Tap any failure mode → flip to its on-site guidance (pure-CSS, no JS needed on mobile)
Control Valvecontrol_valve
⚠ ⚠ Top risk: Spring Fatigue / Fracture · RPN 128 (Critical) — watch this one first at the equipment
Risk Board (all 14 · by RPN · top 6 highlighted urgent)
Shield: Safety = people/environment　Production = production only
Technical mechanism/mitigation body in Chinese (red line: no fabricated MT; EN UI labels translated)
14Failure Modes
11High/Critical
18Standards
8Real Accidents
Tap any failure mode to flip to its on-site guidance
Device-level standard/accident index (18 standards / 8 accidents)
Standards (18 de-duplicated)
  • API 580 — Risk-Based Inspection
  • GB/T 7826-2012
  • ISO 14224:2016 — Petroleum, petrochemical and natural gas industries — Collection and exchange of reliability and maintenance data for equipment
  • SAE JA1011_202411 — Evaluation Criteria for Reliability-Centered Maintenance Processes
  • GB/T 27921-2011
  • GB/T 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 570 — Piping Inspection Code
  • API 754 — Process Safety Performance Indicators
  • API 576 — Inspection of Pressure-Relieving Devices
  • API 689 — Collection and Exchange of Reliability and Maintenance Data
  • API 755 — Human Factors
  • ISO 20815:2018 — Petroleum, petrochemical and natural gas industries — Production assurance and reliability
  • IEC 61511:2016 — Functional safety — Safety instrumented systems for the process industry sector
  • ISO 31000:2018 — Risk management — Guidelines
Accident Lessons (8 de-duplicated)
2021-05-I-TXcsb2021 ↗
LyondellBasell La Porte 控制阀误拆甲醇释放（拉波特）
2010-06-I-GOMcsb2010 ↗
Macondo / Deepwater Horizon Blowout
2021-07-I-TXcsb2021 ↗
LyondellBasell La Porte 醋酸装置柱塞阀压力保持件误拆致命泄漏
2004-04-I-ILcsb2004 ↗
Formosa Plastics Illiopolis PVC 装置反应器底阀安全联锁被旁路爆炸
2014-11-I-TXcsb2014 ↗
DuPont La Porte 甲硫醇经两阀泄漏致命中毒
NUREG-LER-2022-001NUREG2022 ↗
Susquehanna 1 号机 主蒸汽隔离阀阀座磨损泄漏
NUREG-LER-2012-001NUREG2012 ↗
Shearon Harris 1 号机 主蒸汽隔离阀活塞环腐蚀致关闭延迟
HSE-TEXACO-1994HSE1994 ↗
Texaco Milford Haven 炼油厂 控制阀误关（指示开）致 20 吨烃释放爆炸
FM Traceability Cards (14)
Generated by Reliability AI
Spring Fatigue / FractureRPN 128 · Critical
Failure Mechanism
Insufficient spring fatigue strength; prolonged overload or frequent action; corrosive environment causing SCC
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • Monthly inspect spring appearance for cracks or deformation
  • Measure spring stiffness change every half-year
  • Replace spring every 5 years
RCM Strategy
CBMOn-Condition Maintenance
Interval: High risk 1-3 mo / Medium 6-12 mo / Low risk at turnaround (by API 581 RBI risk ranking)
Engineering-inferred (not measured history); confirm with equipment owner before execution
Standards (18)
  • API 580 — Risk-Based Inspection
  • GB/T 7826-2012
  • ISO 14224:2016 — Petroleum, petrochemical and natural gas industries — Collection and exchange of reliability and maintenance data for equipment
  • SAE JA1011_202411 — Evaluation Criteria for Reliability-Centered Maintenance Processes
  • GB/T 27921-2011
  • GB/T 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 570 — Piping Inspection Code
  • API 754 — Process Safety Performance Indicators
  • API 576 — Inspection of Pressure-Relieving Devices
  • API 689 — Collection and Exchange of Reliability and Maintenance Data
  • API 755 — Human Factors
  • ISO 20815:2018 — Petroleum, petrochemical and natural gas industries — Production assurance and reliability
  • IEC 61511:2016 — Functional safety — Safety instrumented systems for the process industry sector
  • ISO 31000:2018 — Risk management — Guidelines
Lessons Learned (8)
2021-05-I-TXcsb2021Fatalities 2 · Injuries 30 · Safety/Environmental
LyondellBasell La Porte 控制阀误拆甲醇释放（拉波特）
Root cause: 阀门维护中承压部件被误拆，隔离与作业程序不足导致甲醇大量释放；2 死 30 伤
Official source ↗
2010-06-I-GOMcsb2010Fatalities 11 · Injuries 17 · Safety/Environmental
Macondo / Deepwater Horizon Blowout
Root cause: Blowout-preventer valve sticking + cement plug failure + missing well-integrity verification.
Official source ↗
2021-07-I-TXcsb2021Fatalities 2 · Injuries 2 · Toxic/Safety
LyondellBasell La Porte 醋酸装置柱塞阀压力保持件误拆致命泄漏
Root cause: 阀门设计未防人误拆（同类事故重复发生）；无拆卸程序与培训；承包商与公司均未识别风险
Official source ↗
2004-04-I-ILcsb2004Fatalities 5 · Injuries 3 · Fire/Explosion/Toxic
Formosa Plastics Illiopolis PVC 装置反应器底阀安全联锁被旁路爆炸
Root cause: 未充分规划人因后果；安全联锁可被轻易旁路且无锁具；反应器分组相似无状态指示；培训与演练不足
Official source ↗
2014-11-I-TXcsb2014Fatalities 4 · Toxic/Safety
DuPont La Porte 甲硫醇经两阀泄漏致命中毒
Root cause: 有缺陷的工程设计+缺乏充分防护；管道堵塞排查作业风险识别不足；应急响应混乱
Official source ↗
NUREG-LER-2022-001NUREG2022Operational
Susquehanna 1 号机 主蒸汽隔离阀阀座磨损泄漏
Root cause: 阀座密封面磨损与材料沉积物致内漏；未能识别阀门劣化趋势
Official source ↗
NUREG-LER-2012-001NUREG2012Operational
Shearon Harris 1 号机 主蒸汽隔离阀活塞环腐蚀致关闭延迟
Root cause: 阀门活塞环意外长期腐蚀；MSIV 未正确纳入气动阀计划；未识别阀门劣化机会
Official source ↗
HSE-TEXACO-1994HSE1994Fire/Explosion
Texaco Milford Haven 炼油厂 控制阀误关（指示开）致 20 吨烃释放爆炸
Root cause: 控制阀实际关闭而控制系统的指示为开；仪表/设备维护不足；改造未做后果评估；控制室人机界面缺陷
Official source ↗
Valve Plug Sticking -> Failure to ActuateRPN 128 · Critical
Failure Mechanism
Air supply contains impurities or moisture; long idle causing rust; lubricant dry or degraded
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • Weekly solenoid-valve actuation test
  • Daily check air-supply filter quality
  • Monthly monitor solenoid-valve actuation time
RCM Strategy
PMScheduled (Proactive) Maintenance
Interval: High risk 1-3 mo / Medium 6-12 mo / Low risk at turnaround (by API 581 RBI risk ranking)
Engineering-inferred (not measured history); confirm with equipment owner before execution
Standards (18)
  • API 580 — Risk-Based Inspection
  • GB/T 7826-2012
  • ISO 14224:2016 — Petroleum, petrochemical and natural gas industries — Collection and exchange of reliability and maintenance data for equipment
  • SAE JA1011_202411 — Evaluation Criteria for Reliability-Centered Maintenance Processes
  • GB/T 27921-2011
  • GB/T 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 570 — Piping Inspection Code
  • API 754 — Process Safety Performance Indicators
  • API 576 — Inspection of Pressure-Relieving Devices
  • API 689 — Collection and Exchange of Reliability and Maintenance Data
  • API 755 — Human Factors
  • ISO 20815:2018 — Petroleum, petrochemical and natural gas industries — Production assurance and reliability
  • IEC 61511:2016 — Functional safety — Safety instrumented systems for the process industry sector
  • ISO 31000:2018 — Risk management — Guidelines
Lessons Learned (8)
2021-05-I-TXcsb2021Fatalities 2 · Injuries 30 · Safety/Environmental
LyondellBasell La Porte 控制阀误拆甲醇释放（拉波特）
Root cause: 阀门维护中承压部件被误拆，隔离与作业程序不足导致甲醇大量释放；2 死 30 伤
Official source ↗
2010-06-I-GOMcsb2010Fatalities 11 · Injuries 17 · Safety/Environmental
Macondo / Deepwater Horizon Blowout
Root cause: Blowout-preventer valve sticking + cement plug failure + missing well-integrity verification.
