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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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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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Understanding the VOC

C O S P I CustomerOutputProcessInputSupplier

ACN plant, RIL-VMD

ACN plant, RIL-VMD

ACN plant, RIL-VMD

ACN plant, RIL-VMD

Receipt of HCN monitoring system complying to specs.

Installation as per OEM guidelines and good engineering practice

To achieve required functionality of HCN monitoring system.

To maintain reliable system operation

Procurement of HCN monitoring system

Installation of HCN monitoring system

Commissioning of HCN monitoring system

Maintenance of HCN monitoring system

Specifications

Utility (Power supply), barrier, cables, JB’s etc and vendor/contractor services

Calibration ampoules, calibration setup, OEM service personnel.

Awareness/Training to maintenance crew.

CES/ACN plant

ACN plant, Vendor, contractor.

M/s. Dragger (OEM)

M/s. Dragger (OEM)

R Requirements

Not Met

6 Nos. of HCN monitor card failures in 18 months since installation

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Project Charter

Business: Reliable HCN monitoring for PSMDefect(s): High no. of HCN monitor card failures.Primary: No. of HCN monitor card failures per quarter.Consequential: Periodical replacement of card/complete unit.

Business Case

Defects & Metrics

Problem Statement

Project Leader(s): Mr. MC Chokshi /Mr. Snehal MehtaChampion/Sponsor: Mr N.V. HarpalaniRCBB : Mr. J.K. ShahTeam: Mr AV Shah/Mr NK Patel/Mr. Sachin/ Mr. DV Solanki/ Mr.AtaliaProcess Owner(s): Mr. AV Shah

Project Scope/Boundaries:Process Start: Procurement Process Stop: MaintenanceIn Scope: Installation & Maintenance Out of Scope: Procurement & Calibration

Milestones/Timeline: Scheduled ActualDefine Tollgate Review: Jan, 2009 Jan’09Measure Tollgate Review: Mar, 2009 Mar’09Analyze Tollgate Review: Apr , 2009 Apr’09Improve Tollgate Review: Apr, 2009 Apr’09Control Tollgate Review: May, 2009 June’09

Customer

Objective Statement

In view of better Process Safety Management, the obsolete HCN monitoring system was replaced. After installation, within 18 months, 6 times card failures were observed for 18 installed monitors. Inspite of putting all efforts problem persisted. Hence, the project was taken as six sigma project in Dec’08.

External: NA

Internal: HOD(ACN Plan)/HOS (Inst-ACN)

Failure of HCN monitor cards in ACN plant from Oct'07 to Dec'08 6 times against expected failures NIL.

Reduce failures of HCN monitor cards from an average of 4/year to zero by April’09.

Financial Impact (SOFT Project)

Type of BenefitsAnnualized

Savings (Rs. Lacs)

Top line Growth (Revenue) NA

Net Bottom-line Growth (Hard Savings) NA

Cost Avoidance NA

Total

D A M I C

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Project Scoping D A M I C

 

