‫ﺩﺭﺍﺳﺔ ﻟﺣﺎﻟﺔ ﺍﻧﻔﺟﺎﺭ ﻏﻼﻳﺔ‬

CASE STUDY ON BOILER ACCIDENT

CHIA BAK KHIANG
ASST. EXECUTIVE ENGINEER
OSD, MOM

‫‪OVERVIEW OF UTILITY BOILERS‬‬
‫ﻫﺫﻩ ﺍﻟﻐﻼﻳﺔ ﺍﻟﻣﻧﻔﺟﺭﺓ ﻛﺎﻧﺕ ﻣﻥ ﺍﻟﻧﻭﻋﻳﺔ ﺫﺍﺕ ﺍﻧﺎﺑﻳﺏ ﺍﻟﻣﻳﺎﻩ ﻭﺍﻟﻣﻭﺻﻠﺔ ﺑﻭﺣﺩﺓ‬
‫ﺍﻟﻣﻘﺗﺻﺩ ﻭﺭﺍﻓﻊ ﺍﻟﺣﺭﺍﺭﺓ ‪ :‬ﺍﻟﺫﻯ ﻳﺻﻝ ﺍﻟﻰ ﺣﺭﺍﺭﺓ ﺳﻁﺣﻳﺔ ﺣﻭﺍﻟﻰ ‪ 2203‬ﺩﺭﺟﺔ‬
‫ﻟﻠﻣﺗﺭ ﺍﻟﻣﺭﺑﻊ ﻭﻫﻭ ﻣﺻﻣﻡ ﻻﺣﺗﻣﺎﻝ ﺿﻐﻁ ‪ 12000‬ﻛﻳﻠﻭ ﺑﺳﻛﺎﻝ‬
‫ﻭﻳﻣﻛﻧﻬﺎ ﺍﻧﺗﺎﺝ ‪ 160,000‬ﻛﻳﻠﻭﺟﺭﺍﻡ ‪/‬ﺍﻟﺳﺎﻋﺔ ﻣﻥ ﺍﻟﺑﺧﺎﺭ ﺍﻟﺳﺎﺧﻥ‬
‫ﻭﻣﻭﻗﺩ ﺍﻟﻐﻼﻳﺔ ﻳﻣﻛﻧﻬﺎ ﺣﺭﻕ ‪ 8‬ﺍﻧﻭﺍﻉ ﻣﺧﺗﻠﻔﺔ ﻣﻥ ﺍﻟﻭﻗﻭﺩ ﺑﺎﺳﺗﺧﺩﺍﻡ ﻣﺟﻣﻭﻋﺔ ﺭﺷﺎﺷﺎﺕ‬
‫ﻣﺧﺗﻠﻔﺔ ﺍﻻﻧﻭﺍﻉ ﻭﺍﻟﻐﻼﻳﺔ ﺑﻬﺎ ﺣﻣﺎﻳﺔ ﺿﺩ ﺍﻟﺿﻐﻁ ﺍﻟﺯﺍﺋﺩ ﻓﻰ ﻣﺟﻣﻊ ﺍﻟﺑﺧﺎﺭ ﻭﺫﻟﻙ ﺑﺎﺳﺗﺧﺩﺍﻡ‬
‫ﺻﻣﺎﻣﻳﻥ ﺁﻣﺎﻥ ﻭﻛﺫﻟﻙ ﺻﻣﺎﻡ ﺁﻣﺎﻥ ﻟﻠﺿﻐﻁ ﻋﻠﻰ ﺟﻬﺎﺯ ﺭﺍﻓﻊ ﺍﻟﺣﺭﺍﺭﺓ‬

‫‪The boiler involved in the accident was a water tube unit with attached‬‬
‫‪economizer and super heater. Total heating surface is 2203 sq.m and its‬‬
‫‪design pressure is about 12 000 KPa and it can produce 160,000 kg/hr of‬‬
‫‪steam.‬‬
‫‪The burner system can burn 8 different types of fuel using various‬‬
‫‪nozzles.‬‬
‫‪The boiler is protected from overpressure by 2 PSVs at the steam drum‬‬
‫‪and 1 PSV at the superheater.‬‬