Official source ↗
2021-07-I-TXcsb2021Fatalities 2 · Injuries 2 · Toxic/Safety
LyondellBasell La Porte 醋酸装置柱塞阀压力保持件误拆致命泄漏
Root cause: 阀门设计未防人误拆（同类事故重复发生）；无拆卸程序与培训；承包商与公司均未识别风险
Official source ↗
2004-04-I-ILcsb2004Fatalities 5 · Injuries 3 · Fire/Explosion/Toxic
Formosa Plastics Illiopolis PVC 装置反应器底阀安全联锁被旁路爆炸
Root cause: 未充分规划人因后果；安全联锁可被轻易旁路且无锁具；反应器分组相似无状态指示；培训与演练不足
Official source ↗
2014-11-I-TXcsb2014Fatalities 4 · Toxic/Safety
DuPont La Porte 甲硫醇经两阀泄漏致命中毒
Root cause: 有缺陷的工程设计+缺乏充分防护；管道堵塞排查作业风险识别不足；应急响应混乱
Official source ↗
NUREG-LER-2022-001NUREG2022Operational
Susquehanna 1 号机 主蒸汽隔离阀阀座磨损泄漏
Root cause: 阀座密封面磨损与材料沉积物致内漏；未能识别阀门劣化趋势
Official source ↗
NUREG-LER-2012-001NUREG2012Operational
Shearon Harris 1 号机 主蒸汽隔离阀活塞环腐蚀致关闭延迟
Root cause: 阀门活塞环意外长期腐蚀；MSIV 未正确纳入气动阀计划；未识别阀门劣化机会
Official source ↗
HSE-TEXACO-1994HSE1994Fire/Explosion
Texaco Milford Haven 炼油厂 控制阀误关（指示开）致 20 吨烃释放爆炸
Root cause: 控制阀实际关闭而控制系统的指示为开；仪表/设备维护不足；改造未做后果评估；控制室人机界面缺陷
Official source ↗
Pressure-Relief Valve Set-point DriftRPN 120 · Medium
Failure Mechanism
Spring material creep; diaphragm aging losing elasticity; adjusting screw loose
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • Calibrate output pressure every 6 months, adjust to set point ±5%
  • Replace diaphragm and spring assembly every 12 months
  • Lock adjusting screw and mark after each calibration
RCM Strategy
CBMOn-Condition Maintenance
Interval: High risk 1-3 mo / Medium 6-12 mo / Low risk at turnaround (by API 581 RBI risk ranking)
Engineering-inferred (not measured history); confirm with equipment owner before execution
Standards (18)
  • API 580 — Risk-Based Inspection
  • GB/T 7826-2012
  • ISO 14224:2016 — Petroleum, petrochemical and natural gas industries — Collection and exchange of reliability and maintenance data for equipment
  • SAE JA1011_202411 — Evaluation Criteria for Reliability-Centered Maintenance Processes
  • GB/T 27921-2011
  • GB/T 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 570 — Piping Inspection Code
  • API 754 — Process Safety Performance Indicators
  • API 576 — Inspection of Pressure-Relieving Devices
  • API 689 — Collection and Exchange of Reliability and Maintenance Data
  • API 755 — Human Factors
  • ISO 20815:2018 — Petroleum, petrochemical and natural gas industries — Production assurance and reliability
  • IEC 61511:2016 — Functional safety — Safety instrumented systems for the process industry sector
  • ISO 31000:2018 — Risk management — Guidelines
Lessons Learned (8)
2021-05-I-TXcsb2021Fatalities 2 · Injuries 30 · Safety/Environmental
LyondellBasell La Porte 控制阀误拆甲醇释放（拉波特）
Root cause: 阀门维护中承压部件被误拆，隔离与作业程序不足导致甲醇大量释放；2 死 30 伤
Official source ↗
2010-06-I-GOMcsb2010Fatalities 11 · Injuries 17 · Safety/Environmental
Macondo / Deepwater Horizon Blowout
Root cause: Blowout-preventer valve sticking + cement plug failure + missing well-integrity verification.