AQUEOUS WASTE STREAM FOR TREATMENTLP STEAM

PROCESS VENT TO ATMOSHPERE FROM ABSORBER

PROPYLENE

AMMONIA

CONDENSATE

DM WATER

STEAMB/D

WASTE WATER

SEWER

ACN TO PRODUCT STORAGE

ACN PRODUCT HCN PRODUCT

HCN MONITORING SYSTEM IN ACN PLANT

PROCESS AIR COMPRESSOR

OXYGEN FROM PP4

REACTOR SECTION

CATALYST STORAGE & HANDLING

BOILER FEED WATER

TREATMENT

BFW CHEMICAL ADDITION

QUENCH SYSTEMRECOVERY

SYSTEM

PURIFICATION SECTION

PRODUCT RUNDOWN

TANK

SULPHURIC ACID

CHEMICAL AND INHIBITOR

PRE TREATMENT

SYSTEM

CIRCULAR POND

CRUDE ACRYLO TANK

SEGREGATED PROCESS SEWER

SLOP WATER TANK

CATALYST SETTLING

INCINERATOR

HCN SECTION

ACETONITRILE PURIFICATION

POND

INHIBITORS

HM19HM11HM16

HM18

HM14

HM28

HM21

HM29

HM12 HM13

HM17 HM15HM23

HM22

HM27

HM24

HM26

HM25

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Target Setting

Baseline 4 failures/yr

Entitlement NA

Target 0 failures/yr

Result 0 failures since April’09

D A M I C

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Measure Phase Overview

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

M A D I C

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POND

HCN MONITORING SYSTEM IN ACN PLANT

AQUEOUS WASTE STREAM FOR TREATMENT

LP STEAM

PROCESS VENT TO

ATMOSHPERE FROM ABSORBER

PROPYLENE

AMMONIA Process Mapping

CONDENSATE

DM WATER

STEAM

B/D

WASTE WATER

SEWER

ACN TO PRODUCT STORAGE

ACN PRODUCT HCN PRODUCT

HCN MONITORING SYSTEM

UPS POWER

SENSOR

TRANSMITTER UNIT

SIGNAL CONDITION

ER

POWER SUPPLY CARD

MEMORYOUTPUT MODULE

BARRIER DCS I/O CARD

110VAC/24VDC P/S

Procurement Installation Commissioning Maintenance

M A D I C

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Fishbone Analysis M A D I C

Improper regulation

Defective PS boardincompatible barrier Earthpit drydefective barrier Improper MOC

Salt level low

Deliberate touch

Improper location

Improper support

Nearby steam or otherhot source Water spray

steam leakagesteam leakage process drains

Periodical area cleaning

Nearbyhot work

Fire hydrant testing

Improper mounting of canopySkill

KnowledgeExperience

Lack of trainingHeavy rain

High temperature Vibration Poor maintenance

Poor mounting

improper supportmounting on beamAmbient

condition

Poor quality of component

Sunlight exporsure

RF interference

Nearby heavy machines

Component failure

Dry solderImproper fixing of PCB'sHigh voltage to Tx. Card

Poor supervision

Technical ability

Defective hardware

Improper handling

Poor installation

Water ingress

Surrounding steam/water

Poor Tx. ProtectionCanopy not providedCanopy damaged

Humidity high

SMP not followed

No SMP

High voltage cable running parallel

On/Off switching of heavy equipment

Shield connected to both ends

Interference/Noise in power supply

Human errorSOP not followed

Fluctuation in power supply

Loose connection

Human improper crimpingFaulty/rusted TB

nearby welding work

Failure of HCN monitor cards

High resistance of earthpit

Improper Earthing/ Shielding

No connection/continuity

nearby walkie-talkie / mobile

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List of Quick wins M A D 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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List of Xs Shortlisted from CE Matrix

Name of ‘X’Sl. No.

Power supply characteristicsX1

M A D I C

EnclosureX2

Noise immunityX3

Barrier compatibility with Tx.X4

OEM recommendation for installationX5

Grounding / EarthingX6

Skill / Knowledge of maintenance personnelX7

Health check / LLF of HCN monitoring systemX8

Quality inspection for workmanship of Tx. modulesX9

File

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Analyze Phase Overview

Analyze FMEA Form FMEA Action Details Data Collection Plan MAIC Funnel

A D M I C

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FMEA Form A D M I C

Power supply characteristics

supply>30V component failure of PS board

10 Malfunctioning of voltage regulatory system of COSEL PS.

3 COSEL regulated supply & barrier

6 180

10 High voltage cable running parallel

3 BMP compliance 6 180

10 On/Off switching of heavy equipment

3 Good engineering practice 6 180

10 Faulty barrier 2 procurement of standard make barriers

6 120

Rapid ON/OFF switching of power supply corruption of microcontroller memory/ damage to PS board

10 loose connection 6 skill technician, scheduled audits, standard wiring practice

