Tap any failure mode → flip to its on-site guidance (pure-CSS, no JS needed on mobile)
Fired Heaterfired_heater
⚠ ⚠ Top risk: Refractory Lining Thinning -> Shell Over-temperature (Hot Spot) · RPN 288 (Critical) — watch this one first at the equipment
Risk Board (all 29 · 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)
29Failure Modes
26High/Critical
30Standards
3Real Accidents
Tap any failure mode to flip to its on-site guidance
Device-level standard/accident index (30 standards / 3 accidents)
Standards (30 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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
  • API 581-2025
  • GB/T 44692
  • GB/T 11348
  • GB/T 6075
  • ISO 13372 — Condition monitoring and diagnostics of machines — Vocabulary
  • ISO 13374 — Condition monitoring and diagnostics of machines — Data processing, communication and presentation
  • ISO 17359 — Condition monitoring and diagnostics of machines — General guidelines
Accident Lessons (3 de-duplicated)
2024-01-I-CAcsb2023 ↗
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
2022-01-I-OHcsb2022 ↗
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
2011-05-I-KYcsb2011 ↗
Carbide Industries 电石电弧炉爆炸（Louisville）
FM Traceability Cards (29)
Generated by Reliability AI
Refractory Lining Thinning -> Shell Over-temperature (Hot Spot)RPN 288 · Critical
Failure Mechanism
Long-term high-temperature attack on lining; mechanical wear or erosion; construction-quality defect
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every6months
Mitigation (What to Do)
  • Periodically replace valve plate
  • Inspect valve-plate cracks
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 (23)
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Weld CrackRPN 240 · Critical
Failure Mechanism
焊接质量缺陷（如未熔合、气孔）；热应力循环导致疲劳；材料高温蠕变
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every6months
Mitigation (What to Do)
  • 定期进行焊缝无损检测
  • 检查热循环记录
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 (23)
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Furnace Tube Oxidation / SpallingRPN 168 · High
Failure Mechanism
Excessive furnace oxygen; local over-temperature accelerating oxidation; insufficient material oxidation resistance
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every6months
Mitigation (What to Do)
  • Periodically inspect furnace-tube scale
  • Clean oxide scale
  • Apply anti-oxidation coating
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 (25)
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • API 580 — Risk-Based Inspection
  • API 581-2025
  • GB/T 44692
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Ignition Failure / FlameoutRPN 144 · Critical
Failure Mechanism
Ignition electrode damaged or carbon-fouled; fuel pressure fluctuation or loss; improper damper adjustment
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • Inspect ignition transformer and electrodes
  • Check fuel supply pressure
  • Clean ignition-electrode carbon
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 (23)
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Stack CorrosionRPN 144 · Critical
Failure Mechanism
High fuel sulfur, high flue-gas dew point; poor stack insulation causing wall temperature below acid dew point; frequent start/stop producing condensate
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • Periodic thickness check of stack wall
  • Inspect liner corrosion
  • Monitor flue-gas dew-point temperature
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 (24)
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 580 — Risk-Based Inspection
  • API 581-2025
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Bend ThinningRPN 120 · Critical
Failure Mechanism
介质流速过高或含固体颗粒；弯头处流道突变加剧冲刷；材质耐腐蚀性不足
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • 定期测量回弯头壁厚
  • 检查冲刷腐蚀
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 (24)
  • API 580 — Risk-Based Inspection
  • API 581-2025
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Valve Seat LeakageRPN 120 · Low
Failure Mechanism
Impurities in fuel gas wear sealing face; long idle causes scaling on face; actuator closing force insufficient or stroke incomplete
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • Periodically replace seals
  • Test actuator action
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 (23)
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Fan ImbalanceRPN 112 · High