Official source ↗
2021-07-I-TXcsb2021Fatalities 2 · Injuries 2 · Toxic/Safety
LyondellBasell La Porte 醋酸装置柱塞阀压力保持件误拆致命泄漏
Root cause: 阀门设计未防人误拆（同类事故重复发生）；无拆卸程序与培训；承包商与公司均未识别风险
Official source ↗
2004-04-I-ILcsb2004Fatalities 5 · Injuries 3 · Fire/Explosion/Toxic
Formosa Plastics Illiopolis PVC 装置反应器底阀安全联锁被旁路爆炸
Root cause: 未充分规划人因后果；安全联锁可被轻易旁路且无锁具；反应器分组相似无状态指示；培训与演练不足
Official source ↗
2014-11-I-TXcsb2014Fatalities 4 · Toxic/Safety
DuPont La Porte 甲硫醇经两阀泄漏致命中毒
Root cause: 有缺陷的工程设计+缺乏充分防护；管道堵塞排查作业风险识别不足；应急响应混乱
Official source ↗
NUREG-LER-2022-001NUREG2022Operational
Susquehanna 1 号机 主蒸汽隔离阀阀座磨损泄漏
Root cause: 阀座密封面磨损与材料沉积物致内漏；未能识别阀门劣化趋势
Official source ↗
NUREG-LER-2012-001NUREG2012Operational
Shearon Harris 1 号机 主蒸汽隔离阀活塞环腐蚀致关闭延迟
Root cause: 阀门活塞环意外长期腐蚀；MSIV 未正确纳入气动阀计划；未识别阀门劣化机会
Official source ↗
HSE-TEXACO-1994HSE1994Fire/Explosion
Texaco Milford Haven 炼油厂 控制阀误关（指示开）致 20 吨烃释放爆炸
Root cause: 控制阀实际关闭而控制系统的指示为开；仪表/设备维护不足；改造未做后果评估；控制室人机界面缺陷
Official source ↗
Valve Body Corrosion / ErosionRPN 96 · Critical
Failure Mechanism
Excessive medium velocity with solids; corrosive medium; improper material selection
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • UT thickness measurement every 3 months
  • Monthly visual inspect corrosion pits
  • Annual pressure test
RCM Strategy
RTFDesign Modification / Inspection Task
Interval: High risk 1-3 mo / Medium 6-12 mo / Low risk at turnaround (by API 581 RBI risk ranking)
Engineering-inferred (not measured history); confirm with equipment owner before execution
Standards (18)
  • API 580 — Risk-Based Inspection
  • GB/T 7826-2012
  • ISO 14224:2016 — Petroleum, petrochemical and natural gas industries — Collection and exchange of reliability and maintenance data for equipment
  • SAE JA1011_202411 — Evaluation Criteria for Reliability-Centered Maintenance Processes
  • GB/T 27921-2011
  • GB/T 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 570 — Piping Inspection Code
  • API 754 — Process Safety Performance Indicators
  • API 576 — Inspection of Pressure-Relieving Devices
  • API 689 — Collection and Exchange of Reliability and Maintenance Data
  • API 755 — Human Factors
  • ISO 20815:2018 — Petroleum, petrochemical and natural gas industries — Production assurance and reliability
  • IEC 61511:2016 — Functional safety — Safety instrumented systems for the process industry sector
  • ISO 31000:2018 — Risk management — Guidelines
Lessons Learned (8)
2021-05-I-TXcsb2021Fatalities 2 · Injuries 30 · Safety/Environmental
LyondellBasell La Porte 控制阀误拆甲醇释放（拉波特）
Root cause: 阀门维护中承压部件被误拆，隔离与作业程序不足导致甲醇大量释放；2 死 30 伤
Official source ↗
2010-06-I-GOMcsb2010Fatalities 11 · Injuries 17 · Safety/Environmental
Macondo / Deepwater Horizon Blowout
Root cause: Blowout-preventer valve sticking + cement plug failure + missing well-integrity verification.
Official source ↗
2021-07-I-TXcsb2021Fatalities 2 · Injuries 2 · Toxic/Safety
LyondellBasell La Porte 醋酸装置柱塞阀压力保持件误拆致命泄漏
Root cause: 阀门设计未防人误拆（同类事故重复发生）；无拆卸程序与培训；承包商与公司均未识别风险
Official source ↗
2004-04-I-ILcsb2004Fatalities 5 · Injuries 3 · Fire/Explosion/Toxic
Formosa Plastics Illiopolis PVC 装置反应器底阀安全联锁被旁路爆炸
Root cause: 未充分规划人因后果；安全联锁可被轻易旁路且无锁具；反应器分组相似无状态指示；培训与演练不足
Official source ↗
2014-11-I-TXcsb2014Fatalities 4 · Toxic/Safety
DuPont La Porte 甲硫醇经两阀泄漏致命中毒
Root cause: 有缺陷的工程设计+缺乏充分防护；管道堵塞排查作业风险识别不足；应急响应混乱
Official source ↗
NUREG-LER-2022-001NUREG2022Operational
Susquehanna 1 号机 主蒸汽隔离阀阀座磨损泄漏
Root cause: 阀座密封面磨损与材料沉积物致内漏；未能识别阀门劣化趋势
Official source ↗
NUREG-LER-2012-001NUREG2012Operational
Shearon Harris 1 号机 主蒸汽隔离阀活塞环腐蚀致关闭延迟
Root cause: 阀门活塞环意外长期腐蚀；MSIV 未正确纳入气动阀计划；未识别阀门劣化机会
Official source ↗
HSE-TEXACO-1994HSE1994Fire/Explosion
Texaco Milford Haven 炼油厂 控制阀误关（指示开）致 20 吨烃释放爆炸
Root cause: 控制阀实际关闭而控制系统的指示为开；仪表/设备维护不足；改造未做后果评估；控制室人机界面缺陷
Official source ↗
Valve Stem Sticking / BendingRPN 96 · High
Failure Mechanism
Insufficient lubrication; gland too tight; poor alignment or external impact
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • Manually operate weekly to feel resistance
  • Monthly check valve-stem straightness
  • Check actuator stroke quarterly
RCM Strategy
CBMOn-Condition Maintenance
Interval: High risk 1-3 mo / Medium 6-12 mo / Low risk at turnaround (by API 581 RBI risk ranking)
Engineering-inferred (not measured history); confirm with equipment owner before execution
Standards (18)
  • API 580 — Risk-Based Inspection
  • GB/T 7826-2012
  • ISO 14224:2016 — Petroleum, petrochemical and natural gas industries — Collection and exchange of reliability and maintenance data for equipment
  • SAE JA1011_202411 — Evaluation Criteria for Reliability-Centered Maintenance Processes
  • GB/T 27921-2011
  • GB/T 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 570 — Piping Inspection Code
  • API 754 — Process Safety Performance Indicators
  • API 576 — Inspection of Pressure-Relieving Devices
  • API 689 — Collection and Exchange of Reliability and Maintenance Data
  • API 755 — Human Factors
  • ISO 20815:2018 — Petroleum, petrochemical and natural gas industries — Production assurance and reliability
  • IEC 61511:2016 — Functional safety — Safety instrumented systems for the process industry sector
  • ISO 31000:2018 — Risk management — Guidelines
Lessons Learned (8)
2021-05-I-TXcsb2021Fatalities 2 · Injuries 30 · Safety/Environmental
LyondellBasell La Porte 控制阀误拆甲醇释放（拉波特）
Root cause: 阀门维护中承压部件被误拆，隔离与作业程序不足导致甲醇大量释放；2 死 30 伤
Official source ↗
2010-06-I-GOMcsb2010Fatalities 11 · Injuries 17 · Safety/Environmental
Macondo / Deepwater Horizon Blowout
Root cause: Blowout-preventer valve sticking + cement plug failure + missing well-integrity verification.
