- Before
- Runs investigations that each need data from SCADA, the relay archive, the oil lab, work orders and the field team's photos. “I spend three weeks finding the data and one afternoon thinking.”
- Now
- Opens a fault tree the agents have already built, with the evidence for and against on every branch, and confirms the root cause in his own name.
One bushing failure, from the trip to a 14-unit campaign
Lumina Utilities runs the Kestrel Bay 132/33 kV substation. On Sep 28 2026 at 03:47, the B-phase 132 kV bushing on transformer T2 flashes over. Here is what happens next, screen by screen, in the working solution.
- 0103:47:12
T2 trips and 18,420 customers lose supply
Timeline builderB-phase HV current rises to 11.2 kA, the 87T differential operates in 38 ms and both 132 kV breakers, CB-T2-H1 and CB-T2-H2, open at 03:47:12.476. Deluge valve DV-2 opens at 03:49:05 and the turret fire is out by 03:52. The control room starts a 33 kV backfeed from Orrin Vale; 14,900 customers are back at 05:12 and the last 3,520 at 06:38. The timeline builder merges the fault recorder, SCADA and restoration log into one sequence, each entry with its source.
“Last 3,520 customers restored (2 h 51 min)” · 1.87 million customer minutes lost
- 02Sep 28, by 07:40
46 records gathered while the crew is still on site
Evidence gathererThe control room opens RCA-2026-0147 at 03:58 and the evidence gatherer starts on the fault recorder and relay files at 04:02. By 07:40 it has pulled 46 records: the SCADA log, seven years of tests, oil results, three work orders and the 11 photos Lina Moreau took on site. Every step of the run is listed with its time, so the engineer can see what was read and when.
“Pulled 46 records” · “SCADA, 7 years of tests, oil results, 3 work orders, 11 photos”
- 03Sep 30
Lightning, overload and a winding fault ruled out — each with a record
Fault tree builderNo cloud-to-ground strikes within 10 km between 02:00 and 05:00, and the arrester counters read 14, 9 and 11, the same as in July. T2 was at 55.8 MVA, 62 % of its 90 MVA rating, with top oil at 54 °C. Post-event SFRA matches the 2018 baseline, winding resistance is within 0.6 % and main-tank acetylene is 0.4 ppm — no internal arc.
Limit: “A branch is ruled out only with a cited record.”
- 04Oct 2
Moisture got in through a cracked top-cap seal
Fault tree builderPhoto 9 shows the flashover track on the lower porcelain, so bushing insulation breakdown is confirmed. The bushing's power factor rose from 0.36 % at commissioning to 0.61 % in March 2025, up 69 % from baseline, with C1 capacitance +4.1 %; photo 7 shows water staining on the top layers of condenser paper, and A-phase bushing oil reads 26 ppm moisture. Photo 3 shows the top-cap gasket cracked and hardened, and in July the B-phase top cap ran 6.8 °C warmer than A and C.
Ruled out: moisture left in at the factory — “0.36% in March 2018 — normal for a new OIP bushing.”
- 05Oct 2, 11:09
The root cause: a seal lot the supplier had already warned about
Library matcher and Fault tree builderThe library matcher finds Orsella service bulletin SB-2024-07 of Nov 14 2024: the top-cap gasket compound from seal lot SL-1709 can harden early and admit moisture. It reached a procurement mailbox and was never linked to the asset register. It also finds RCA-2021-0042: Redcliff T1, the same OTB-145 bushing and the same seal lot, closed in 2021 as an “isolated defect” with no fleet check. The fault tree builder proposes “Seal compound, 2017 batch” at 92 %, and marks as contributing an alarm rule that looks only at the 1.0 % limit and a retest deferred twice.
Evidence against: “No other cause of seal damage in the work history: no top-cap work since 2018.”
- 06Oct 13 · day 15 of 30
Tomás confirms the root cause and signs
Tomás Reyes · Reliability engineerKwame Osei signed the protection review on Oct 3: the 87T, Buchholz and breaker failure schemes operated correctly. Tomás reads the tree, the evidence for and against and the contributing causes, then confirms the root cause in his own name. The meaning of his signature, root cause confirmed, goes on the audit trail.
“I confirm the root cause of this failure is: seal compound, 2017 batch.”
- 07The same minute
Fourteen sister units light up on the fleet map
Fleet checkerThe fleet checker matches model OTB-145 and seal lot SL-1709 in the asset register: 33 bushings on 14 transformers at 12 substations, serving 178,200 customers. It ranks them by last test result, time since test, customers served and site exposure — 3 high, 6 medium and 5 lower — with the reason for each. Marlow Cross T1 leads at 0.58 % power factor, up 66 % from baseline, with 21,300 customers.
“Not matched: 49 OTB-145 bushings from other seal lots on 17 transformers.”
- 08Oct 13
One failure becomes a 14-unit campaign
Graham Ives · Head of Asset ManagementThe campaign planner drafts PC-2026-009: a power factor and C1 test, top-cap seal inspection and thermography on all 14 units, the three high-risk ones on Oct 16, 20 and 23, each window with its switching plan. It totals an estimated $186,000 and lists the spares: 4 OTB-145 bushings at Calder Rise depot, 6 on order at 26 weeks, 40 seal kits with a lot-free compound. Graham approves and work orders WO-2026-14201 to 14214 are raised.
Limit: “Drafts only; work orders are raised after approval.”
- 09Drafted Oct 13
The RCA report, every sentence cited
Report writerThe report writer drafts eight sections in Lumina's RCA template v3 — summary, event, fault tree, root cause, contributing causes, actions, fleet and sign-off — with 19 sources cited. It links the case to RCA-2021-0042 and adds failure code BSH-MOIST-SEAL, so the library can find it by failure mode. The draft is ready to send to Helen Achterberg for review.
“Drafted 8 sections from the fault tree. 19 sources cited; no sentence without one.”
- 10Actions open
The fix reaches the rule, the register and the fleet
Helen Achterberg · Asset managerLina Moreau owns replacing the T2 B-phase bushing and resealing A and C, due Oct 31. Helen owns the new alarm on a 30 % rise in bushing power factor from baseline, due Oct 24, and the test and reseal of the 14 sister units, due Jan 11. Ruth Okonjo links supplier bulletins to serials and lots on arrival, and Graham Ives reviews deferred condition retests every month.
On Kestrel Bay T2 the new alarm “would have alarmed in March 2025, 18 months before the failure.”