1.5 JB-BA611-02E NO YES YES YES
6 BACNHM1.6 JB-BA121-03E NO NO* YES YES
7 BACNHM1.7 JB-BA611-02E NO NO* YES YES
8 BACNHM1.8 JB-BA121-02E NO NO* YES YES
9 BACNHM1.9 JB-BA121-03E NO NO* YES YES
10 BACNHM2.1 JB-BA141-03E NO YES YES YES
11 BACNHM2.2 JB-BA141-03E NO YES YES YES
12 BACNHM2.3 JB-BA141-05E NO YES YES YES
13 BACNHM2.4 JB-BA141-02E NO NO* YES YES
14 BACNHM2.5 JB-BA141-02E NO YES YES YES
15 BACNHM2.6 JB-BA141-02E NO YES YES YES
16 BACNHM2.7 JB-BA141-03E NO YES YES YES
17 BACNHM2.8 JB-BA141-05E NO NO* YES YES
18 BACNHM2.9 DIRECT NO NO JB NO JB YES

Note
* FOUND NOT CONNECTED IN SHIELD BAR IN JB BUT NOW CONNECTED.

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 SIX SIGMA
D M A
MAIC Funnel – Xs Prioritization I C

Tool Box
Measure Tools
119 PFD, Input/Output worksheet,
Fishbone, CE-Matrix

Analyze Tools
19 FMEA

Improve Tools
9 Brainstorming

Control Tools
6 Brainstorming, Control plan

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 SIX SIGMA
Improve Phase D M A I C

Summary of Changes Made:

Existing MTL 5042 barriers replaced by MTL 5041 in all 18 nos. HCN
monitoring system in ACN plant.

 Additional two sets of diagnostic dongles to be purchased and

installed on rotational basis. This shall improve monitoring as each
detector shall be monitored once every 6 months as compared to once
every 18 months with existing one set of dongles.

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 SIX SIGMA
Control Phase Overview D M A I C

Control
 Control Plans for Sustainable Results
 Project Transition Action Plan (PTAP)
 Revised FMEA Form
 Learning
 Project Closure Sign-off

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 SIX SIGMA
Control Plans for Sustainable Results D M A I C
Wha t's Input or Spec. Limits / Measure ment Control Me thod
Process Step Sa mple Size
Controlled? Output? Require me nts Method Type Brief Details
What are the
How will you
specifications /
Me ntion the How w ill you ensure that the
Is the re quire ments What is the
pa ra meter measure / know the pa ramete r rema ins Explain the control
The Column A para meter a n w hich the sample size ,
(Input - X / value/status of the w ithin method
of FMEA form input or an pa ramete r take n a t one time ,
Output - Y) to paramete r "What's spe cifications or impleme nted
output? "What's for measure me nt?
be controlle d Controlled"? meets
Controlled"
requirements?
should meet?
Maintenance of Power supply Input Supply to Tx. By measurement SOP (1) Log of Tx. Supply One
Monitors characteristics Within limits voltage shall be helpful
(Voltage between in knowing PS variation
16 - 30 VDC) etc.
(2) Whenever barrier is As and when
changed it should be required
replaced with MTL
5041 barrier

Maintenance of Power supply Input No power supply Using diagnostic SOP Diagnostic dongle logs 1 for 30 days
Monitors characteristics interruption to Tx. dongle power cycle as an
event. So, any power
interruption to Tx. can
be determined
Maintenance of Water ingress Input No water ingress Physical inspection SOP (1) Coordination One
Monitors should be observed of Tx. during between Instrument &
calibration Process at time of
area cleaning.
(2) Coordination
between Inst/ Process
& Fire during fire
system checking
(3)Monsoon protection
Maintenance of No high vibration Input LLF SOP During LLF to be One
Monitors of Tx. ensured that there is
no vibration of Tx.

Maintenance of Protection from Input Such that Temp Using sensor dongle SOP Dongle data to be 1 for 30 days
Monitors sunlight should be < 60 deg analysed for any high
C temp alarm event.
Also, to be checked
that proper sunlight
protection to Tx. Is
provided by canopy.
Maintenance of Shielding/Ground Input As per OEM Physical checking SOP (1) All shields to be One
Monitors ing integrity recommendations intact. Also, shields to
be grounded only at
C/R.
(2) Earthpit resistance
should be < 10 ohm
Maintenance of Knowledge about Input Knowledge about Refresher training SOP All supervisory/non One
Monitors monitors operation and and validation supervisory to undergo
maintenance refresher training in
procedures as per operation &
OEM manual maintenance of HCN
monitors

D M A I C
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 SIX SIGMA
Control Plan actions for Sustainable Results D M A I C
(1) To maintain supply at HCN monitor between 16-30 V DC, any replacement
of barrier should be by MTL 5041 only.
(2) Diagnostic dongles to be installed in monitors on rotating basis (monthly)
to have log of events related to power interruption and over temperature
exposure
(3) Shielding integrity and earthpit resistance to be checked once per year for
reliable performance of HCN monitoring system.
(4) Healthcheck to be done once in a month for ensuring no vibration on HCN
monitor.
(5) Water ingress to HCN monitor to be prevented by:
• Carrying out healthcheck as per schedule.
• Carrying out monsoon protection as per standard procedure.
• Coordination between Instrument, Process and Fire deptt. during
fire
monitor testing and periodical area cleaning.
(6) Refresher training and validation for supervisory/nonsupervisory personnel
for HCN monitoring system should be carried out once in a year.

