CENTER FOR NANO SCIENCE AND NGINEERING
INCIDENT REPORT
1
Location
Utility Building/ Clean room.
2
Type of incident reported
No power at utility/clean room.
3
Incident in brief
On 4-8-11 at 20-09 Hrs there was a power
failure at utility building & clean room, due to EB
ACB tripped and UPS failure.
At 20:30 Hrs Security person informed that there
was a blasting sound from the utility building 2nd
floor to maintenance team. Maintenance team
observed smoke and burning smell around the
UPS and MSB panel at 21:30 at the same time
DG was running (Stared by Mr.Bhupathy as
instructed by Mr.Umesh).
4
The incident attended by
Maintenance/CCMD/UPS Numeric service
person
5
Date and time of the incident
4-8-2011, 20:09 Hrs
6
Action taken
Informed the CCMD and project people.
7
Root cause
As per S/S ACB log on 4-8-11 at 20:09 Hrs ACB
was tripped due to ground fault. (Found there
was a rat struck in between the input lines & the
panel body of the UPS). UPS -1,2 & 3 bypass
supply control boards were burnt (and Ups-3
transformer also damaged) maybe due to
improper grounding of DG and UPS panels.
There was no ELCB installed DG & MSB panel to
protect any ground fault locally.
8
Status
UPS-1 & 2 (PCB changed), UPS-3 waiting for
transformer.
9
Action plan with remedy
ELCB to be provided for all panels. Need to test the
grounding quality of all panels by project people
(E+HPS) . Pest control to be implemented.
Date: 8th Aug 2011
Prepared By: Maintenance team.
CENTER FOR NANO SCIENCE AND ENGINEERING
CENTER FOR NANO SCIENCE AND NGINEERING
S/S ACB tripped
Rat struck in UPS
UPS bypass supply control board burnt out.
CENTER FOR NANO SCIENCE AND ENGINEERING
CENTER FOR NANO SCIENCE AND NGINEERING
Root Cause Analysis Tree
Issue
Root Cause
Machines/Equipment
Manpower
Lubrication failure
Lack of tech skills
Setting failure
Attitude problems
Parts/Ass’y failure
Lack of team spirit / ownership
Insufficient capacity
Lack of Eqpmt knowledge
✔
Power failure
Fatigue, stress, sick
Fuses blown
Lack of communication/awareness
Controls malfunction
Design / Commissioning
problem
Methods
Lack of relationship bldg
Lack of org. objectives/goals
Measurements
Lack of policies & procedures
Gauges/meter malfunction
Lack of work instructions
Calibration errors
Lack of technical training
Lack of history analysis tools
Lack of soft skills training
Measurement systems not in place
Improper equipment layouts
Lack of predictive knowledge
Lack of quality concepts
Insufficient measuring systems
Lack of PM systems
Lack of policies & procedures
Material
Parts premature failure
Insufficient stock levels
Poor quality materials
Over aged materials
Structural defects
Environment
Room/facility temperatures high/low
High humidity conditions
High dusty conditions
Noise pollution
Smoke or haze pollution
Heavy rains/Tsunami/Typhoons
Fire / volcano eruptions
CENTER FOR NANO SCIENCE AND ENGINEERING