Table of Contents:

1. Executive Summary Overview of Incident Key Findings
2. Introduction Purpose of the Report Scope and Methodology
3. Background and Context Overview of Muscat Bay Staff Accommodation Building 1 Chiller System Description
4. Incident Timeline Chronological Events Leading to System Failure
5. Technical Analysis Examination of the Failure Roles and Responsibilities of Involved Parties COMO Genetcoo ATPC
6. Impact Assessment Operational Impacts Financial Impacts Reputation and Compliance Implications
7. Recommendations Maintenance Protocol Revisions BMS System Upgrades Emergency Response Protocols Staff Training Initiatives
8. Legal and Financial Considerations Warranty Claims and Liability Issues Cost-Benefit Analysis of Recommendations
9. Stakeholder Engagement Communication Framework Progress Monitoring and Updates
10. Conclusion 10.1 Summary of Findings and Recommendations
11. Appendices Service Records BMS Logs Inspection Reports Photographic Evidence Contractual Documents

Executive Summary

Incident Overview

1.1 Overview of Incident

On May 18, 2023, a critical operational failure struck Muscat Bay's Staff Accommodation Building 1 (B1), involving simultaneous breakdowns of two York chiller evaporators (YORK YCAL0046 1). This incident, happening during the peak of summer, demanded immediate attention from COMO, the facility management service provider, alongside interventions from Genetcoo, the maintenance contractor, and ATPC, the BMS service provider.

Immediate Response and Actions

1.2 Key Findings

The response from COMO included swift actions using the Building Management System (BMS), as recorded in the BMS trend data. This failure occurred despite recent maintenance activities: a minor chiller maintenance by Genetcoo ten days earlier and a major BMS overhaul by ATPC around the same period. The crisis was further aggravated by the unavailability of replacement parts, leading to an interim solution of transferring a chiller unit from Building 2 to B1, thereby straining both buildings with limited cooling capacity.

Introduction

Introduction with Company Involves

2.1 Purpose of the Report

This comprehensive report delves into the simultaneous failure of two York chiller evaporators (YORK YCAL0046 1) at Muscat Bay's Staff Accommodation Building 1 on May 18, 2023. The objective is to conduct a detailed examination of the events, scrutinize the roles and responsibilities of involved entities, and assess the incident's impact. While focusing on technical analysis, the report also serves as a basis for exploring the financial and operational consequences of the incident.

Introducing the Involved Companies

2.2 Scope and Methodology

• Genetcoo: As the chiller system's Annual Maintenance Contract (AMC) service provider, Genetcoo was responsible for routine maintenance. Remarkably, their last service, indicating no issues, was just ten days before the failure.
• ATPC: Responsible for the AMC of the Building Management System (BMS), ATPC concluded a major service a mere ten days prior to the malfunction, with assurances of proper system functionality.
• COMO: Overseeing the facility management, COMO's role extended beyond general operations to coordinating with subcontractors like Genetcoo and ATPC. Their involvement, although not directly in maintenance, was crucial in monitoring and reporting system status.

Background and Context

Chiller System Specifications and Operational Role

3.1 Overview of Muscat Bay Staff Accommodation Building 1

At the heart of Muscat Bay's comfort and climate control are the York chiller evaporators, models YORK YCAL0046 1, integral to the HVAC (Heating, Ventilation, and Air Conditioning) system in Staff Accommodation Building 1.

Contractual Roles of Involved Parties

3.2 Chiller System Description

• Genetcoo (Chiller Maintenance): Under their Annual Maintenance Contract, Genetcoo is tasked with quarterly maintenance, including three minor and one major service annually. Remarkably, their third minor service, reported as issue-free, was conducted just 10 days before the system failure.
• ATPC (BMS Maintenance): Responsible for the Building Management System (BMS) maintenance, ATPC ensures the BMS's integration and functionality with the chiller system. Their latest major service, completed 10 days prior to the failure, affirmed the system's optimal working condition.
• COMO (Facility Management): COMO's role in facility management encompasses helpdesk operations and coordination with subcontractors like Genetcoo and ATPC. Their immediate response to the failure, including BMS status checks and basic system adjustments, was vital in managing the situation.

Incident Timeline

Key Dates and Events Leading Up to the Failure

4.1 Chronological Events Leading to System Failure

This section outlines the pivotal dates and occurrences preceding the chiller system failure, with a focus on maintenance activities and relevant events:

• 01 May 2023 (Approx. 17 Days Before Failure): Genetcoo completes the third minor service of the chiller system. The post-service report indicates all systems functioning normally, with no immediate concerns noted.
• 05 May 2023 (Approx. 13 Days Before Failure): ATPC conducts the major BMS service. Their report post-service confirms the BMS's full operational status, with no issues detected.
• 18 May 2023 (Day of Incident): Simultaneous failures of both York chiller evaporators (YORK YCAL0046 1) occur in Staff Accommodation Building 1, leading to significant operational disruption.

Technical Analysis

Comprehensive Analysis of System Failures and Maintenance Lapses

5.1 Examination of the Failure

This section scrutinizes the critical technical aspects related to the failure of the chiller evaporators in Building 1, covering aspects like evaporator damage, sensor malfunctions, BMS performance issues, maintenance lapses, and operational procedures.

Roles and Responsibilities of Involved Parties

5.2 Roles and Responsibilities of Involved Parties

• Genetcoo: Failed to adhere to OEM guidelines, lacked crucial communication, and inadequately provided spare parts.
• ATPC: Overlooked BMS issues during their service, missing command mismatches.
• COMO: Flawed system restart approach, as evidenced by BMS logs showing rapid, repeated commands.

Impact Assessment

Operational Impacts

6.1 Operational Impacts

The breakdown led to immediate climate control issues in B1, affecting B2 as well.

Financial Impacts

6.2 Financial Impacts

Unanticipated expenses emerged from emergency repairs, potential equipment replacement, and possible warranty or liability claims.

Reputation and Compliance Implications

6.3 Reputation and Compliance Implications

The incident posed a threat to Muscat Bay’s reputation for reliability, impacting resident trust and future business prospects.

Recommendations

Maintenance Protocol Revisions

7.1 Maintenance Protocol Revisions

Align maintenance checklists with YORK's guidelines, ensuring all critical components are covered.

BMS System Upgrades

7.2 BMS System Upgrades

Regular, comprehensive reviews of the BMS functionality are vital to detect and address command mismatches.

Emergency Response Protocols

7.3 Emergency Response Protocols

Develop clear, structured emergency procedures for system alerts to prevent equipment damage and ensure a coordinated response.

Staff Training Initiatives

7.4 Staff Training Initiatives

Comprehensive training for BMS users on functionalities and emergency responses.

Legal and Financial Considerations

Warranty Claims and Liability Issues

8.1 Warranty Claims and Liability Issues

Evaluate potential warranty and liability scenarios.

Cost-Benefit Analysis of Recommendations

8.2 Cost-Benefit Analysis of Recommendations

Assess the financial implications of the recommended actions.

Stakeholder Engagement

Communication Framework

9.1 Communication Framework

Establish a structured communication framework for stakeholder engagement.

Progress Monitoring and Updates

9.2 Progress Monitoring and Updates

Regularly update stakeholders on the investigation progress and relevant outcomes.

Conclusion

10.1 Summary of Findings and Recommendations

This section provides a summary of the key findings and recommendations from the report.

Appendices

11.1 Service Records

11.2 BMS Logs

11.3 Inspection Reports

11.4 Photographic Evidence

11.5 Contractual Documents