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 SIX SIGMA
Project Transition Action Plan (PTAP) D M A I C
Project Title: Failures of HCN monitor cards in ACN.
Transition Owner: Mr. Newand Harpalani
Plan Date: 31/05/'09
Sr. Action Scheduled Actual
No. Actions Required for Completion Initials
Owner Completion Completion
1 To ensure monsoon protection to HCN monitors every fortnight HOS Ongoing
during monsoon
2 Determine probability of steam leakage in sensor/Tx. Vicinity HOS Ongoing
and decide frequency of LLF.
3 (1) Process drains to be avoided HOS Ongoing
(2) If required, to be done after informing inst. For necessary
precautionary measures.
4 Periodical area cleaning to be done after informing inst. for HOS Ongoing
necessary precautionary measures.
5 (1) Probability of water ingress due to fire hydrant testing to be HOS Ongoing
ensured.
(2) Fire personnel to be made aware about possible Tx. failure
due to water ingress.
6 Ensure canopy and monsoon protection is intact HOS Ongoing
7 (1) Ensure cable entry to Tx. Is from bottom. HOS Ongoing
(2) Ensure gland sealant or monsoon protection tape is applied.
8 Verify condition of canopy during LLF HOS Ongoing
9 Verify whether instrument has proper sunlight protection or not HOS Ongoing
during LLF
10 Training/Counselling to all supervisors/technicians to be HOS 31.07.2009
ensured

D M A I C
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 SIX SIGMA
Revised FMEA Form D M A I C
Action Results
S O Current D R
Characteristic of Potential Failure Mode (What is Recommended S O D R
E C Process E P
Input (KPIV / X) wrong with the X / How the X fails?) Action(s) E C E P
V C Controls T N
V C T N
Power supply 180 60

10
supply>30V COSEL regulated supply & (1) Confirm Tx. 10 1 6

6
characteristics barrier Sensitivity (Volt
V/s time ) to PS
over voltage.
(2) COSEL P/S
regulation
(3) Characteristic of
BMP compliance 180 audit for cable 20

10
10 1 2

6
routing
Good engineering practice 180 audit of Tx. 10 1 1 10

10

6
Installation
procurement of standard 120 test setup to study 60

10
10 1 6

6
make barriers variation in barrier
Rapid ON/OFF switching of power supply skill technician, scheduled 360 Wago screwless 10 1 6 60

10

6
audits, standard wiring terminals, proper
practice size wires
procurement of standard 180 ferrules,
test setuplugs,
to study 120

10
10 2 6

6
make barriers /PS variation in barrier
Compatibility with Tx. Supply to Tx. Out of limits (Current at 6 1 Barrier compatibility check 3 18 ensure & follow 6 1 3 18
Tx > 22 mA, Voltage > 30 VDC) before OEM
Good engineering Enclosure not as per IP54 10 3 skill technician, scheduled 3 90 Checking of 10 10
practice audits enclosure fixing
10 1 specifications, inspections 1 10 Checking of 10 10
enclosure
Water ingress 10 3 scheduled audits for 3 90 To ensure 10 10
monsoon protection/ monsoon
10 3 LLF 2 60 Determine 10 10
probability of
10 2 LLF 2 40 (1) Process drains 10 10
to be avoided
10 2 LLF 2 40 To be done after 10 10
informing inst. For
10 2 Canopy provision done/ 2 40 (1) Probability of 10 10
Monsoon protection for Tx. water ingress due
10 2 LLF 3 60 Ensure canopy 10 10
and monsoon
10 2 skilled technician, LLF 3 60 (1) Ensure cable 10 10
entry to Tx. Is

D M A I C
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 SIX SIGMA
Learning

 OEM had recommended MTL 5042 for LAB HF monitor being

procured. However, based upon the findings regarding
compatibility of barrier MTL 5042 with HCN monitor,
procurement of barriers changed from MTL 5042 to MTL 5041.

 Earthing of critical loops of ACN plant to be checked for

shielding integrity in earliest available opportunity. Grounding
should be done as per standard engineering practice and
should be audited immediately after commissioning for
compliance of the same and subsequently to be monitored
periodically.

Thank you

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