OVERVIEW OF UTILITY BOILER

‫ﻧﻅﺭﺓ ﻋﺎﻣﺔ ﻋﻠﻰ ﺍﻟﻐﻼﻳﺔ‬

OVERVIEW OF BOILER CONTROL SYSTEM
‫ﺩﺭﺍﺳﺔ ﻧﻅﺎﻡ ﺍﻟﺗﺣﻛﻡ ﻟﻠﻐﻼﻳﺔ‬
Boiler Control System
‫ﻧﻅﺎﻡ ﺍﻟﺗﺣﻛﻡ ﻓﻰ ﺍﻟﻐﻼﻳﺔ‬

‫ﺍﻟﺗﺣﻛﻡ ﻓﻰ ﻋﻣﻝ ﺍﻟﺻﻣﺎﻣﺎﺕ ﻭﺍﻟﺩﻭﺍﻓﻊ‬
‫ﺍﻟﻣﻳﻛﺎﻧﻳﻛﻳﺔ‬

‫ﻣﺭﺍﻗﺑﺔ ﻣﺅﺷﺭﺍﺕ ﺍﻟﺗﺣﻛﻡ ﺍ ﻟﺣﺭﺝ‬
‫ﻟﻠﺗﺷﻐﻳﻝ ﺍﻵﻣﻥ ﻟﻠﻐﻼﻳﺔ‬

Control the operation of
valves and actuators

Monitor critical control
functions for safe
operation of boiler

‫‪Status of valves during normal light up‬‬
‫ﻭﺿﻊ ﺍﻟﺻﻣﺎﻣﺎﺕ) ﺍﻟﺑﻠﻭﻑ ( ﺍﻟﻁﺑﻳﻌﻳﺔ ﺍﺛﻧﺎء ﺑﺩﺃ ﺍﺷﻌﺎﻝ ﺍﻟﻣﻭﻗﺩ‬

INTRODUCTION ‫ﻣﻘﺩﻣﺔ‬
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

‫ ﺻﺑﺎﺣﺎ – ﺛﻼﺛﺔ ﺍﺷﺧﺎﺹ ﺣﺎﻭﻟﻭﺍ ﺍﻋﺎﺩﺓ ﺗﺷﻐﻳﻝ ﺍﻟﻐﻼﻳﺔ‬2:30 ‫ ﺣﻭﺍﻟﻰ ﺍﻟﺳﺎﻋﺔ‬2000 ‫ ﺩﻳﺳﻣﺑﺭ‬9
‫ﺍﺛﻧﺎء ﺣﺩﻭﺙ ﺍﻻﻧﻔﺟﺎﺭ ﺩﺍﺧﻝ ﻓﺭﻥ ﺍﻟﻐﻼﻳﺔ‬
‫ ﻧﺳﺑﺔ ﺣﺭﻕ ﻣﻥ ﺍﻟﺩﺭﺟﺔ ﺍﻟﺛﺎﻧﻳﺔ‬% 50 ‫ﻫﺫﻩ ﺍﻻﺷﺧﺎﺹ ﺍﺻﻳﺑﻭﺍ ﺑﺄﻛﺛﺭ ﻣﻥ‬
‫ﻣﻧﻬﻡ ﺷﺧﺻﻳﻥ ﻗﺩ ﺭﺣﻠﻭﺍ ﻓﻳﻣﺎ ﺑﻌﺩ ﻋﻥ ﺍﻟﺣﻳﺎﺓ ﻓﻰ ﺍﻟﻣﺳﺗﺷﻔﻰ‬
‫ ﺳﻧﺔ‬23 / ‫ ﺫﻛﺭ‬/ ‫ﺍﻟﺭﺍﺣﻝ ﺍﻻﻭﻝ – ﻓﻧﻰ‬
‫ ﺳﻧﺔ‬21 / ‫ﺍﻧﺛﻰ‬/ ‫ﺍﻟﺭﺍﺣﻠﺔ ﺍﻟﺛﺎﻧﻳﺔ – ﻓﻧﻰ‬