Failure Mechanism
燃料或燃烧不充分产生大量粉尘；烟气速度低导致粉尘沉降；缺乏定期清灰措施
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • 监测风机振动值
  • 检查叶轮积灰情况
  • 清理叶轮积灰并做动平衡
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 (28)
  • API 580 — Risk-Based Inspection
  • GB/T 11348
  • GB/T 6075
  • GB/T 7826-2012
  • ISO 13372 — Condition monitoring and diagnostics of machines — Vocabulary
  • ISO 13374 — Condition monitoring and diagnostics of machines — Data processing, communication and presentation
  • ISO 14224:2016 — Petroleum, petrochemical and natural gas industries — Collection and exchange of reliability and maintenance data for equipment
  • ISO 17359 — Condition monitoring and diagnostics of machines — General guidelines
  • SAE JA1011_202411 — Evaluation Criteria for Reliability-Centered Maintenance Processes
  • GB/T 27921-2011
  • GB/T 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Creep/BulgingRPN 108 · Critical
Failure Mechanism
操作温度超过设计值；局部过热导致热应力集中；材质高温强度不足
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 定期测量炉管外径
  • 监测炉管温度
  • 检查火焰分布
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 (23)
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
OxidationRPN 108 · High
Failure Mechanism
炉管表面温度过高；燃料含硫等腐蚀性物质；氧化皮剥落加速腐蚀
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 定期测厚检查氧化皮厚度
  • 检查表面氧化层是否剥落
  • 评估剩余壁厚是否满足强度要求
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 (24)
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 580 — Risk-Based Inspection
  • API 581-2025
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Flame ImpingementRPN 108 · Critical
Failure Mechanism
燃烧器安装角度偏差；燃料/空气配比不当；烧嘴堵塞导致火焰偏斜
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 检查火焰形状和位置
  • 调整燃烧器风门
  • 修复或更换偏斜的烧嘴
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 (23)
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Bearing FailureRPN 108 · Critical
Failure Mechanism
润滑脂变质或不足；粉尘进入轴承箱污染润滑脂；长期过载或振动导致疲劳失效
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 定期振动监测
  • 油液分析
  • 红外热成像
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 (28)
  • API 580 — Risk-Based Inspection
  • GB/T 11348
  • GB/T 6075
  • GB/T 7826-2012
  • ISO 13372 — Condition monitoring and diagnostics of machines — Vocabulary
  • ISO 13374 — Condition monitoring and diagnostics of machines — Data processing, communication and presentation
  • ISO 14224:2016 — Petroleum, petrochemical and natural gas industries — Collection and exchange of reliability and maintenance data for equipment
  • ISO 17359 — Condition monitoring and diagnostics of machines — General guidelines
  • SAE JA1011_202411 — Evaluation Criteria for Reliability-Centered Maintenance Processes
  • GB/T 27921-2011
  • GB/T 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
High-temp FailureRPN 105 · High
Failure Mechanism
材料耐热等级不足；局部超温；支架设计强度不足
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 定期检查支架外观，测量变形量
  • 监测支架温度，避免超温
  • 根据蠕变曲线预测剩余寿命
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 (23)
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Dew Point CorrosionRPN 105 · High
Failure Mechanism
燃料含硫产生SO3；排烟温度过低；炉管表面温度低于露点
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 监测烟气温度，确保高于露点
  • 检查炉管表面腐蚀情况
  • 必要时进行化学清洗
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 (23)
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
CarburizationRPN 96 · Critical
Failure Mechanism
燃料不完全燃烧产生富碳气氛；炉管表面结焦促进渗碳；材质抗渗碳性能差
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 定期取样分析炉管材质
  • 监测炉管表面碳含量
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 (23)
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Damper StickingRPN 96 · High
Failure Mechanism
烟气中粉尘在转轴处沉积结垢；高温下金属热膨胀导致间隙消失；润滑不良或轴承损坏
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 检查挡板动作灵活性
  • 清理转轴和叶片积灰
  • 润滑转轴
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 (23)
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
ErosionRPN 90 · High
Failure Mechanism
烟气中颗粒物含量高；烟气速度过高；翅片材料耐磨性不足
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 检查翅片表面磨损痕迹
  • 测量翅片厚度
  • 评估烟气速度分布
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 (23)
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Burner Tip PluggingRPN 90 · Medium
Failure Mechanism
燃料过滤不充分；燃料含焦油或固体颗粒；烧嘴温度过低导致结焦
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 定期清理烧嘴孔
  • 检查燃料过滤器
  • 更换堵塞严重的烧嘴
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 (23)
