Typical Technical RCA Format
Typical Technical RCA Format
Typical Technical RCA Format
INCIDENT DESCRIPTION :
IMPACT : 1.Safety
2.Production Loss
3.Property loss
4. Financial Loss/Others
DETAILS OF THE
IMPACT :
ROOT CAUSE ANALYSIS OF HV-2003 control valve 100 % opening in DCS upgradation activity on 8 th December, 2021
Unit : INOX Air Products Private Limited – Hazira, Surat PLANT : 885 TPD
INCIDENT DESCRIPTION/PROBLEM STATEMENT:
During plant shut down, the DCS up gradation activities are going on continuous. The DCS up gradation work has start at 11:35 hour and
completed at 13: 25 hours. For those two hour the DCS system are off line (no control through DCS). On 13:25 hour the DCS system has
taken to the online and during that time, Suddenly the both control valve (HV2003 & PIC 1820) are open and the air passed through
suction line of BAC and then enter through recycle line and 3 rd stage cooler then through compressor and pass out through suction line of
2nd stage inter cooler. (the spool piece of 2nd stage after cooler suction line has removed for maintenance).
NOTE : PV-1820 control valve was 100 % open before DCS upgrade.
PHOTOGRAPHS /DOCUMENTS /TRENDS
ROOT CAUSE OF THE ICIDENT:
CONTRIBUTORY CAUSE:
Possible causes
For HV-2003, in logic SD11-LOGIC6, (HIC2003.PSW.1) is used. So it is possible that PSW could be changed from 1 to 2 during offline download due to change in system tag name (.BL reference
number) because of change in FCS. (FCS0202 to FCS0201).
PSW.1= MSL (0% control valve opening)
PSW.2=MSH (100% opening)
For HV-2003, HIC2003.MV could be changed to 100% from 0 % during offline download.