Tap any failure mode → flip to its on-site guidance (pure-CSS, no JS needed on mobile)
Centrifugal Pumpcentrifugal_pump
⚠ ⚠ Top risk: Cage Fracture · RPN 320 (Low) — watch this one first at the equipment
Risk Board (all 59 · 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)
59Failure Modes
39High/Critical
25Standards
6Real Accidents
Tap any failure mode to flip to its on-site guidance
Device-level standard/accident index (25 standards / 6 accidents)
Standards (25 de-duplicated)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 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
  • API 579-1/ASME FFS-1 — Fitness-For-Service
  • GB/T 44692
Accident Lessons (6 de-duplicated)
2020-01-I-TXcsb2019 ↗
Aghorn 注水泵站硫化氢泄漏（敖德萨）
2019-01-I-TXcsb2019 ↗
ITC Deer Park Tank-farm Circulation Pump Failure Fire
2004-08-I-NMcsb2004 ↗
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
2019-03-I-TXcsb2019 ↗
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
NUREG-LER-2019-001NUREG2019 ↗
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
NUREG-PNO-2013-006NUREG2013 ↗
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
FM Traceability Cards (59)
Generated by Reliability AI
Cage FractureRPN 320 · Low
Failure Mechanism
Improper installation deforming cage; excessive bearing vibration; cage material defect or fatigue
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every6months
Mitigation (What to Do)
  • Replace bearing
  • Inspect cage condition
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 (17)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Diaphragm Fatigue FractureRPN 256 · Critical
Failure Mechanism
Coupling misalignment causing extra bending stress; frequent start/stop or torque shock; insufficient diaphragm fatigue strength
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every6months
Mitigation (What to Do)
  • Replace diaphragm
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
轴承疲劳剥落失效RPN 224 · High
Failure Mechanism
Insufficient lubrication or contaminated grease; improper installation causing too high/low preload; bearing load exceeds design rating
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every6months
Mitigation (What to Do)
  • Replace bearing
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
轴承润滑失效RPN 224 · High
Failure Mechanism
Insufficient lubrication or contaminated grease; improper installation causing too high/low preload; bearing load exceeds design rating
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every6months
Mitigation (What to Do)
  • Replace bearing
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Dry-running BurnRPN 216 · Critical
Failure Mechanism
Pump cavitation or suction blockage; seal-flush system failure; operator error causing dry running
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every6months
Mitigation (What to Do)
  • Install dry-run protection
  • Ensure seal chamber filled with medium before start
  • Train operators
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Crack/PerforationRPN 200 · Critical
Failure Mechanism
材料疲劳或应力集中；腐蚀性介质侵蚀；铸造缺陷或焊接不良
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every6months
Mitigation (What to Do)
  • 监测振动和压力
  • Periodic nondestructive testing
  • 控制应力循环
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Bladder FailureRPN 192 · High
Failure Mechanism
气囊材料与隔离液不兼容；预充压力过高或过低；气囊老化或安装时损伤
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every6months
Mitigation (What to Do)
  • 按MTBF周期更换蓄能器气囊
  • 检查气囊压力
  • 使用耐腐蚀材料
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 (17)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
ContaminationRPN 192 · High
Failure Mechanism
密封件材料老化或选型不当；轴表面粗糙或磨损；轴承箱压力异常（如呼吸器堵塞）
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every6months
Mitigation (What to Do)
  • 更换密封件
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 (17)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Blade Fracture / BreakageRPN 180 · Critical
