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Accident # | 102669 |
State Police # | 08-00537 |
Accident Date | 2008-01-29 |
Report Date | 2008-05-06 |
Follow-up Date | 0000-00-00 |
Follow-up: | No Information Provided |
Pollutant | Duration | Point Source | Greenhouse Gas | Criteria Pollutant | Ozone forming chemical | Amount of Release |
Nitrogen Oxide | 15m | FLARE- instrument air dryer and plant air headers | NO | YES | YES | 43.0 pounds |
Volatile Organic Compounds (VOCs) | 15m | FLARE- instrument air dryer and plant air headers | NO | NO | YES | 308.0 pounds |
Accident Classified As:
The root cause was determined to be inadequate labeling and operator understanding of the instrument and plant air utilities system.
This incident was listed as preventable because MOUSA did not maintain current labeling and P&IDs for the utilities section, and did not provide adequate training on the system. Remedial Measures - MOUSA will upgrade the labeling on pipes and valvesin the plant and instrument air utilities, update P&ID's for the air systems, install chain locks on critical valves, and provide operator training of the air systems. The report from Murphy states, MOUSA experienced automatic safety shutdowf several units following the loss of instrument air. As MOUSA attempted to restart units and restore balanced operations, the C3/C4 Splitter experienced a malfunction, resulting in a large flame with smoke emissions at the North Flare. MOUSA had sta
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