PHOTOGRAPHS OF BOILER
AFTER EXPLOSION
‫ﺻﻭﺭﺓ ﺍﻟﻐﻼﻳﺔ ﺑﻌﺩ ﺍﻻﻧﻔﺟﺎﺭ‬

PHOTOGRAPHS OF BOILER
AFTER EXPLOSION
‫ﺻﻭﺭﺓ ﺍﻟﻐﻼﻳﺔ ﺑﻌﺩ ﺍﻻﻧﻔﺟﺎﺭ‬

PHOTOGRAPHS OF BOILER
AFTER EXPLOSION
‫ﺻﻭﺭﺓ ﺍﻟﻐﻼﻳﺔ ﺑﻌﺩ ﺍﻻﻧﻔﺟﺎﺭ‬

PHOTOGRAPHS OF BOILER
AFTER EXPLOSION
‫ﺻﻭﺭﺓ ﺍﻟﻐﻼﻳﺔ ﺑﻌﺩ ﺍﻻﻧﻔﺟﺎﺭ‬

PHOTOGRAPHS OF BOILER
AFTER EXPLOSION
‫ﺻﻭﺭﺓ ﺍﻟﻐﻼﻳﺔ ﺑﻌﺩ ﺍﻻﻧﻔﺟﺎﺭ‬

DESCRIPTION OF ACCIDENT

‫ﻭﺻﻑ ﺍﻟﺣﺎﺩﺙ‬

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.
‫ﺳﻳﻝ – ﻧﺗﻳﺟﺔ ﺃﻣﺭ ﻣﺳﺎﺋﻰ ﻗﺩ ﺃُﻋﻁﻰ ﺑﺈﺷﻌﺎﻝ ﻣﻭﻗﺩ ﺍﻟﺩﻳﺯﻝ‬
ّ ‫ﺍﻟﻣﻭﻗﺩ ﻛﺎﻥ ﻳﻌﻣﻝ ﺑﻧﻅﺎﻡ ﺍﻟﻐﺎﺯ ﺍﻟﻣ‬
‫ﺍﻻﺷﺧﺎﺹ ﺍﻟﺛﻼﺛﺔ ﺣﺎﻭﻟﻭﺍ ﺍﺷﻌﺎﻝ ﻣﻭﻗﺩ ﺍﻟﺩﻳﺯﻝ ﺑﺎﻟﻐﻼﻳﺔ‬
‫ ﺣﺎﻭﻟﻭﺍ ﺍﺷﻌﺎﻝ ﻣﻭﻗﺩ ﺍﻟﺩﻳﺯﻝ ﺑﻳﻧﻣﺎ ﻛﺎﻥ ﺻﻣﺎﻡ ﺍﻟﻭﻗﻭﺩ ﺍﻟﻘﺎﻁﻊ ﺍﻟﺭﺋﻳﺳﻰ ﻗﺩ ﺍﻏﻠﻕ‬2:20 ‫ﺍﻟﺳﺎﻋﺔ‬
‫ﺍﻟﻐﻼﻳﺔ ﺗﻣﺎﻣﺎ‬
‫ ( ﻣﺭﺓ ﺃﺧﺭﻯ – ﺣﺩﺙ ﺍﻻﻧﻔﺟﺎﺭ‬LPG ) ‫ﻋﻧﺩﻣﺎ ﻗﺎﻣﻭﺍ ﺑﻣﺣﺎﻭﻟﺔ ﺍﻟﻌﻭﺩﺓ ﻹﺷﻌﺎﻝ ﻣﻭﻗﺩ ﺍﻟﻐﺎﺯ ﺍﻟﺳﺎﺋﻝ‬