Official source ↗
2021-07-I-TXcsb2021Fatalities 2 · Injuries 2 · Toxic/Safety
LyondellBasell La Porte 醋酸装置柱塞阀压力保持件误拆致命泄漏
Root cause: 阀门设计未防人误拆（同类事故重复发生）；无拆卸程序与培训；承包商与公司均未识别风险
Official source ↗
2004-04-I-ILcsb2004Fatalities 5 · Injuries 3 · Fire/Explosion/Toxic
Formosa Plastics Illiopolis PVC 装置反应器底阀安全联锁被旁路爆炸
Root cause: 未充分规划人因后果；安全联锁可被轻易旁路且无锁具；反应器分组相似无状态指示；培训与演练不足
Official source ↗
2014-11-I-TXcsb2014Fatalities 4 · Toxic/Safety
DuPont La Porte 甲硫醇经两阀泄漏致命中毒
Root cause: 有缺陷的工程设计+缺乏充分防护；管道堵塞排查作业风险识别不足；应急响应混乱
Official source ↗
NUREG-LER-2022-001NUREG2022Operational
Susquehanna 1 号机 主蒸汽隔离阀阀座磨损泄漏
Root cause: 阀座密封面磨损与材料沉积物致内漏；未能识别阀门劣化趋势
Official source ↗
NUREG-LER-2012-001NUREG2012Operational
Shearon Harris 1 号机 主蒸汽隔离阀活塞环腐蚀致关闭延迟
Root cause: 阀门活塞环意外长期腐蚀；MSIV 未正确纳入气动阀计划；未识别阀门劣化机会
Official source ↗
HSE-TEXACO-1994HSE1994Fire/Explosion
Texaco Milford Haven 炼油厂 控制阀误关（指示开）致 20 吨烃释放爆炸
Root cause: 控制阀实际关闭而控制系统的指示为开；仪表/设备维护不足；改造未做后果评估；控制室人机界面缺陷
Official source ↗
Valve-seat Surface Damage -> Internal LeakRPN 84 · High
Failure Mechanism
介质含硬质颗粒；频繁开关操作；密封面材料不耐磨
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 每月关闭阀门后监测下游压力上升
  • 每季度声发射检测泄漏
  • 每年检查密封面
RCM Strategy
RTFDesign Modification / Inspection Task
Interval: High risk 1-3 mo / Medium 6-12 mo / Low risk at turnaround (by API 581 RBI risk ranking)
Engineering-inferred (not measured history); confirm with equipment owner before execution
Standards (18)
  • API 580 — Risk-Based Inspection
  • GB/T 7826-2012
  • ISO 14224:2016 — Petroleum, petrochemical and natural gas industries — Collection and exchange of reliability and maintenance data for equipment
  • SAE JA1011_202411 — Evaluation Criteria for Reliability-Centered Maintenance Processes
  • GB/T 27921-2011
  • GB/T 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 570 — Piping Inspection Code
  • API 754 — Process Safety Performance Indicators
  • API 576 — Inspection of Pressure-Relieving Devices
  • API 689 — Collection and Exchange of Reliability and Maintenance Data
  • API 755 — Human Factors
  • ISO 20815:2018 — Petroleum, petrochemical and natural gas industries — Production assurance and reliability
  • IEC 61511:2016 — Functional safety — Safety instrumented systems for the process industry sector
  • ISO 31000:2018 — Risk management — Guidelines
Lessons Learned (8)
2021-05-I-TXcsb2021Fatalities 2 · Injuries 30 · Safety/Environmental
LyondellBasell La Porte 控制阀误拆甲醇释放（拉波特）
Root cause: 阀门维护中承压部件被误拆，隔离与作业程序不足导致甲醇大量释放；2 死 30 伤
Official source ↗
2010-06-I-GOMcsb2010Fatalities 11 · Injuries 17 · Safety/Environmental
Macondo / Deepwater Horizon Blowout
Root cause: Blowout-preventer valve sticking + cement plug failure + missing well-integrity verification.
Official source ↗
2021-07-I-TXcsb2021Fatalities 2 · Injuries 2 · Toxic/Safety
LyondellBasell La Porte 醋酸装置柱塞阀压力保持件误拆致命泄漏
Root cause: 阀门设计未防人误拆（同类事故重复发生）；无拆卸程序与培训；承包商与公司均未识别风险
Official source ↗
2004-04-I-ILcsb2004Fatalities 5 · Injuries 3 · Fire/Explosion/Toxic
Formosa Plastics Illiopolis PVC 装置反应器底阀安全联锁被旁路爆炸
Root cause: 未充分规划人因后果；安全联锁可被轻易旁路且无锁具；反应器分组相似无状态指示；培训与演练不足
Official source ↗
2014-11-I-TXcsb2014Fatalities 4 · Toxic/Safety
DuPont La Porte 甲硫醇经两阀泄漏致命中毒
Root cause: 有缺陷的工程设计+缺乏充分防护；管道堵塞排查作业风险识别不足；应急响应混乱
Official source ↗
NUREG-LER-2022-001NUREG2022Operational
Susquehanna 1 号机 主蒸汽隔离阀阀座磨损泄漏
Root cause: 阀座密封面磨损与材料沉积物致内漏；未能识别阀门劣化趋势
Official source ↗
NUREG-LER-2012-001NUREG2012Operational
Shearon Harris 1 号机 主蒸汽隔离阀活塞环腐蚀致关闭延迟
Root cause: 阀门活塞环意外长期腐蚀；MSIV 未正确纳入气动阀计划；未识别阀门劣化机会
Official source ↗
HSE-TEXACO-1994HSE1994Fire/Explosion
Texaco Milford Haven 炼油厂 控制阀误关（指示开）致 20 吨烃释放爆炸
Root cause: 控制阀实际关闭而控制系统的指示为开；仪表/设备维护不足；改造未做后果评估；控制室人机界面缺陷
Official source ↗
Diaphragm RuptureRPN 72 · Critical
Failure Mechanism
膜片材料老化；压力波动过大；安装时膜片受损
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 每月检查执行机构动作是否正常
  • 每季度进行气密性测试
  • 每3年更换膜片
RCM Strategy
CBMOn-Condition Maintenance
Interval: High risk 1-3 mo / Medium 6-12 mo / Low risk at turnaround (by API 581 RBI risk ranking)
Engineering-inferred (not measured history); confirm with equipment owner before execution
Standards (18)
  • API 580 — Risk-Based Inspection
  • GB/T 7826-2012
  • ISO 14224:2016 — Petroleum, petrochemical and natural gas industries — Collection and exchange of reliability and maintenance data for equipment
  • SAE JA1011_202411 — Evaluation Criteria for Reliability-Centered Maintenance Processes
  • GB/T 27921-2011
  • GB/T 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 570 — Piping Inspection Code
  • API 754 — Process Safety Performance Indicators
  • API 576 — Inspection of Pressure-Relieving Devices
  • API 689 — Collection and Exchange of Reliability and Maintenance Data
  • API 755 — Human Factors
  • ISO 20815:2018 — Petroleum, petrochemical and natural gas industries — Production assurance and reliability
  • IEC 61511:2016 — Functional safety — Safety instrumented systems for the process industry sector
  • ISO 31000:2018 — Risk management — Guidelines
Lessons Learned (8)
2021-05-I-TXcsb2021Fatalities 2 · Injuries 30 · Safety/Environmental
LyondellBasell La Porte 控制阀误拆甲醇释放（拉波特）
Root cause: 阀门维护中承压部件被误拆，隔离与作业程序不足导致甲醇大量释放；2 死 30 伤
Official source ↗
2010-06-I-GOMcsb2010Fatalities 11 · Injuries 17 · Safety/Environmental
Macondo / Deepwater Horizon Blowout
Root cause: Blowout-preventer valve sticking + cement plug failure + missing well-integrity verification.