Failure Mechanism
汽蚀或流体激振；材料缺陷或疲劳强度不足；运行工况偏离设计点
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every6months
Mitigation (What to Do)
  • 每半年进行磁粉或超声NDT检查叶片
  • 每月分析振动频谱，关注叶片通过频率
  • 每次大修检查诱导轮安装对中
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Oil Sight Glass LeakRPN 168 · Medium
Failure Mechanism
安装时扭矩过大导致应力集中；材质不耐化学腐蚀或紫外线；外部机械碰撞
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every6months
Mitigation (What to Do)
  • 检查油位镜
  • 更换破损件
  • 补充润滑脂
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 (17)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Secondary Seal FailureRPN 160 · Medium
Failure Mechanism
材料与介质不兼容；安装损伤或压缩不当；热循环或压力波动
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every6months
Mitigation (What to Do)
  • 按MTBF周期更换辅助密封件
  • 检查密封件安装质量
  • 使用耐腐蚀材料
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
O-ring Groove LeakRPN 160 · Medium
Failure Mechanism
O型圈材料与介质不兼容；安装时扭曲或划伤；长期高温导致老化
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every6months
Mitigation (What to Do)
  • 按MTBF周期更换O型圈
  • 检查安装槽尺寸
  • 使用合适材料
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 (17)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Internal Corrosion ThinningRPN 144 · Critical
Failure Mechanism
Highly corrosive liquid; insufficient material resistance; excessive velocity
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • Monitor medium corrosivity
  • Periodic thickness measurement
  • Use corrosion-resistant material or 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 (18)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
泵轴失效RPN 144 · Critical
Failure Mechanism
轴材料缺陷或热处理不当；长期过载或频繁启停；不对中或动平衡不良导致附加应力
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • 检查轴表面
  • 监测振动
  • 进行无损检测
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 (22)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Keyway Wear/CrackRPN 140 · High
Failure Mechanism
键配合过松或过紧；频繁启停或反转；扭矩过大
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • 检查键槽尺寸和表面
  • Monitor vibration and torque
  • 更换磨损键
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 (17)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Corrosion PerforationRPN 135 · Critical
Failure Mechanism
液体腐蚀性强；材料耐蚀性不足；存在电偶腐蚀
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • Monitor medium corrosivity
  • 定期测厚或检查穿孔
  • Use corrosion-resistant material or 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 (20)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
BendingRPN 128 · Critical
Failure Mechanism
叶轮不平衡或卡涩；热膨胀不均；安装对中不良
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • 监测轴跳动和振动
  • 检查轴直线度
  • 调整对中
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Fatigue FractureRPN 120 · Low
Failure Mechanism
叶片存在应力集中；材料疲劳强度不足；运行工况波动大
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • 监测振动和噪声
  • 定期无损检测裂纹
  • 优化叶轮设计减少应力集中
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 (22)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Surface WearRPN 120 · High
Failure Mechanism
密封面硬颗粒嵌入；润滑不足或干运转；轴套材料硬度不足
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • 测量轴套外径尺寸
  • 检查表面粗糙度
  • 监测振动和泄漏
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 (17)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Fatigue FractureRPN 120 · Low
Failure Mechanism
轴设计应力集中；长期过载或振动；材料缺陷或热处理不当
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • 定期进行轴振动监测
  • 检查轴表面裂纹
  • 分析应力集中区域
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 (22)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Journal WearRPN 120 · High
Failure Mechanism
润滑不良或润滑油污染；轴颈表面硬度不足；安装对中偏差导致偏磨
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • 测量轴颈直径
  • 检查轴承间隙
  • 监测振动和温度
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 (17)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Misalignment OverheatingRPN 120 · High
Failure Mechanism
安装时对中精度不足；基础沉降或管道应力导致对中变化；热膨胀补偿不当