OBSERVATIONS & FINDINGS

‫ﺍﻟﻣﺷﺎﻫﺩﺓ ﻭﺍﻟﺩﻻﺋﻝ‬
‫ﺍﻟﻐﻼﻳﺔ ﻛﺎﻧﺕ ﻓﻰ ﻣﺭﺣﻠﺔ ﺍﻟﺗﺟﻣﻳﻊ ﻭ ﺍﻟﺗﺟﻬﻳﺯ ﻭﻗﺕ ﺍﻟﺣﺎﺩﺙ – ﺗﻭﻓﺭ ﺇﺟﺭﺍءﺍﺕ ﺗﺷﻐﻳﻝ ﻣﻛﺗﻭﺑﺔ ﻟﻛﻼ ﻣﻥ ﺍﻟﺗﺷﻐﻳﻝ‬
‫ﺍﻟﺑﺎﺭﺩ ﻭﺍﻟﺳﺎﺧﻥ‬
‫ﺍﻟﺗﺣﻘﻳﻕ ﺍﺛﺑﺕ ﺍﻥ ﻣﺟﻣﻭﻋﺔ ﺑﺩﺃ ﺍﻟﺗﺷﻐﻳﻝ ﻗﺩ ﺻﺎﺩﻓﺗﻬﻡ ﺑﻌﺽ ﺍﻟﻣﺻﺎﻋﺏ ﻗﺩﻳﻣﺎ ﺍﺛﻧﺎء ﻣﺣﺎﻭﻟﺔ ﻋﻣﻠﻳﺔ ﺍﺷﻌﺎﻝ‬
LPG ‫ﺍﻟﻣﻭﻗﺩ ﺑﺎﺳﺗﺧﺩﺍﻡ ﻏﺎﺯ ﺍﻟﺑﺗﺭﻭﻝ ﺍﻟﻣﺳﻳﻝ‬
‫ﻭﻟﺣﻝ ﻫﺫﻩ ﺍﻟﻣﺷﻛﻠﺔ ﻗﺎﻣﻭﺍ ﺑﺈﺿﺎﻓﺔ ﻣﺣﺑﺱ ﻳﺩﻭﻯ ﻣﺅﻗﺕ ﺟﺎﻧﺑﻰ ﻳﺟﺗﺎﺯ ﺍﻟﺳﺭﻳﺎﻥ ﺍﻟﻁﺑﻳﻌﻰ‬
‫ﻫﺫﺍ ﺍﻟﻣﺣﺑﺱ ﺍﻟﺟﺎﻧﺑﻰ ﻟﻳﺱ ﻣﺫﻛﻭﺭﺍ ﻓﻰ ﺧﻁﻭﺍﺕ ﺍﻟﺗﺷﻐﻳﻝ‬
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

‫ﺍﻟﻣﻼﺣﻅﺎﺕ ﻭﺍﻟﺩﻻﺋﻝ‬

‫ﻫﺫﺍ ﺍﻟﻣﺣﺑﺱ ﺍﻟﺟﺎﻧﺑﻰ ﻗﺩ ﺍﺳﺗﺧﺩﻡ ﺑﻭﺍﺳﻁﺔ ﻣﺟﻣﻭﻋﺔ ﺍﻟﺗﺷﻐﻳﻝ ﺍﻟﻣﺑﺩﺋﻰ ) ﻗﺑﻝ ﺗﺳﻠﻳﻡ ﺍﻟﻐﻼﻳﺔ ( ﻛﺣﻝ ﻣﺅﻗﺕ ﻭﻟﻘﺩ‬
‫ﺗﻭﻗﻔﻭﺍ ﻋﻥ ﺍﺳﺗﺧﺩﺍﻣﻪ ﺑﻌﺩ ﻭﺿﻊ ﺍﻟﺣﻝ ﺍﻟﺩﺍﺋﻡ ﻟﻠﺗﺷﻐﻳﻝ ﻟﺣﻝ ﺍﻟﻣﺷﻛﻠﺔ‬
‫ﻫﺫﻩ ﺍﻟﻁﺭﻳﻘﺔ ) ﺍﻟﺗﺣﻭﻳﻠﻳﺔ ( ﻓﻘﺩ ﺗﺳﺗﺧﺩﻡ ﻟﻣﺟﻣﻭﻋﺔ ﺍﻻﻋﺩﺍﺩ ﻟﻠﺗﺷﻐﻳﻝ ﻭﻟﻡ ﻳﻛﻥ ﻫﻧﺎﻙ ﺃﻯ ﺗﻌﻠﻳﻣﺎﺕ ﻓﻧﻳﺔ ﻟﻠﺗﺷﻐﻳﻝ‬
‫ﺑﻬﺫﻩ ﺍﻟﻁﺭﻳﻘﺔ‬
‫ﺍﻟﺗﺣﻘﻳﻕ ﺃﺛﺑﺕ ﺣﺿﻭﺭ ﻓﻧﻳﻳﻥ ﺍﻟﻣﻌﺎﻟﺟﺔ ﻋﻣﻠﻳﺎﺕ ﺍﻟﺗﺷﻐﻳﻝ ﺑﻬﺫﻩ ﺍﻟﻁﺭﻳﻘﺔ ﻣﻊ ﻓﺭﻳﻕ ﺍﻟﺗﺟﻬﻳﺯ ﺑﺩﺃ ﺍﻟﺗﺷﻐﻳﻝ ﻋﻧﺩﻣﺎ‬
.‫ﻗﺎﻣﻭﺍ ﺑﺎﺳﺗﺧﺩﺍﻣﻬﺎ‬
‫ﻫﺫﻩ ﺍﻟﻁﺭﻳﻘﺔ ﻗﺩ ﺗﻡ ﺍﺳﺗﺧﺩﺍﻣﻬﺎ ﻓﻰ ﺍﻭﻗﺎﺕ ﺍﺧﺭﻯ ﺑﻭﺍﺳﻁﺔ ﻣﻌﻅﻡ ﻓﻧﻳﻳﻥ ﺍﻟﻣﻌﺎﻟﺟﺔ‬
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