Official source ↗
2021-07-I-TXcsb2021Fatalities 2 · Injuries 2 · Toxic/Safety
LyondellBasell La Porte 醋酸装置柱塞阀压力保持件误拆致命泄漏
Root cause: 阀门设计未防人误拆（同类事故重复发生）；无拆卸程序与培训；承包商与公司均未识别风险
Official source ↗
2004-04-I-ILcsb2004Fatalities 5 · Injuries 3 · Fire/Explosion/Toxic
Formosa Plastics Illiopolis PVC 装置反应器底阀安全联锁被旁路爆炸
Root cause: 未充分规划人因后果；安全联锁可被轻易旁路且无锁具；反应器分组相似无状态指示；培训与演练不足
Official source ↗
2014-11-I-TXcsb2014Fatalities 4 · Toxic/Safety
DuPont La Porte 甲硫醇经两阀泄漏致命中毒
Root cause: 有缺陷的工程设计+缺乏充分防护；管道堵塞排查作业风险识别不足；应急响应混乱
Official source ↗
NUREG-LER-2022-001NUREG2022Operational
Susquehanna 1 号机 主蒸汽隔离阀阀座磨损泄漏
Root cause: 阀座密封面磨损与材料沉积物致内漏；未能识别阀门劣化趋势
Official source ↗
NUREG-LER-2012-001NUREG2012Operational
Shearon Harris 1 号机 主蒸汽隔离阀活塞环腐蚀致关闭延迟
Root cause: 阀门活塞环意外长期腐蚀；MSIV 未正确纳入气动阀计划；未识别阀门劣化机会
Official source ↗
HSE-TEXACO-1994HSE1994Fire/Explosion
Texaco Milford Haven 炼油厂 控制阀误关（指示开）致 20 吨烃释放爆炸
Root cause: 控制阀实际关闭而控制系统的指示为开；仪表/设备维护不足；改造未做后果评估；控制室人机界面缺陷
Official source ↗
Contact Corrosion / Poor ContactRPN 72 · High
Failure Mechanism
环境湿度过高或含腐蚀性气体；触点材料不耐腐蚀；密封不良导致进水
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 每3个月测量触点接触电阻，记录趋势
  • 每6个月检查触点外观，清洁氧化层
  • 当接触电阻超过初始值20%时更换限位开关
RCM Strategy
RTFDesign Modification / Inspection Task
Interval: High risk 1-3 mo / Medium 6-12 mo / Low risk at turnaround (by API 581 RBI risk ranking)
Engineering-inferred (not measured history); confirm with equipment owner before execution
Standards (18)
  • API 580 — Risk-Based Inspection
  • GB/T 7826-2012
  • ISO 14224:2016 — Petroleum, petrochemical and natural gas industries — Collection and exchange of reliability and maintenance data for equipment
  • SAE JA1011_202411 — Evaluation Criteria for Reliability-Centered Maintenance Processes
  • GB/T 27921-2011
  • GB/T 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 570 — Piping Inspection Code
  • API 754 — Process Safety Performance Indicators
  • API 576 — Inspection of Pressure-Relieving Devices
  • API 689 — Collection and Exchange of Reliability and Maintenance Data
  • API 755 — Human Factors
  • ISO 20815:2018 — Petroleum, petrochemical and natural gas industries — Production assurance and reliability
  • IEC 61511:2016 — Functional safety — Safety instrumented systems for the process industry sector
  • ISO 31000:2018 — Risk management — Guidelines
Lessons Learned (8)
2021-05-I-TXcsb2021Fatalities 2 · Injuries 30 · Safety/Environmental
LyondellBasell La Porte 控制阀误拆甲醇释放（拉波特）
Root cause: 阀门维护中承压部件被误拆，隔离与作业程序不足导致甲醇大量释放；2 死 30 伤
Official source ↗
2010-06-I-GOMcsb2010Fatalities 11 · Injuries 17 · Safety/Environmental
Macondo / Deepwater Horizon Blowout
Root cause: Blowout-preventer valve sticking + cement plug failure + missing well-integrity verification.
Official source ↗
2021-07-I-TXcsb2021Fatalities 2 · Injuries 2 · Toxic/Safety
LyondellBasell La Porte 醋酸装置柱塞阀压力保持件误拆致命泄漏
Root cause: 阀门设计未防人误拆（同类事故重复发生）；无拆卸程序与培训；承包商与公司均未识别风险
Official source ↗
2004-04-I-ILcsb2004Fatalities 5 · Injuries 3 · Fire/Explosion/Toxic
Formosa Plastics Illiopolis PVC 装置反应器底阀安全联锁被旁路爆炸
Root cause: 未充分规划人因后果；安全联锁可被轻易旁路且无锁具；反应器分组相似无状态指示；培训与演练不足
Official source ↗
2014-11-I-TXcsb2014Fatalities 4 · Toxic/Safety
DuPont La Porte 甲硫醇经两阀泄漏致命中毒
Root cause: 有缺陷的工程设计+缺乏充分防护；管道堵塞排查作业风险识别不足；应急响应混乱
Official source ↗
NUREG-LER-2022-001NUREG2022Operational
Susquehanna 1 号机 主蒸汽隔离阀阀座磨损泄漏
Root cause: 阀座密封面磨损与材料沉积物致内漏；未能识别阀门劣化趋势
Official source ↗
NUREG-LER-2012-001NUREG2012Operational
Shearon Harris 1 号机 主蒸汽隔离阀活塞环腐蚀致关闭延迟
Root cause: 阀门活塞环意外长期腐蚀；MSIV 未正确纳入气动阀计划；未识别阀门劣化机会
Official source ↗
HSE-TEXACO-1994HSE1994Fire/Explosion
Texaco Milford Haven 炼油厂 控制阀误关（指示开）致 20 吨烃释放爆炸
Root cause: 控制阀实际关闭而控制系统的指示为开；仪表/设备维护不足；改造未做后果评估；控制室人机界面缺陷
Official source ↗
Valve-plug ErosionRPN 63 · High
Failure Mechanism
介质含固体颗粒；压差大流速高；阀芯材料硬度不足
How to Detect
Inspection/offline · Detection rate 55% ；Interval by RBI
Mitigation (What to Do)
  • 每月检查阀芯外观（通过拆检或内窥镜）
  • 每日监测流量或压降异常
RCM Strategy
CBMOn-Condition Maintenance
Interval: High risk 1-3 mo / Medium 6-12 mo / Low risk at turnaround (by API 581 RBI risk ranking)
Engineering-inferred (not measured history); confirm with equipment owner before execution
Standards (18)
  • API 580 — Risk-Based Inspection
  • GB/T 7826-2012
  • ISO 14224:2016 — Petroleum, petrochemical and natural gas industries — Collection and exchange of reliability and maintenance data for equipment
  • SAE JA1011_202411 — Evaluation Criteria for Reliability-Centered Maintenance Processes
  • GB/T 27921-2011
  • GB/T 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 570 — Piping Inspection Code
  • API 754 — Process Safety Performance Indicators
  • API 576 — Inspection of Pressure-Relieving Devices
  • API 689 — Collection and Exchange of Reliability and Maintenance Data
  • API 755 — Human Factors
  • ISO 20815:2018 — Petroleum, petrochemical and natural gas industries — Production assurance and reliability
  • IEC 61511:2016 — Functional safety — Safety instrumented systems for the process industry sector
  • ISO 31000:2018 — Risk management — Guidelines
Lessons Learned (8)
2021-05-I-TXcsb2021Fatalities 2 · Injuries 30 · Safety/Environmental
LyondellBasell La Porte 控制阀误拆甲醇释放（拉波特）
Root cause: 阀门维护中承压部件被误拆，隔离与作业程序不足导致甲醇大量释放；2 死 30 伤
Official source ↗
2010-06-I-GOMcsb2010Fatalities 11 · Injuries 17 · Safety/Environmental
Macondo / Deepwater Horizon Blowout
Root cause: Blowout-preventer valve sticking + cement plug failure + missing well-integrity verification.
