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Accident # | 108122 |
State Police # | 08-05043 |
Accident Date | 2008-08-16 |
Report Date | 2008-12-30 |
Follow-up Date | 0000-00-00 |
Follow-up: | Yes |
Pollutant | Duration | Point Source | Greenhouse Gas | Criteria Pollutant | Ozone forming chemical | Amount of Release |
Sulfur Dioxide | 4h | FLARE - Boiler Feed Water System / #2 SRU Startup / Hydrocracker | NO | YES | NO | 13,897.0 pounds |
Particulate Matter | 4h | FLARE - Boiler Feed Water System / #2 SRU Startup / Hydrocracker | NO | YES | NO | BRQ |
Accident Classified As:
corrosion damage in B-V-454 - the control systems did not allow B-V-453 and B-V-454 to run reliably in parallel, as the level controllers attempt to work independently operators were unaware that the north and south BFW systems were operating on a common BFW line because a seldom used valve was open. Operating procedures did not address the potential for imbalance in the system when B-P-006B was shut down. in order to overcome the aforementioned design flaw, operators run the level control bypass on B-V-454 on manual. MOUSA found that existing procedures did not address all potential failure events in this operational mode.
This was an incident that involved three separate incidents. It is listed as preventable because the Boiler Feed Water trip on 8/16/2008 was found to be the result of faulty design, equipment malfunction, and operator and procedural error. Emissions from the startup of the #2 SRU were part of the normal startup procedure. The hydrocracker trip on 08/20/2008 was found to be the result of operator and procedural error. REMEDIAL ACTIONS -MOUSA repaired the trays in deaerator B-V-454. They modified prores regarding boiler feed water pump operations and is investigating engineering changes to improve controls on the deaerators. Also, they are developing procedural updated regarding the startup of the Hydrocracker. They completed repairs on MUG Comp
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