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • 每半年进行激光对中检查
  • 若温度或振动异常则立即对中
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Screen DamageRPN 120 · Critical
Failure Mechanism
介质腐蚀性强；长期冲刷导致磨损；安装时损伤或异物撞击
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • 每半年进行目视检查或探伤
  • 若泵入口压力波动或颗粒物进入则检查滤网
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Bolt LooseningRPN 112 · High
Failure Mechanism
初始预紧力不足或扭矩衰减；振动频率与螺栓固有频率共振；螺栓材料或热处理缺陷
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every12months
Mitigation (What to Do)
  • 每季度使用扭矩扳手检查螺栓预紧力
  • 振动监测，若振动值超过ISO 10816-3报警值则检查螺栓
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 (22)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Seizure/GallingRPN 108 · Critical
Failure Mechanism
间隙过小；润滑失效；异物进入
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 监测温度和振动
  • 检查配合面润滑
  • 避免干运转
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 (22)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Lubrication FailureRPN 108 · Critical
Failure Mechanism
润滑剂加注不足或泄漏；润滑剂老化或污染；密封失效导致润滑剂流失
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 定期检测润滑脂状态
  • 分析油样中金属颗粒
  • 监测轴承温度
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Flange LeakageRPN 105 · Medium
Failure Mechanism
垫片压缩回弹不足或老化；螺栓预紧力不均匀或松弛；法兰面损伤或变形
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 定期更换垫片
  • 检查螺栓扭矩
  • 热循环后重新紧固
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 (17)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Corrosion PittingRPN 105 · High
Failure Mechanism
介质含氯离子或酸性物质；轴套材料耐腐蚀性不足；局部流速过高或冲刷腐蚀
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 检查轴套表面腐蚀点
  • Analyze medium corrosivity
  • 更换耐腐蚀材料
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Clearance WearRPN 100 · Medium
Failure Mechanism
液体含颗粒；润滑不良；材料硬度不足
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 监测泵性能（流量、扬程）
  • 定期测量间隙
  • 更换耐磨环
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Spring Sticking/FractureRPN 100 · Medium
Failure Mechanism
介质腐蚀或杂质卡涩；弹簧材料疲劳或应力腐蚀；安装不当或振动
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 定期检查弹簧外观及弹性
  • 监测密封泄漏量趋势
  • 更换老化或腐蚀弹簧
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 (17)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Elastomer AgingRPN 100 · Medium
Failure Mechanism
环境温度过高或存在臭氧；弹性体材料与介质不兼容；长期运行超过设计寿命
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 每运行40000小时或3年更换弹性体
  • 检查弹性体状态，记录老化程度
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 (20)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Grout CrackingRPN 100 · Medium
Failure Mechanism
灌浆材料配比不当；养护条件不达标；底座振动过大导致疲劳开裂
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 每5年检查灌浆层完整性
  • 若发现裂纹则修复或重新灌浆
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Uneven WearRPN 96 · High
Failure Mechanism
安装偏差；轴弯曲；轴承磨损
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 监测振动和噪声
  • 检查安装对中
  • 定期检查磨损均匀性
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 (17)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Fatigue SpallingRPN 96 · Critical
Failure Mechanism
过载或冲击载荷；润滑不足或油膜破裂；轴承材料疲劳强度不足
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • Monitor bearing vibration and temperature
  • 分析润滑油中金属颗粒
  • Periodically replace bearing
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 (22)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Bearing FailureRPN 96 · Critical
Failure Mechanism
润滑不良或润滑脂老化；轴承游隙不当或安装歪斜；异物进入轴承内部
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 监测振动
  • 检查保持架
  • 分析油样
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 (22)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Soft FootRPN 96 · High
Failure Mechanism
安装时底座未调平；基础表面不平整；地脚螺栓预紧力不均匀
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 每季度检查底座与基础接触面，使用塞尺测量间隙
  • 若振动异常则检查软脚
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 (22)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Flow Passage BlockageRPN 90 · High
Failure Mechanism
液体含杂质或易结晶；流道设计不合理；泵长期低流量运行