Official source ↗
2021-07-I-TXcsb2021Fatalities 2 · Injuries 2 · Toxic/Safety
LyondellBasell La Porte 醋酸装置柱塞阀压力保持件误拆致命泄漏
Root cause: 阀门设计未防人误拆（同类事故重复发生）；无拆卸程序与培训；承包商与公司均未识别风险
Official source ↗
2004-04-I-ILcsb2004Fatalities 5 · Injuries 3 · Fire/Explosion/Toxic
Formosa Plastics Illiopolis PVC 装置反应器底阀安全联锁被旁路爆炸
Root cause: 未充分规划人因后果；安全联锁可被轻易旁路且无锁具；反应器分组相似无状态指示；培训与演练不足
Official source ↗
2014-11-I-TXcsb2014Fatalities 4 · Toxic/Safety
DuPont La Porte 甲硫醇经两阀泄漏致命中毒
Root cause: 有缺陷的工程设计+缺乏充分防护；管道堵塞排查作业风险识别不足；应急响应混乱
Official source ↗
NUREG-LER-2022-001NUREG2022Operational
Susquehanna 1 号机 主蒸汽隔离阀阀座磨损泄漏
Root cause: 阀座密封面磨损与材料沉积物致内漏；未能识别阀门劣化趋势
Official source ↗
NUREG-LER-2012-001NUREG2012Operational
Shearon Harris 1 号机 主蒸汽隔离阀活塞环腐蚀致关闭延迟
Root cause: 阀门活塞环意外长期腐蚀；MSIV 未正确纳入气动阀计划；未识别阀门劣化机会
Official source ↗
HSE-TEXACO-1994HSE1994Fire/Explosion
Texaco Milford Haven 炼油厂 控制阀误关（指示开）致 20 吨烃释放爆炸
Root cause: 控制阀实际关闭而控制系统的指示为开；仪表/设备维护不足；改造未做后果评估；控制室人机界面缺陷
Official source ↗
Filter-element Blockage -> Insufficient SupplyRPN 63 · High
Failure Mechanism
气源净化不彻底；滤芯未定期更换；上游管道锈蚀产生杂质
How to Detect
Inspection/offline · Detection rate 55% ；Interval by RBI
Mitigation (What to Do)
  • 每1个月检查滤芯压差指示器，记录压差
  • 每3个月更换滤芯，使用原厂备件
  • 安装气源净化装置，定期排放冷凝水
RCM Strategy
CBMOn-Condition Maintenance
Interval: High risk 1-3 mo / Medium 6-12 mo / Low risk at turnaround (by API 581 RBI risk ranking)
Engineering-inferred (not measured history); confirm with equipment owner before execution
Standards (18)
  • API 580 — Risk-Based Inspection
  • GB/T 7826-2012
  • ISO 14224:2016 — Petroleum, petrochemical and natural gas industries — Collection and exchange of reliability and maintenance data for equipment
  • SAE JA1011_202411 — Evaluation Criteria for Reliability-Centered Maintenance Processes
  • GB/T 27921-2011
  • GB/T 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 570 — Piping Inspection Code
  • API 754 — Process Safety Performance Indicators
  • API 576 — Inspection of Pressure-Relieving Devices
  • API 689 — Collection and Exchange of Reliability and Maintenance Data
  • API 755 — Human Factors
  • ISO 20815:2018 — Petroleum, petrochemical and natural gas industries — Production assurance and reliability
  • IEC 61511:2016 — Functional safety — Safety instrumented systems for the process industry sector
  • ISO 31000:2018 — Risk management — Guidelines
Lessons Learned (8)
2021-05-I-TXcsb2021Fatalities 2 · Injuries 30 · Safety/Environmental
LyondellBasell La Porte 控制阀误拆甲醇释放（拉波特）
Root cause: 阀门维护中承压部件被误拆，隔离与作业程序不足导致甲醇大量释放；2 死 30 伤
Official source ↗
2010-06-I-GOMcsb2010Fatalities 11 · Injuries 17 · Safety/Environmental
Macondo / Deepwater Horizon Blowout
Root cause: Blowout-preventer valve sticking + cement plug failure + missing well-integrity verification.
Official source ↗
2021-07-I-TXcsb2021Fatalities 2 · Injuries 2 · Toxic/Safety
LyondellBasell La Porte 醋酸装置柱塞阀压力保持件误拆致命泄漏
Root cause: 阀门设计未防人误拆（同类事故重复发生）；无拆卸程序与培训；承包商与公司均未识别风险
Official source ↗
2004-04-I-ILcsb2004Fatalities 5 · Injuries 3 · Fire/Explosion/Toxic
Formosa Plastics Illiopolis PVC 装置反应器底阀安全联锁被旁路爆炸
Root cause: 未充分规划人因后果；安全联锁可被轻易旁路且无锁具；反应器分组相似无状态指示；培训与演练不足
Official source ↗
2014-11-I-TXcsb2014Fatalities 4 · Toxic/Safety
DuPont La Porte 甲硫醇经两阀泄漏致命中毒
Root cause: 有缺陷的工程设计+缺乏充分防护；管道堵塞排查作业风险识别不足；应急响应混乱
Official source ↗
NUREG-LER-2022-001NUREG2022Operational
Susquehanna 1 号机 主蒸汽隔离阀阀座磨损泄漏
Root cause: 阀座密封面磨损与材料沉积物致内漏；未能识别阀门劣化趋势
Official source ↗
NUREG-LER-2012-001NUREG2012Operational
Shearon Harris 1 号机 主蒸汽隔离阀活塞环腐蚀致关闭延迟
Root cause: 阀门活塞环意外长期腐蚀；MSIV 未正确纳入气动阀计划；未识别阀门劣化机会
Official source ↗
HSE-TEXACO-1994HSE1994Fire/Explosion
Texaco Milford Haven 炼油厂 控制阀误关（指示开）致 20 吨烃释放爆炸
Root cause: 控制阀实际关闭而控制系统的指示为开；仪表/设备维护不足；改造未做后果评估；控制室人机界面缺陷
Official source ↗
Packing Wear -> External LeakRPN 60 · Medium
Failure Mechanism
填料材质不耐磨；阀杆表面粗糙；填料压盖预紧力不足
How to Detect
Inspection/offline · Detection rate 55% ；Interval by RBI
Mitigation (What to Do)
  • 每月目视检查阀杆处有无泄漏
  • 每3个月调整填料压盖
  • 每2年更换填料
RCM Strategy
RTFDesign Modification / Inspection Task
Interval: High risk 1-3 mo / Medium 6-12 mo / Low risk at turnaround (by API 581 RBI risk ranking)
Engineering-inferred (not measured history); confirm with equipment owner before execution
Standards (18)
  • API 580 — Risk-Based Inspection
  • GB/T 7826-2012
  • ISO 14224:2016 — Petroleum, petrochemical and natural gas industries — Collection and exchange of reliability and maintenance data for equipment
  • SAE JA1011_202411 — Evaluation Criteria for Reliability-Centered Maintenance Processes
  • GB/T 27921-2011
  • GB/T 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 570 — Piping Inspection Code
  • API 754 — Process Safety Performance Indicators
  • API 576 — Inspection of Pressure-Relieving Devices
  • API 689 — Collection and Exchange of Reliability and Maintenance Data
  • API 755 — Human Factors
  • ISO 20815:2018 — Petroleum, petrochemical and natural gas industries — Production assurance and reliability
  • IEC 61511:2016 — Functional safety — Safety instrumented systems for the process industry sector
  • ISO 31000:2018 — Risk management — Guidelines
Lessons Learned (8)
2021-05-I-TXcsb2021Fatalities 2 · Injuries 30 · Safety/Environmental
LyondellBasell La Porte 控制阀误拆甲醇释放（拉波特）
Root cause: 阀门维护中承压部件被误拆，隔离与作业程序不足导致甲醇大量释放；2 死 30 伤
Official source ↗
2010-06-I-GOMcsb2010Fatalities 11 · Injuries 17 · Safety/Environmental
Macondo / Deepwater Horizon Blowout
Root cause: Blowout-preventer valve sticking + cement plug failure + missing well-integrity verification.