6 360

10 barrier/PS malfunction 3 procurement of standard make barriers /PS

6 180

Compatibility with Tx. Supply to Tx. Out of limits (Current at Tx > 22 mA, Voltage > 30 VDC)

Failure of component of P/S

6 Improper current regulation by barrier

1 Barrier compatibility check before

3 18

Good engineering practice

Enclosure not as per IP54 SC in PCB's due to water ingress

10 Improper fixing of enclosure

3 skill technician, scheduled audits

3 90

10 Improper dimensions of enclosure

1 specifications, inspections 1 10

Water ingress SC in PCB's 10 Heavy rain 3 scheduled audits for monsoon protection/

3 90

10 Nearby steam leakages

3 LLF 2 60

10 process drains 2 LLF 2 40

10 Periodical area cleaning with water jet

2 LLF 2 40

10 Fire hydrant testing 2 Canopy provision done/ Monsoon protection for Tx.

2 40

10 Canopy improper 2 LLF 3 60

10 improper glanding 2 skilled technician, LLF 3 60

RPN

DET

Potential Failure Mode (What is wrong with the X / How the X fails?)

Characteristic of Input (KPIV / X)

Current Process Controls

Potential Cause(s)/Mechanism(s) of Failure (Sub X's)

OCC

Potential Effects of Failure (Y or

Mini-Y)

SEV

File

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Xs Treatment based on FMEA

# 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)

A D M I C

Actions have been taken for Xs irrespective of RPN wherever simple, quick and cost-effective solutions were possible

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Actions Count

Total Recommended

30

Timely Completion/ Ongoing

28

Delayed Completion

0

Pending Completion

2

FMEA Action Summary

Action Type Summary Count

Mistake Proofing 1

Occurrence Reduction (w/o Mistake Proofing)

23

Detection Improvement 6

A D M I C

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Data collection -1 A D M I C

RZ-6 13/14 RB-1/64 RZ-2 31/32 RB-2/47 RZ-3 15/16 RB-2/42

Barrier input (V)

Barrier output (V)

Sensor head (V)

Barrier input (V)

Barrier output (V)

Sensor head (V)

Barrier input (V)

Barrier output (V)

Sensor head (V)

1 31.01.09 23.13 17.78 23.36 17.63 23.13 17.62 02.02.09 23.12 17.78 23.36 17.63 23.13 17.63 04.02.09 23.12 17.78 17.79 23.36 17.63 17.65 23.13 17.6 17.634 06.02.09 23.12 17.78 17.8 23.36 17.63 17.64 23.12 17.6 17.65 08.02.09 23.13 17.78 17.79 23.37 17.63 17.64 23.13 17.59 17.636 10.02.09 23.13 17.78 17.79 23.37 17.63 17.64 23.12 17.6 17.637 12.02.09 23.12 17.78 17.8 23.37 17.63 23.11 17.68 12.02.09 23.12 17.78 23.38 23.37 23.3 23.12 23.1 239 14.02.09 23.12 17.79 17.79 23.38 23.37 23.3 23.12 23.1 23

10 16.02.09 23.13 17.8 17.8 23.38 23.37 23.3 23.12 23.1 2311 18.02.09 23.13 17.8 17.79 23.38 23.37 23.3 23.13 23.1 23

Measurement of voltages in loop at barrier and at sensor head

Sr. No. Date Remarks

After replacing barrier with MTL 5041

HM-17 HM-22 HM-24MRC-302 MRC-303 MRC-302

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Data collection -2 A D M I C

TransmitterDCS

marshelling cabinet

Shield connected to earth (Y/N)

Branch cable shield connected to JB shield bus bar (Y/N)

Shields from multicore cable connected to JB shield bus bar (Y/N)

Shields of multicore cable connected to signal earth (Y/N)