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 定期清洗叶轮流道
  • 安装过滤网
  • 检查介质结晶倾向
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 (17)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Volute ErosionRPN 90 · High
Failure Mechanism
介质含固体颗粒或气泡；流速过高或流道设计不当；材料硬度不足
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 监测介质颗粒和气泡
  • 定期检查蜗壳壁厚
  • 优化流道设计
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 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Erosion WearRPN 84 · High
Failure Mechanism
液体中含固体颗粒；颗粒硬度高；流速过高
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 监测介质颗粒含量
  • 定期检查叶轮磨损量
  • 安装过滤器或耐磨涂层
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 (17)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Cavitation DamageRPN 84 · High
Failure Mechanism
入口压力低于汽化压力；介质温度过高或含气；诱导轮设计或安装不当
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 每月监测泵入口压力和温度
  • 每季度振动频谱分析，关注高频成分
  • 每半年目视检查诱导轮叶片
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Anchor Bolt LooseningRPN 84 · High
Failure Mechanism
初始预紧力不足；长期振动导致螺母松动；环境腐蚀导致螺栓截面减小
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 每季度使用扭矩扳手检查地脚螺栓预紧力
  • 每年进行腐蚀检查
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 (20)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Cavitation PittingRPN 72 · Critical
Failure Mechanism
泵入口压力不足；液体温度过高；泵转速过高
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 监测入口压力和温度
  • 定期检查叶轮表面蚀坑
  • 优化运行工况避免汽蚀
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Face LeakageRPN 72 · High
Failure Mechanism
端面比压不当或润滑不足；介质含颗粒或结晶；安装对中不良或振动
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 监测泄漏量
  • 检查密封面磨损
  • 调整安装或更换密封
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 (17)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
驱动端轴承失效RPN 72 · High
Failure Mechanism
润滑不足或润滑脂污染；安装不当导致预紧力过大或过小；驱动端轴承承受更大径向与轴向联合载荷
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 监测振动
  • 分析油样
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 (22)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
轴承过热失效RPN 72 · High
Failure Mechanism
润滑不足或润滑脂失效；冷却不良或环境温度过高；轴承预紧过大或超载导致摩擦热积聚
How to Detect
Inspection/offline · Detection rate 55% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 监测振动
  • 分析油样
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 (22)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Valve StickingRPN 72 · High
Failure Mechanism
介质中杂质沉积；阀芯与阀套间隙过小；长期未动作导致锈蚀
How to Detect
Online monitoring · Detection rate 80% ；Re-inspect ≤every24months
Mitigation (What to Do)
  • 每季度进行阀芯动作测试
  • 若回流流量异常则检查阀芯
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
ImbalanceRPN 63 · High
Failure Mechanism
制造误差；磨损不均匀；叶轮结垢或腐蚀
How to Detect
Online monitoring · Detection rate 80% ；Interval by RBI
Mitigation (What to Do)
  • 监测振动和相位
  • 定期动平衡校正
  • 检查安装对中
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 (22)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
O-ring AgingRPN 60 · Medium
Failure Mechanism
介质化学腐蚀或溶胀；温度超过材料耐受范围；安装压缩量过大或老化
How to Detect
Inspection/offline · Detection rate 55% ；Interval by RBI
Mitigation (What to Do)
  • 定期更换O型圈
  • 检查介质温度和化学兼容性
  • 选用耐老化材料
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Grease DegradationRPN 60 · Medium
Failure Mechanism
润滑脂型号错误或加注过量；轴承箱散热不良导致高温；润滑脂更换周期过长
How to Detect
Online monitoring · Detection rate 80% ；Interval by RBI
Mitigation (What to Do)
  • 定期检测润滑脂状态
  • 分析油样
  • 监测温度
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Sensor DriftRPN 60 · Medium
Failure Mechanism
长期使用后零点漂移；敏感元件污染或腐蚀；温度影响未补偿
How to Detect
Inspection/offline · Detection rate 55% ；Interval by RBI
Mitigation (What to Do)
  • 每季度进行零点与量程校准
  • 若测量值异常则检查传感器
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Wiring LoosenessRPN 60 · Low
Failure Mechanism
安装时未紧固；长期振动导致松动；环境潮湿导致氧化
How to Detect
Inspection/offline · Detection rate 55% ；Interval by RBI
Mitigation (What to Do)
  • 每半年检查接线端子紧固情况
  • 若信号波动则检查接线
