Professional Documents
Culture Documents
02 Boiler Explosion Incident
02 Boiler Explosion Incident
ON BOILER ACCIDENT
OVERVIEW OF BOILER
CONTROL SYSTEM
Boiler Control System
Control the
operation of
valves and
actuators
Monitor critical
control
functions for
safe operation of
boiler
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
PHOTOGRAPHS OF BOILER
AFTER EXPLOSION
PHOTOGRAPHS OF BOILER
AFTER EXPLOSION
PHOTOGRAPHS OF BOILER
AFTER EXPLOSION
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.
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.
50% open
100% close
100% closed
Control valve
66% open
Block valve
100% open
Block valve
100% open
Block valve
100% open
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
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.
THANK YOU