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Pakarab RELIABILITY INCIDENT REPORT Ref No.

02-RIR
Document No.

( RIR )
Revision No. 05
Fertilizers Prepared on: 01.9.16

Ltd.
Unit / Section: Plant:
REF IRIR #
1 TITLE: Transmission failure of Wheel Loader TCM L-26 of NP Plant.
AREA OF INCIDENT: : NP
DATE OF INCIDENT: 29-11-2016
Plant
From: ______1500Hrs.
TOTAL DOWN TIME: Low load operation Hrs. : on 29-11-2016 to (not To: _________hrs.
determinted yet)
2 DESCRIPTION OF INCIDENT:

On 29-11-2016, TCM Wheel Loader was sent to Garage with complaint of high noise in forward gear shift. On opening
the gear oil sump, bearings balls were observed in the oil. The transmission system is still in dismantling phase. (details
will be shared later)

3 INCIDENT SEQUENCE

4 SEVERITY OF FAILURE:

PRODUCTION LOSS DAMAGE TO EQUIPMENT ENVIRONMENTAL LOSS



5 FACTORS
MEN MATERIAL METHOD MACHINE
Careless Act Design issue Procedure not available Reached End of Life

Judgment Manufacturing defect Procedure inadequate Foreign Object Damage


Lack of training /Skills Improper selection Incompliance of Procedure Misalignment
Communication Gap Malfunctioning Inadequate Control Unbalance
Lack of supervision Others Thermal Stresses Mechanical Failure
Lack of Knowledge Others Instrument Failure

Others Electrical Failure
Others
6 PLEASE TICK THE PSMs VIOLATED DUE TO WHICH THIS INCIDENT OCCURRED

Emergency
Risk Assessment
Process Safety Management of Change Preparedness
and Process
Information Technology and Contingency
Hazard Analysis
Planning

Management of Contractor Safety Pre Startup


Quality Assurance
Change Personnel Management Safety Review

Visible
Management of Change Policies and
Mechanical Integrity Management
Facilities Principles
Commitment

Integrated Line Management


Goals, Objectives
Organization Accountability and Safety Personnel
and Plans
Structure Responsibility

Procedures and
Training and Effective Motivation and
Performance
Development Communication Awareness
Standards
Observations and
Incident Investigation
Audits
7 FACTS CONSIDERED / METHODOLOGY

8 CONCLUSION

DIRECT / CONTRIBUTORY CAUSE :

ROOT CAUSE :
9 RECOMMENDATIONS ACTION BY COMPLETION DATE

NO

Ye
s

Do you have concurrence of responsibility individual on action items completion dates


10 SUGGESTIONS FOR IMPROVEMENT (If any)

RCA Team member RCA Team Member RCA Team Member RCA Team Leader Approving Authority

Sign.

Name:

Design

Date

Distribution: - GM (Manufacturing), MM, SPM, TSM, E&I Manager


- All UM Operations
- All UM / SH / IC - Mechanical Maintenance/Civil
- All UM / SH / IC - E&I
- UM HSE