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Barrier Fluid LossRPN 56 · High
Failure Mechanism
密封面磨损或安装不当；管路接头松动或密封件老化；蓄能器气囊破裂导致隔离液与气体混合
How to Detect
Inspection/offline · Detection rate 55% ；Interval by RBI
Mitigation (What to Do)
  • 监测隔离液液位和压力
  • 检查管路连接密封性
  • 定期分析隔离液成分
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
非驱动端轴承失效RPN 54 · High
Failure Mechanism
同驱动端轴承；同驱动端轴承；同驱动端轴承
How to Detect
Inspection/offline · Detection rate 55% ；Interval by RBI
Mitigation (What to Do)
  • 监测振动
  • 分析油样
  • 检查轴承温度
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 (22)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Positioner FailureRPN 50 · Medium
Failure Mechanism
气源不洁或压力波动；电子元件老化；振动导致内部接线松动
How to Detect
Inspection/offline · Detection rate 55% ；Interval by RBI
Mitigation (What to Do)
  • 每半年检查定位器输出信号与实际阀位一致性
  • 若偏差超过1%则校准或更换
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Fretting CorrosionRPN 45 · Medium
Failure Mechanism
轴承与轴或轴承座配合过松；振动导致微动；环境潮湿或腐蚀性介质
How to Detect
Online monitoring · Detection rate 80% ；Interval by RBI
Mitigation (What to Do)
  • 检查配合面微动痕迹
  • 监测振动频谱
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 11348
  • GB/T 44692
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Electrical ErosionRPN 42 · High
Failure Mechanism
电机轴电流未有效接地；变频器产生高频共模电压；轴承绝缘设计不足
How to Detect
Online monitoring · Detection rate 80% ；Interval by RBI
Mitigation (What to Do)
  • 检查接地碳刷
  • 测量轴电压
  • 监测轴承振动
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 (22)
  • 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 44958-2024
  • GB/T 4888-2008
  • GB/T 29639-2020
  • AQ/T 3034-2022
  • API 581 — Risk-Based Inspection Methodology
  • API 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Orifice CloggingRPN 36 · Medium
Failure Mechanism
冲洗液含固体颗粒或易结垢；孔板孔径过小；系统未设置过滤器或过滤器失效
How to Detect
Online monitoring · Detection rate 80% ；Interval by RBI
Mitigation (What to Do)
  • 监测节流孔板前后压差
  • 定期清洗孔板
  • 安装过滤器前置
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Filter CloggingRPN 30 · Medium
Failure Mechanism
冲洗液中含有固体颗粒或杂质；过滤器选型不当（目数过细）；系统启动前未充分冲洗管线
How to Detect
Online monitoring · Detection rate 80% ；Interval by RBI
Mitigation (What to Do)
  • 监测过滤器压差
  • 定期清洗或更换滤芯
  • 分析介质杂质含量
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗
Screen CloggingRPN 24 · Medium
Failure Mechanism
上游管道清洁度不足；介质中固体含量高；过滤器选型不当（目数过细）
How to Detect
Online monitoring · Detection rate 80% ；Interval by RBI
Mitigation (What to Do)
  • 每周检查过滤器压差
  • 若压差超过0.1 MPa则清洗或更换滤网
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 (17)
  • 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 571 — Damage Mechanisms Affecting Fixed Equipment in the Refining Industry
  • API 754 — Process Safety Performance Indicators
  • 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 (6)
2020-01-I-TXcsb2019Fatalities 2 · Safety/Environmental
Aghorn 注水泵站硫化氢泄漏（敖德萨）
Root cause: H2S 检测/报警失效、LOTO 未执行，泵房 H2S 积聚泄漏；2 死（1 工人+1 公众）
Official source ↗
2019-01-I-TXcsb2019Safety/Environmental
ITC Deer Park Tank-farm Circulation Pump Failure Fire
Root cause: Missing pump mechanical-integrity program + no condition monitoring (vibration / LEL) + no remote emergency isolation valve.
Official source ↗
2004-08-I-NMcsb2004Injuries 6 · Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Root cause: Missing pump/compressor mechanical integrity + repeated seal failures not root-caused + inadequate isolation / pressure-relief procedure (missing MOC).
Official source ↗
2019-03-I-TXcsb2019Safety/Environmental/Fire
Intercontinental Terminals Company (ITC) Deer Park 罐区循环泵失效火灾
Root cause: 泵未纳入机械完整性/检验计划；无泄漏监测报警；无远程紧急隔离阀；罐区布置/围堰设计缺陷；PSM/RMP 监管覆盖空隙
Official source ↗
NUREG-LER-2019-001NUREG2019Operational
Arkansas Nuclear One 2 号机 反应堆冷却剂泵电机失效导致反应堆跳机
Root cause: 定子铁芯压紧丧失+压紧指焊缝断裂使指片移入接触转子；绝缘损坏对地短路
Official source ↗
NUREG-PNO-2013-006NUREG2013Operational
Davis-Besse 反应堆冷却剂泵电气故障跳闸并发现反应堆压力边界泄漏
Root cause: RCP 电气故障；¾ 英寸管道焊接/材料相关反应堆压力边界泄漏
Official source ↗