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Lining LossRPN 90 · Critical
Failure Mechanism
Sharp temperature change causing thermal stress cracking; poor construction, anchor failure; flue-gas alkali or sulfide attacking lining
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • Inspect lining surface cracks and spalling
  • Hammer-test lining soundness
  • Repair or replace damaged lining
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 (23)
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Pilot OutageRPN 84 · High
Failure Mechanism
燃料供应不稳定；风门过大吹灭火焰；长明灯结构堵塞
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 检查长明灯燃料供应
  • 检查火焰检测器
  • 清理长明灯喷嘴
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 (23)
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Refractory SpallingRPN 84 · High
Failure Mechanism
温度急剧变化引起热震；安装或烘烤不当；燃料含硫等腐蚀性物质
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 定期壁厚测量
  • 红外热成像
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 (24)
  • API 580 — Risk-Based Inspection
  • API 581-2025
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Fin Loss/FoulingRPN 80 · Medium
Failure Mechanism
烟气冲刷导致翅片疲劳；腐蚀性气氛加速翅片失效；积灰堵塞翅片间隙
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 检查翅片完整性，记录脱落数量
  • 清理积灰，测量传热效率
  • 振动监测，评估机械状态
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 (23)
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Internal CokingRPN 72 · Critical
Failure Mechanism
介质易结焦（如重油）；管内流速过低；管壁温度过高
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 监测炉管压差
  • 定期清焦
  • 优化操作温度
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 (23)
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Lens FoulingRPN 72 · Critical
Failure Mechanism
燃烧不充分产生大量碳黑；燃料含重质烃类在镜头凝结；吹扫风量不足或吹扫方向不当
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 定期清洁镜头
  • 检查吹扫系统
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 (23)
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Actuator FailureRPN 72 · High
Failure Mechanism
密封件老化或磨损；弹簧疲劳或断裂；电磁阀故障或卡涩
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 定期红外热成像
  • 目视检查
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 (23)
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
TC FailureRPN 70 · High
Failure Mechanism
高温氧化导致热电极材料劣化；绝缘层破损引起短路；机械振动导致接线松动或断裂
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 定期校准热电偶
  • 检查绝缘电阻
  • 更换老化或损坏的热电偶
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 (23)
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Actuator FailureRPN 60 · High
Failure Mechanism
电气元件老化或受潮短路；气动执行机构密封件磨损漏气；机械传动部分润滑不足导致卡涩
How to Detect
Online monitoring · Detection rate 80% ；Interval by RBI
Mitigation (What to Do)
  • 检查执行机构电机和齿轮
  • 测试动作响应时间
  • 更换磨损的密封件
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 (23)
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Hot SpotRPN 54 · Critical
Failure Mechanism
燃烧器火焰偏斜；炉管结焦导致局部过热；燃料气组分波动
How to Detect
Online monitoring · Detection rate 80% ；Interval by RBI
Mitigation (What to Do)
  • 安装炉管温度监测
  • 调整燃烧器
  • 检查火焰形状
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 (23)
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗
Electronics FailureRPN 48 · Critical
Failure Mechanism
环境温度过高超出元件耐受范围；电路板受潮导致短路或腐蚀；电源波动或雷击造成过电压损坏
How to Detect
Online monitoring · Detection rate 80% ；Interval by RBI
Mitigation (What to Do)
  • 定期功能测试
  • 检查环境温湿度
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 (23)
  • 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 36894-2018
  • GB/T 44958-2024
  • GB/T 37243-2019
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 510 — Pressure Vessel Inspection Code
  • API 570 — Piping Inspection Code
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • 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 (3)
2024-01-I-CAcsb2023Injuries 1 · Safety
Marathon Martinez Renewable Diesel Unit Heater Tube Rupture Fire
Root cause: Valve misalignment caused low-flow maldistribution + burner air-duct blockage reignition -> furnace tube over-temperature rupture.
Official source ↗
2022-01-I-OHcsb2022Fatalities 2 · Safety
BP-Husky Toledo Fuel-gas Mix Drum Overflow -> Boiler/Heater Fire
Root cause: Missing Fuel Gas Mix Drum high-level / overflow safeguards + alarm flooding + inadequate abnormal-situation management (ASM).
Official source ↗
2011-05-I-KYcsb2011Fatalities 2 · Injuries 2 · Safety
Carbide Industries 电石电弧炉爆炸（Louisville）
Root cause: 电弧炉炉盖冷却水泄漏长期带病运行（多年反复维修而不更换），水入炉与电石反应压力骤升爆炸，热气与飞屑击穿控制室窗致 2 死 2 伤
Official source ↗