CASE STUDY ON BOILER ACCIDENT

CHIA BAK KHIANG

ASST. EXECUTIVE ENGINEER
OSD, MOM

OVERVIEW OF UTILITY BOILERS

: 2203
12000
160,000 /
8

The boiler involved in the accident was a water tube unit with attached
economizer and super heater. Total heating surface is 2203 sq.m and its
design pressure is about 12 000 KPa and it can produce 160,000 kg/hr of
steam.
The burner system can burn 8 different types of fuel using various
nozzles.
The boiler is protected from overpressure by 2 PSVs at the steam drum
and 1 PSV at the superheater.

OVERVIEW OF UTILITY BOILER

OVERVIEW OF BOILER CONTROL SYSTEM

Boiler Control System

Control the operation of

valves and actuators

Monitor critical control

functions for safe
operation of boiler

Status of valves during normal light up

) (

INTRODUCTION
On 9 Dec 2000, at about 2:30am, three personnel were trying to re-start
the boiler when an explosion occurred inside the furnace of the boiler.
The three personnel were badly injured with more than 50% 2nd degree
burns on their bodies.
Two of them subsequently passed away later in the hospital:
Deceased 1 - Technician/ Male / 23 yrs old
Deceased 2 - Technician/ Female / 21 yrs old

2:30 2000 9

% 50

23 / /
21 / /

PHOTOGRAPHS OF BOILER
AFTER EXPLOSION

PHOTOGRAPHS OF BOILER
AFTER EXPLOSION

PHOTOGRAPHS OF BOILER
AFTER EXPLOSION

PHOTOGRAPHS OF BOILER
AFTER EXPLOSION

PHOTOGRAPHS OF BOILER
AFTER EXPLOSION

DESCRIPTION OF ACCIDENT

Boiler was on LPG firing. Night Order was given to light up

diesel burner in Boiler.
The three personnel attempted to light up the diesel burner at
about 12:30am. They made several attempts but were
unsuccessful.
At 2:20am, they attempted to light up the diesel burner.
However, the boiler experienced a master fuel trip which shut
down the boiler totally.
While restarting the boiler on LPG, an explosion occurred.



2:20

( LPG )

OBSERVATIONS & FINDINGS

LPG


The boilers were in the commissioning stage at the time of the
accident. Written operational procedures were available for cold and
hot start-up of the boilers
Investigations revealed that the startup team encountered some
difficulties in lighting the boiler with LPG some time back. To
overcome the problem, they devised a temporary manual bypass
method.
This bypass method was not the same as the operational procedures.

OBSERVATIONS & FINDINGS

) (

) (


.

The bypass method was used by the startup team as a temporary
measure and they had stopped using it when a permanent solution
was found to overcome the problem.
This method was only to be used by the startup team and no process
technicians were instructed to use it.
Investigations revealed that process technicians were present working
on this method with the startup team when it was used. This method
had been used on several occasions by most of the process
technicians

OBSERVATIONS & FINDINGS

Company Internal Safety Management System

Investigations revealed that the S.M.S. was not effectively
implemented in the plant prior to the accident




. 2

-

There was no Management of Change approval put up for
management approval to use the temporary bypass method.
The bypass method required the opening of 2 bypass valves.
There was no Control of Defeat procedures put up to the
management for approval to remove the sealed wire on these
valves.

OBSERVATIONS & FINDINGS

Company Internal Safety Management System
Pre-Startup Safety Review (PSSR) was claimed to be carried out
on the Boiler. But the PSSR document was not available for our
review during the investigation.
It was found that the bypass valves did not have any sealed wire
when the startup team first implemented the bypass method.
However, the team did not find out further why there was no
sealed wire on these valves.

OBSERVATIONS & FINDINGS

8


9

Training & Experience
All technicians were given 8 months of orientation and training program.
This included technical and S.M.S. training.
The 2 deceased were Process Technicians but were not certified boiler
attendants. The injured was a Supervisor and a certified 1st Class Steam
Boiler Attendant.
The injured claimed that he was unaware of the bypass method and that it
was being used on 9 Dec. He also felt that the training provided was
insufficient for him to operate the boiler.

SITE FINDINGS

%50

( LPG )
% 66

( LPG )
Site investigations after the accident confirmed that the 2 bypass
valves were 50% open. This confirmed that the bypass method
was utilized to restart the boiler.
Data records confirmed that the LPG control valve was about
66% open just before the explosion.
The block valves before and after the control valve were fully
open.
A direct path was therefore established to allow LPG to enter the
firebox, resulting in the explosion of the boiler.

Status of valves after accident

Fuel Flow Line after accident

2 2nd bypass valve
1 1st bypass valve
50% open

2nd Trip valve

50% open
1st Trip valve

100% close

100% closed

Control valve

66% open

Block valve
100% open

Block valve

100% open

Block valve
100% open

CAUSE OF ACCIDENT


( LPG )



Use of temporary bypass method to restart the boiler after it had
tripped.
Two bypass valves of the trip valves were opened without first closing
the two block valves, downstream of the LPG control valve
Non-compliance of the company internal S.M.S.s safety requirements:
- The use of unauthorized temporary bypass method
- The removal of sealed wire on the bypass valves.

CONCLUSION

Air (Oxygen)

LPG
FIRE
TRIANGLE

Hot Furnace Wall

LESSONS LEARNT




All personnel who are operating boiler must follow Safe
Operating Procedures.
Authorization must be obtained before introducing change to
the boiler system or procedures.
Ensure all personnel who are operating boiler received adequate
training and supervision.
Ensure proper documentation.

ACTIONS TAKEN


( BMS ) ( )

The company had been instructed to carry out a thorough
inspection and examination on the remaining Boiler and carry out
necessary rectification works to restore the boiler to safe
operating condition.
The company had also thoroughly reviewed the BMS and carried
out rectification to improve the system.
They had also reviewed and audited their internal S.M.S. to
identify weaknesses and to close such gaps.

Don't Neglect Your Boilers Operation

Just Because They Operate
Automatically

THANK YOU