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Advanced Problem Solving in a complex chemical plant discovers 2-year-old minor change to be root cause of multiple major plant failures

Client situation

The client produces Urea in a large-scale Urea reactor, and it is the core ingredient to downstream chemical plants on the same site.

14 months previously, problems with the Urea reactor began and since then, the reactor has come to a standstill 4 times due to a process failure. In fact, the problems were so severe that output reduced to less than 50%. Losses amounted to more than €10 Million

The client’s efforts to resolve the problem were without success and the root cause(s) could not be identified.


EFESO was asked to guide an expert team to identify the root cause:

  • We put together a team consisting of Engineers in Chemical Technology and Applied Physics along with problem solving experts.
  • PM analysis was used for this complex problem. This very thorough approach looked at the Physical Phenomena to really understand the Mechanics of the problem
  • After carefully excluding many possible causes, the root cause was finally identified as being related to the introduction, in early 2019, of a new chemical used for lubrication and sealing in a pump upstream of the reactor
  • Reversing the root-cause established a good stable high performance of the Urea reactor.


  • The problem was fully eradicated
  • The reactor is operating at a stable, high performance
  • The root-cause was proven using causal effects, with supporting theoretical explanations
  • Early indicators of the problem have been identified to monitor possible decay
  • Internal change processes are under review to prevent the recurrence of similar mistakes

The Senior Technologist Urea Factory said “In my 36-year career this is the most frustrating problem I have ever had to deal with. I would never have guessed that that was the root-cause”