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Accident # | 137057 |
State Police # | 12-00773 |
Accident Date | 2012-02-08 |
Report Date | 2012-02-13 |
Follow-up Date | 2013-02-22 |
Follow-up: | Yes |
Pollutant | Duration | Point Source | Greenhouse Gas | Criteria Pollutant | Ozone forming chemical | Amount of Release |
Sulfur Dioxide | 7m | Unit 59 North Flare | NO | YES | NO | 2,581.0 pounds |
Nitrogen Oxide | 7m | Unit 59 North Flare | NO | YES | YES | 9.3 pounds |
Carbon Monoxide | 7m | Unit 59 North Flare | NO | YES | NO | 50.5 pounds |
Volatile Organic Compounds (VOCs) | 7m | Unit 59 North Flare | NO | NO | YES | 82.2 pounds |
Particulate Matter 10 | 7m | Unit 59 North Flare | NO | YES | NO | 1.0 pounds |
Particulate Matter 2.5 | 7m | Unit 59 North Flare | NO | YES | NO | 1.0 pounds |
Highly Reactive Volatile Organic Compounds | 7m | Unit 59 North Flare | NO | NO | YES | 7.8 pounds |
Accident Classified As: Reportable Quantity
A root cause analysis is being conducted to determine why this incident occurred. The Louisiana Refining Division's Investigative Summary Report states that the initiating event was the troubleshooting common alarm on the Bently Nevada radial vibration proximitor card to include a module self-test for diagnostic information.
The results of the Root Cause Analysis determined that the release was not preventable. Troubleshooting common alarm on radial vibration Bentley Nevada proximitor card to include a module self test for diagnostic information. The risk of shutting down the compressor was discussed and identified as low. The low possibility was concluded by the fact that this particular trip is a high vibration trip and because the current status of the card holds the output signal in a not-trip direction -4ma. The module self test was initiated as the next troubleshooting step and the compressor shutdown. It was found from the alarm logs that the vibrations signals being worked on were the first outs. The shutdown was unexpected.
Operations restarted the Wet Gas Compressor. The root cause analysis will result in recommendation items designed to prevent the recurrence of this event. The refinery stated that lessons learned included: On a Bently Nevada 3500 system, a module self-test or replacement will cause the output signal to go to 0ma. If the output signal is wired to a Triconex system, it will report the transmitter as being an unreliable signal (bad transmitter of bad pv). VOC chemical breakdown is provided. Only the RQ for SO2 was exceeded during this release.
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