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
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.
OBSERVATIONS & FINDINGS
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
• 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
Training & Experience
All technicians were given 8 months of orientation and
training programme. 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
• Site investigations after the accident confirmed
that the 2 bypass valves were 50% open. This
confirmed that the bypass method was utilised 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
CAUSE OF ACCIDENT
• 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 unauthorised 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.
• Authorisation 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

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