POWER March 2011 - 22
7. Tragic event. On June 11, 2008, one
worker was killed and seven others were injured
when, during a maintenance operation
on a heat exchanger, ammonia overpressured
the exchanger, causing it to rupture. The cause
of the accident was attributed to failure to
follow the requirements of the ASME Boiler
and Pressure Vessel Code. Employee training
lapses also were found to be the cause of a
slow accounting of all missing employees.
Source: Chemical Safety Board
sor assessing the damage to the incident
area discovered a fatally injured
employee buried in rubble in a dimly
lit area. The CSB case study notes that
because the fatally injured employee
had been a member of the emergency
response team, her absence from the
evacuation muster point was not considered
unusual.
CSB Chairperson Rafael Moure-Eraso
sors in immediately retrieving the list
of personnel in their area; that required
handwritten lists to be generated. At
about 1:20 p.m. an operations supervisaid,
" The absence of this worker had
not been noted due to the lack of training
and drills on worker headcounts.
Plant personnel were not provided with
the proper training to effectively manage
this emergency. Company procedures
called for routine evacuation and
shelter-in-place drills four times a year,
but such drills were not held for several
years prior to the incident. Management's
adherence to company procedures
should have allowed for effective
communication between all members of
the workforce and a more robust emergency
response structure. "
The report further notes that maintenance
work activity was not properly
communicated between maintenance
and operations personnel, resulting in
a subsequent shift not being notified
of the isolation of the pressure relief
line.
Plant Design Mistakes
The CSB's final report outlines several
lessons learned, including the need to
adhere to the existing ASME Boiler and
Pressure Vessel Code.
CSB Investigations Supervisor Robert
Hall said, " We found the accident likely
would not have happened had operators
followed the ASME code. It's crucial
that workers continuously monitor an
isolated pressure relief system throughout
the course of a repair and reopen
blocked valves immediately after the
work is completed. "
The CSB's report notes that the ASME
code states that " Overpressure protections
shall be continually provided . . .
whenever there is a possibility that the
vessel can be over-pressurized by a pressure
source. "
The complete final report can be
downloaded from www.csb.gov. ■
-Edited by Dr. Robert Peltier, PE.
CIRCLE 13 ON READER SERVICE CARD
22
www.powermag.com
POWER | March 2011
http://www.csb.gov
http://www.powermag.com
POWER March 2011
Table of Contents for the Digital Edition of POWER March 2011
Contents
POWER March 2011 - Cover1
POWER March 2011 - Cover2
POWER March 2011 - Contents
POWER March 2011 - 2
POWER March 2011 - 3
POWER March 2011 - 4
POWER March 2011 - 5
POWER March 2011 - 6
POWER March 2011 - 7
POWER March 2011 - 8
POWER March 2011 - 9
POWER March 2011 - 10
POWER March 2011 - 11
POWER March 2011 - 12
POWER March 2011 - 13
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POWER March 2011 - 18
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POWER March 2011 - 20
POWER March 2011 - 21
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POWER March 2011 - 23
POWER March 2011 - 24
POWER March 2011 - 25
POWER March 2011 - 26
POWER March 2011 - 27
POWER March 2011 - 28
POWER March 2011 - 29
POWER March 2011 - 30
POWER March 2011 - 31
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POWER March 2011 - 33
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POWER March 2011 - 35
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POWER March 2011 - Cover3
POWER March 2011 - Cover4
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