recent projects - Root cause analysis


Construction Worker Engulfment

(CP)² was retained to determine the root cause of a worker becoming partially engulfed in the bypass piping while installation of the bypass piping for a steam bed repair project was being completed.  (CP)² interviewed participants, as well reviewing work flow, and then developed the root cause analysis for the accident.


Diversion Dam Radial Gate Binding

(CP)² was retained to perform a causal analysis for a radial gatefailing to

fully close after modification of the gate trunnions.  (CP)²visited the project

site, reviewed the project management plans,engineering design,

fabrication inspections, and developed theroot and contributing causes,

as well as recommendations forchanges prior to modifying the other gates.

Concrete Truck Rollover

(CP)² was retained to investigate the cause of a concrete truck rollover accident while transporting concrete on a single lane mountainous road with traffic controls.  (CP)² visited the accident and project location, interviewed participants, as well reviewing work processes, and then developed the root cause analysis for the accident.


High Pressure Steam Line Support Failures


(CP)²’s client found two broken pipe supports on their high-pressuresteam

line during operation.  (CP)² visited the plant and reviewed the relevant

engineering documentation.  (CP)² determined that the causeof the support

failures was thermal overloads of the pipe supports.  Thecorrective action

was to re-install the supports in a correctedconfiguration.


Condensate Pump Startup Water Hammer


During startup of the condensate pump, (CP)²’s client would oftentimes

experience a water hammerof varying intensity,  sometimes strong enough

to be heard and felt in the control room.  (CP)² determined the root cause

of the water hammersto be formation of a vapor bubble in the pump

discharge piping and subsequent collapse when the pump was started.  The

piping was modified preventing recurrence of the waterhammers.















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