1 BACNHM1.1 J B- BA121- 11E NO YES YES YES2 BACNHM1.2 J B- BA611- 02E NO YES YES YES3 BACNHM1.3 J B- BA611- 02E NO YES YES YES4 BACNHM1.4 J B- BA131- 01E NO YES YES YES5 BACNHM1.5 J B- BA611- 02E NO YES YES YES6 BACNHM1.6 J B- BA121- 03E NO NO* YES YES7 BACNHM1.7 J B- BA611- 02E NO NO* YES YES8 BACNHM1.8 J B- BA121- 02E NO NO* YES YES9 BACNHM1.9 J B- BA121- 03E NO NO* YES YES10 BACNHM2.1 J B- BA141- 03E NO YES YES YES11 BACNHM2.2 J B- BA141- 03E NO YES YES YES12 BACNHM2.3 J B- BA141- 05E NO YES YES YES13 BACNHM2.4 J B- BA141- 02E NO NO* YES YES14 BACNHM2.5 J B- BA141- 02E NO YES YES YES15 BACNHM2.6 J B- BA141- 02E NO YES YES YES16 BACNHM2.7 J B- BA141- 03E NO YES YES YES17 BACNHM2.8 J B- BA141- 05E NO NO* YES YES18 BACNHM2.9 DIRECT NO NO J B NO J B YES

Note* FOUND NOT CONNECTED IN SHIELD BAR IN J B BUT NOW CONNECTED.

Audit for grounding of shield for HCN monitors

Sr. No.

TAG No. J B No.

J unction Box

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MAIC Funnel – Xs PrioritizationTool Box

Measure ToolsPFD, Input/Output worksheet, Fishbone, CE-Matrix

Analyze ToolsFMEA

Improve ToolsBrainstorming

Control ToolsBrainstorming, Control plan

119

19

6

A D M I C

9

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Improve Phase

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.

I D M A C

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Control Phase Overview

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

C D M A I

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Control Plans for Sustainable Results

D M A I C

C D M A I

Type Brief Details

The Column A of FMEA form

Mention the parameter (Input - X /

Output - Y) to be controlled

Is the parameter an

input or an output?

What are the specifications / requirements

which the parameter

"What's Controlled"

should meet?

How will you measure / know the value/status of the parameter "What's

Controlled"?

How will you ensure that the

parameter remains within

specifications or meets

requirements?

Explain the control method

implemented

What is the sample size,

taken at one time, for measurement?

Maintenance of Monitors

Power supply characteristics

Input Supply to Tx. Within limits

(Voltage between 16 - 30 VDC)

By measurement SOP (1) Log of Tx. Supply voltage shall be helpful in knowing PS variation etc.(2) Whenever barrier is changed it should be replaced with MTL 5041 barrier

One

As and when required

Maintenance of Monitors

Power supply characteristics

Input No power supply interruption to Tx.

Using diagnostic dongle

SOP Diagnostic dongle logs power cycle as an event. So, any power interruption to Tx. can be determined

1 for 30 days

Maintenance of Monitors

Water ingress Input No water ingress should be observed

Physical inspection of Tx. during calibration

SOP (1) Coordination between Instrument & Process at time of area cleaning. (2) Coordination between Inst/ Process & Fire during fire system checking(3)Monsoon protection

One

Maintenance of Monitors

No high vibration of Tx.

Input LLF SOP During LLF to be ensured that there is no vibration of Tx.

One

Maintenance of Monitors

Protection from sunlight

Input Such that Temp should be < 60 deg C

Using sensor dongle SOP Dongle data to be analysed for any high temp alarm event. Also, to be checked that proper sunlight protection to Tx. Is provided by canopy.

1 for 30 days

Maintenance of Monitors

Shielding/Grounding integrity

Input As per OEM recommendations

Physical checking SOP (1) All shields to be intact. Also, shields to be grounded only at C/R.(2) Earthpit resistance should be < 10 ohm

One

Maintenance of Monitors

Knowledge about monitors

Input Knowledge about operation and maintenance procedures as per OEM manual

Refresher training and validation

SOP All supervisory/non supervisory to undergo refresher training in operation & maintenance of HCN monitors

One

Input orOutput?