Official source ↗
2021-07-I-TXcsb2021Fatalities 2 · Injuries 2 · Toxic/Safety
LyondellBasell La Porte 醋酸装置柱塞阀压力保持件误拆致命泄漏
Root cause: 阀门设计未防人误拆（同类事故重复发生）；无拆卸程序与培训；承包商与公司均未识别风险
Official source ↗
2004-04-I-ILcsb2004Fatalities 5 · Injuries 3 · Fire/Explosion/Toxic
Formosa Plastics Illiopolis PVC 装置反应器底阀安全联锁被旁路爆炸
Root cause: 未充分规划人因后果；安全联锁可被轻易旁路且无锁具；反应器分组相似无状态指示；培训与演练不足
Official source ↗
2014-11-I-TXcsb2014Fatalities 4 · Toxic/Safety
DuPont La Porte 甲硫醇经两阀泄漏致命中毒
Root cause: 有缺陷的工程设计+缺乏充分防护；管道堵塞排查作业风险识别不足；应急响应混乱
Official source ↗
NUREG-LER-2022-001NUREG2022Operational
Susquehanna 1 号机 主蒸汽隔离阀阀座磨损泄漏
Root cause: 阀座密封面磨损与材料沉积物致内漏；未能识别阀门劣化趋势
Official source ↗
NUREG-LER-2012-001NUREG2012Operational
Shearon Harris 1 号机 主蒸汽隔离阀活塞环腐蚀致关闭延迟
Root cause: 阀门活塞环意外长期腐蚀；MSIV 未正确纳入气动阀计划；未识别阀门劣化机会
Official source ↗
HSE-TEXACO-1994HSE1994Fire/Explosion
Texaco Milford Haven 炼油厂 控制阀误关（指示开）致 20 吨烃释放爆炸
Root cause: 控制阀实际关闭而控制系统的指示为开；仪表/设备维护不足；改造未做后果评估；控制室人机界面缺陷
Official source ↗
Coil BurnoutRPN 54 · Critical
Failure Mechanism
Excessive supply voltage or prolonged overload; poor coil heat dissipation; high ambient temperature
How to Detect
Inspection/offline · Detection rate 55% ；Interval by RBI
Mitigation (What to Do)
  • Monthly measure coil resistance
  • Inspect coil surface for burn marks weekly
  • Daily monitor solenoid-valve actuation current
RCM Strategy
PMScheduled (Proactive) Maintenance
Interval: High risk 1-3 mo / Medium 6-12 mo / Low risk at turnaround (by API 581 RBI risk ranking)
Engineering-inferred (not measured history); confirm with equipment owner before execution
Standards (18)
  • API 580 — Risk-Based Inspection
  • GB/T 7826-2012
  • ISO 14224:2016 — Petroleum, petrochemical and natural gas industries — Collection and exchange of reliability and maintenance data for equipment
  • SAE JA1011_202411 — Evaluation Criteria for Reliability-Centered Maintenance Processes
  • GB/T 27921-2011
  • GB/T 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 570 — Piping Inspection Code
  • API 754 — Process Safety Performance Indicators
  • API 576 — Inspection of Pressure-Relieving Devices
  • API 689 — Collection and Exchange of Reliability and Maintenance Data
  • API 755 — Human Factors
  • ISO 20815:2018 — Petroleum, petrochemical and natural gas industries — Production assurance and reliability
  • IEC 61511:2016 — Functional safety — Safety instrumented systems for the process industry sector
  • ISO 31000:2018 — Risk management — Guidelines
Lessons Learned (8)
2021-05-I-TXcsb2021Fatalities 2 · Injuries 30 · Safety/Environmental
LyondellBasell La Porte 控制阀误拆甲醇释放（拉波特）
Root cause: 阀门维护中承压部件被误拆，隔离与作业程序不足导致甲醇大量释放；2 死 30 伤
Official source ↗
2010-06-I-GOMcsb2010Fatalities 11 · Injuries 17 · Safety/Environmental
Macondo / Deepwater Horizon Blowout
Root cause: Blowout-preventer valve sticking + cement plug failure + missing well-integrity verification.
Official source ↗
2021-07-I-TXcsb2021Fatalities 2 · Injuries 2 · Toxic/Safety
LyondellBasell La Porte 醋酸装置柱塞阀压力保持件误拆致命泄漏
Root cause: 阀门设计未防人误拆（同类事故重复发生）；无拆卸程序与培训；承包商与公司均未识别风险
Official source ↗
2004-04-I-ILcsb2004Fatalities 5 · Injuries 3 · Fire/Explosion/Toxic
Formosa Plastics Illiopolis PVC 装置反应器底阀安全联锁被旁路爆炸
Root cause: 未充分规划人因后果；安全联锁可被轻易旁路且无锁具；反应器分组相似无状态指示；培训与演练不足
Official source ↗
2014-11-I-TXcsb2014Fatalities 4 · Toxic/Safety
DuPont La Porte 甲硫醇经两阀泄漏致命中毒
Root cause: 有缺陷的工程设计+缺乏充分防护；管道堵塞排查作业风险识别不足；应急响应混乱
Official source ↗
NUREG-LER-2022-001NUREG2022Operational
Susquehanna 1 号机 主蒸汽隔离阀阀座磨损泄漏
Root cause: 阀座密封面磨损与材料沉积物致内漏；未能识别阀门劣化趋势
Official source ↗
NUREG-LER-2012-001NUREG2012Operational
Shearon Harris 1 号机 主蒸汽隔离阀活塞环腐蚀致关闭延迟
Root cause: 阀门活塞环意外长期腐蚀；MSIV 未正确纳入气动阀计划；未识别阀门劣化机会
Official source ↗
HSE-TEXACO-1994HSE1994Fire/Explosion
Texaco Milford Haven 炼油厂 控制阀误关（指示开）致 20 吨烃释放爆炸
Root cause: 控制阀实际关闭而控制系统的指示为开；仪表/设备维护不足；改造未做后果评估；控制室人机界面缺陷
Official source ↗
Feedback Link LooseningRPN 45 · Medium
Failure Mechanism
安装时未按规定扭矩紧固；长期振动导致螺纹松动；温度变化引起材料膨胀差异
How to Detect
Online monitoring · Detection rate 80% ；Interval by RBI
Mitigation (What to Do)
  • 每月检查反馈杆紧固螺栓
  • 每周观察阀门行程与指令信号偏差
  • 每季度使用振动监测
RCM Strategy
CBMOn-Condition Maintenance
Interval: High risk 1-3 mo / Medium 6-12 mo / Low risk at turnaround (by API 581 RBI risk ranking)
Engineering-inferred (not measured history); confirm with equipment owner before execution
Standards (18)
  • API 580 — Risk-Based Inspection
  • GB/T 7826-2012
  • ISO 14224:2016 — Petroleum, petrochemical and natural gas industries — Collection and exchange of reliability and maintenance data for equipment
  • SAE JA1011_202411 — Evaluation Criteria for Reliability-Centered Maintenance Processes
  • GB/T 27921-2011
  • GB/T 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 570 — Piping Inspection Code
  • API 754 — Process Safety Performance Indicators
  • API 576 — Inspection of Pressure-Relieving Devices
  • API 689 — Collection and Exchange of Reliability and Maintenance Data
  • API 755 — Human Factors
  • ISO 20815:2018 — Petroleum, petrochemical and natural gas industries — Production assurance and reliability
  • IEC 61511:2016 — Functional safety — Safety instrumented systems for the process industry sector
  • ISO 31000:2018 — Risk management — Guidelines
Lessons Learned (8)
2021-05-I-TXcsb2021Fatalities 2 · Injuries 30 · Safety/Environmental
LyondellBasell La Porte 控制阀误拆甲醇释放（拉波特）
Root cause: 阀门维护中承压部件被误拆，隔离与作业程序不足导致甲醇大量释放；2 死 30 伤
Official source ↗
2010-06-I-GOMcsb2010Fatalities 11 · Injuries 17 · Safety/Environmental
Macondo / Deepwater Horizon Blowout
Root cause: Blowout-preventer valve sticking + cement plug failure + missing well-integrity verification.
