E atomizer explosion 2013.10.26
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E atomizer explosion 2013.10.26






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E atomizer explosion 2013.10.26 E atomizer explosion 2013.10.26 Presentation Transcript

  • Electrical Explosion
  • Luck is NOT a Robust Barrier Fault Occu rred H ere
  • Simplified Schematic of Plant Electric System t Faul ere red H r Occu
  • FT 1.0 Production Decrease 0955-1920 Plant Trip 0955 See FT 2.0 Full Production 1920 No Personnel Injury See FT 4.0 No 4160-volt Blackout See FT 3.0 No Rupture Disc Blow Proper Operator Action Spares Including “Breaker” in Stock Operator Initiative END END END
  • FT 2.0 Plant Trip 0955 Defect in Cubicle Causes are unknown END Contactors Closed Defect in Cubicle Not Known See FT 2.1 4160 Volts on Cubicle CRO Starts Atomizer END END
  • FT 2.1 Defect in Cubicle Not Known Inspections not capable END No test available Instrumentation not capable END END
  • FT 3.0 No 4160volt Blackout Fast Transfer to Start-up Transformer Start-up Transformer Available Fault on 4160 V Bus Cleared Feeder Bkr Tripped See FT 3.1 END END
  • FT 3.1 Fast Transfer to Startup Transformer (Likely Scenario) Aux Xfmr Main Breaker Opens on Undervoltage 4160 Fault Drags Voltage down Aux Xfmr Does Not Open on Overcurrent 4160-volt Feeder Breaker Clears Fault Breaker Opens on Timed Overcurrent Before SUT Main Bkr Shuts Unknown Unknown
  • FT 4.0 No Personnel Injury Stand-off Distance of 22’ END Partial Shielding by Cubicle Stack Fault on 4160 V Bus Cleared to Limit Energy END END
  • The next slide is a Factorsconsequence Matrix It shows how various factors would have affected the consequences of the event.
  • Actual Case Case 1 IP enabled Case 2 Anomaly detected Case 3 Atomizer not started. Case 4 Combustible s present. Case 5 Operator near cubicle. Case 6 No fast transfer Case 7 No circ water pump start Instantaneous protection disabled Yes No (not disabled) Yes Yes Yes Yes Yes Yes Undetected bkr abnormality Yes Yes No Yes Yes Yes Yes Yes Atomizer started Yes Yes Yes No Yes Yes Yes Yes No combustibles nearby Yes Yes Yes Yes No Yes Yes Yes Operator protected by location Yes Yes Yes Yes Yes No Yes Yes Fast transfer Yes Yes Yes Yes Yes Yes No Yes Circ water pump restarted Yes Yes Yes Yes Yes Yes Yes No None Less severe explosion . None. Anomaly fixed. None right away. Latent problem. Worse fire. Potential burns. Severe injury or death. No change. No change. Explosion ,Trip, Lost Revenue, Equipmen t damage No plant trip. Only feeder bkr trip. None None right away. Latent problem. Worse fire, etc.. Explosion, Trip, Lost Revenue, Long outage for investigatio n Explosion,Trip, Lost Revenue, Equipment damage. 4160v blackout. Longer outage due to rupture disc(s) blown. Factors Consequences Personnel Plant/Financial
  • Eight Questions For Insight Quality & Safety Impact What were the event consequences? What was the event significance? Vulnerability Consummation Exacerbation Mitigation Corrective Action (closeout) What set us up for the event? What triggered the event? What made the event as bad as it was? What kept it from being a lot worse? Learning: What should be learned from the event? Doing: What should be done about it? © 2000, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
  • 1. Consequences No personnel injuries. Explosion, fire, trip, lost revenue, etc. 2. Significance Saved by luck, lots of surprises, Arc Flash hazard underestimated, complex event 3. Set-up Bechtel wiring anomaly, latent defect in “breaker” 4. Trigger Starting an atomizer from Control Room 5. Exacerbation Feeder breaker didn’t trip on instantaneous. This caused plant trip. (what made it worse) kept it from being even worse) Operator location! Fast transfer malfunctioned in our favor! Good personnel actions. Spares on hand. 7. Lessons to be Learned Energizing a circuit is a hazard. Distance and shielding work. Control combustibles. 8. Corrective Actions Stand-off from energizations. Ring out protective circuits. Re-do Arc Flash Study. Re-do breaker coordination. 6. Mitigation (what
  • Now is the time for • • • • Questions? Comments? Recommendations? Discussion?