Spec. Limits / Requirements

Measurement Method

Sample SizeControl Method

Process StepWhat's

Controlled?

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Control Plan actions for Sustainable Results C D M A I

(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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Project Transition Action Plan (PTAP)

D M A I C

C D M A I

Project Title: Failures of HCN monitor cards in ACN.Transition Owner: Mr. Newand HarpalaniPlan Date: 31/05/'09

Sr. No. Actions Required for Completion

ActionOwner

InitialsScheduledCompletion

ActualCompletion

1 To ensure monsoon protection to HCN monitors every fortnight during monsoon

HOS Ongoing

2 Determine probability of steam leakage in sensor/Tx. Vicinity and decide frequency of LLF.

HOS Ongoing

3 (1) Process drains to be avoided(2) If required, to be done after informing inst. For necessary precautionary measures.

HOS Ongoing

4 Periodical area cleaning to be done after informing inst. for necessary precautionary measures.

HOS Ongoing

5 (1) Probability of water ingress due to fire hydrant testing to be ensured.(2) Fire personnel to be made aware about possible Tx. failure due to water ingress.

HOS Ongoing

6 Ensure canopy and monsoon protection is intact HOS Ongoing7 (1) Ensure cable entry to Tx. Is from bottom.

(2) Ensure gland sealant or monsoon protection tape is applied.HOS Ongoing

8 Verify condition of canopy during LLF HOS Ongoing9 Verify whether instrument has proper sunlight protection or not

during LLFHOS Ongoing

10 Training/Counselling to all supervisors/technicians to be ensured

HOS 31.07.2009

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Revised FMEA Form

D M A I C

C D M A I

SEV

OCC

DET

RPN

Power supply characteristics

supply>30V 10 3 COSEL regulated supply &

barrier

6 180 (1) Confirm Tx. Sensitivity (Volt V/s time ) to PS over voltage. (2) COSEL P/S regulation(3) Characteristic of

10 1 6 60

10 3 BMP compliance 6 180 audit for cable

routing10 1 2 20

10 3 Good engineering practice 6 180 audit of Tx.

Installation10 1 1 10

10 2 procurement of standard

make barriers

6 120 test setup to study variation in barrier

10 1 6 60

Rapid ON/OFF switching of power supply 10 6 skill technician, scheduled

audits, standard wiring practice

6 360 Wago screwless terminals, proper size wires ferrules, lugs,

10 1 6 60

10 3 procurement of standard

make barriers /PS

6 180 test setup to study variation in barrier

10 2 6 120

Compatibility with Tx. Supply to Tx. Out of limits (Current at Tx > 22 mA, Voltage > 30 VDC)

6 1 Barrier compatibility check before

3 18 ensure & follow OEM

6 1 3 18

Good engineering practice

Enclosure not as per IP54 10 3 skill technician, scheduled audits

3 90 Checking of enclosure fixing

10 10

10 1 specifications, inspections 1 10 Checking of enclosure

10 10

Water ingress 10 3 scheduled audits for monsoon protection/

3 90 To ensure monsoon

10 10

10 3 LLF 2 60 Determine probability of

10 10

10 2 LLF 2 40 (1) Process drains to be avoided

10 10

10 2 LLF 2 40 To be done after informing inst. For

10 10

10 2 Canopy provision done/ Monsoon protection for Tx.

2 40 (1) Probability of water ingress due

10 10

10 2 LLF 3 60 Ensure canopy and monsoon

10 10

10 2 skilled technician, LLF 3 60 (1) Ensure cable entry to Tx. Is

10 10

Action ResultsRPN

RecommendedAction(s)

DET

Potential Failure Mode (What is wrong with the X / How the X fails?)

Characteristic of Input (KPIV / X)

Current Process Controls

OCC

SEV

File

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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