Official source ↗
2021-07-I-TXcsb2021Fatalities 2 · Injuries 2 · Toxic/Safety
LyondellBasell La Porte 醋酸装置柱塞阀压力保持件误拆致命泄漏
Root cause: 阀门设计未防人误拆（同类事故重复发生）；无拆卸程序与培训；承包商与公司均未识别风险
Official source ↗
2004-04-I-ILcsb2004Fatalities 5 · Injuries 3 · Fire/Explosion/Toxic
Formosa Plastics Illiopolis PVC 装置反应器底阀安全联锁被旁路爆炸
Root cause: 未充分规划人因后果；安全联锁可被轻易旁路且无锁具；反应器分组相似无状态指示；培训与演练不足
Official source ↗
2014-11-I-TXcsb2014Fatalities 4 · Toxic/Safety
DuPont La Porte 甲硫醇经两阀泄漏致命中毒
Root cause: 有缺陷的工程设计+缺乏充分防护；管道堵塞排查作业风险识别不足；应急响应混乱
Official source ↗
NUREG-LER-2022-001NUREG2022Operational
Susquehanna 1 号机 主蒸汽隔离阀阀座磨损泄漏
Root cause: 阀座密封面磨损与材料沉积物致内漏；未能识别阀门劣化趋势
Official source ↗
NUREG-LER-2012-001NUREG2012Operational
Shearon Harris 1 号机 主蒸汽隔离阀活塞环腐蚀致关闭延迟
Root cause: 阀门活塞环意外长期腐蚀；MSIV 未正确纳入气动阀计划；未识别阀门劣化机会
Official source ↗
HSE-TEXACO-1994HSE1994Fire/Explosion
Texaco Milford Haven 炼油厂 控制阀误关（指示开）致 20 吨烃释放爆炸
Root cause: 控制阀实际关闭而控制系统的指示为开；仪表/设备维护不足；改造未做后果评估；控制室人机界面缺陷
Official source ↗
I/P Converter FailureRPN 42 · High
Failure Mechanism
环境湿度过高导致电路板腐蚀；电源电压波动或过载；长期振动导致焊点松动
How to Detect
Inspection/offline · Detection rate 55% ；Interval by RBI
Mitigation (What to Do)
  • 每月检查输出气压与输入电流对应关系
  • 每季度使用诊断工具检测响应
  • 每日观察阀门定位精度变化
RCM Strategy
CBMOn-Condition Maintenance
Interval: High risk 1-3 mo / Medium 6-12 mo / Low risk at turnaround (by API 581 RBI risk ranking)
Engineering-inferred (not measured history); confirm with equipment owner before execution
Standards (18)
  • API 580 — Risk-Based Inspection
  • GB/T 7826-2012
  • ISO 14224:2016 — Petroleum, petrochemical and natural gas industries — Collection and exchange of reliability and maintenance data for equipment
  • SAE JA1011_202411 — Evaluation Criteria for Reliability-Centered Maintenance Processes
  • GB/T 27921-2011
  • GB/T 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 570 — Piping Inspection Code
  • API 754 — Process Safety Performance Indicators
  • API 576 — Inspection of Pressure-Relieving Devices
  • API 689 — Collection and Exchange of Reliability and Maintenance Data
  • API 755 — Human Factors
  • ISO 20815:2018 — Petroleum, petrochemical and natural gas industries — Production assurance and reliability
  • IEC 61511:2016 — Functional safety — Safety instrumented systems for the process industry sector
  • ISO 31000:2018 — Risk management — Guidelines
Lessons Learned (8)
2021-05-I-TXcsb2021Fatalities 2 · Injuries 30 · Safety/Environmental
LyondellBasell La Porte 控制阀误拆甲醇释放（拉波特）
Root cause: 阀门维护中承压部件被误拆，隔离与作业程序不足导致甲醇大量释放；2 死 30 伤
Official source ↗
2010-06-I-GOMcsb2010Fatalities 11 · Injuries 17 · Safety/Environmental
Macondo / Deepwater Horizon Blowout
Root cause: Blowout-preventer valve sticking + cement plug failure + missing well-integrity verification.
Official source ↗
2021-07-I-TXcsb2021Fatalities 2 · Injuries 2 · Toxic/Safety
LyondellBasell La Porte 醋酸装置柱塞阀压力保持件误拆致命泄漏
Root cause: 阀门设计未防人误拆（同类事故重复发生）；无拆卸程序与培训；承包商与公司均未识别风险
Official source ↗
2004-04-I-ILcsb2004Fatalities 5 · Injuries 3 · Fire/Explosion/Toxic
Formosa Plastics Illiopolis PVC 装置反应器底阀安全联锁被旁路爆炸
Root cause: 未充分规划人因后果；安全联锁可被轻易旁路且无锁具；反应器分组相似无状态指示；培训与演练不足
Official source ↗
2014-11-I-TXcsb2014Fatalities 4 · Toxic/Safety
DuPont La Porte 甲硫醇经两阀泄漏致命中毒
Root cause: 有缺陷的工程设计+缺乏充分防护；管道堵塞排查作业风险识别不足；应急响应混乱
Official source ↗
NUREG-LER-2022-001NUREG2022Operational
Susquehanna 1 号机 主蒸汽隔离阀阀座磨损泄漏
Root cause: 阀座密封面磨损与材料沉积物致内漏；未能识别阀门劣化趋势
Official source ↗
NUREG-LER-2012-001NUREG2012Operational
Shearon Harris 1 号机 主蒸汽隔离阀活塞环腐蚀致关闭延迟
Root cause: 阀门活塞环意外长期腐蚀；MSIV 未正确纳入气动阀计划；未识别阀门劣化机会
Official source ↗
HSE-TEXACO-1994HSE1994Fire/Explosion
Texaco Milford Haven 炼油厂 控制阀误关（指示开）致 20 吨烃释放爆炸
Root cause: 控制阀实际关闭而控制系统的指示为开；仪表/设备维护不足；改造未做后果评估；控制室人机界面缺陷
Official source ↗