‫ﺍﻟﻣﻼﺣﻅﺎﺕ ﻭﺍﻟﺩﻻﺋﻝ‬

Company Internal Safety Management System
Investigations revealed that the S.M.S. was not effectively
implemented in the plant prior to the accident
‫ﻧﻅﺎﻡ ﺍﻻﺩﺍﺭﺓ ﻟﻠﺳﻼﻣﺔ ﺑﺎﻟﺷﺭﻛﺔ‬
‫ﺍﺛﺑﺗﺕ ﺍﻟﺗﺣﻘﻳﻘﺎﺕ ﺍﻥ ﻧﻅﺎﻡ ﺍﻻﺩﺍﺭﺓ ﻟﻠﺳﻼﻣﺔ ﻏﻳﺭ ﻓﻌﺎﻝ ﻭﻏﻳﺭ ﻣﻧﻔﺫ ﺑﺎﻟﻣﺻﻧﻊ ﻗﺑﻝ ﺣﺩﻭﺙ ﺍﻟﺣﺎﺩﺙ‬
‫ ﻟﻳﺱ ﻫﻧﺎﻙ ﻧﻅﺎﻡ ﺍﺩﺍﺭﺓ ﺍﻟﺗﻐﻳﻳﺭ ﻣﻌﺗﻣﺩ ﻣﻭﺟﻭﺩ ﻻﻋﺗﻣﺎﺩ ﺍﻟﺗﺷﻐﻳﻝ ﺑﻬﺫﻩ ﺍﻟﻁﺭﻳﻘﺔ ﺍﻟﻣﺅﻗﺗﺔ‬
. ‫ ﻣﺣﺑﺱ ﺗﺣﻭﻳﻠﻰ‬2 ‫ ﺍﻟﻁﺭﻳﻘﺔ ﺍﻟﺗﺣﻭﻳﻠﻳﺔ ﺗﺣﺗﺎﺝ ﺍﻟﻰ ﻓﺗﺢ ﻋﺩﺩ‬
‫ ﻋﻧﺩ ﺍﻟﻐﺎء‬- ‫ﻟﻳﺱ ﻫﻧﺎﻙ ﺃﻯ ﻣﺭﺍﻗﺑﺔ‬
‫ﺍﻟﺗﻌﻠﻳﻣﺎﺕ ﺍﻟﻣﻌﺗﻣﺩﺓ ﺑﺧﺻﻭﺹ ﺍﺯﺍﻟﺔ ﺳﻠﻙ ﺍﺣﻛﺎﻡ ﺍﻻﻏﻼﻕ ﻓﻰ ﻫﺫﻩ ﺍﻟﻣﺣﺎﺑﺱ‬
• 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

‫ﺍﻟﻣﻼﺣﻅﺎﺕ ﻭﺍﻟﺩﻻﺋﻝ‬
‫ﻧﻅﺎﻡ ﺍﻻﺩﺍﺭﺓ ﻟﻠﺳﻼﻣﺔ ﺑﺎﻟﺷﺭﻛﺔ‬

‫ﻭﺟﻭﺏ ﺗﻧﻔﻳﺫ ﺍﻟﻣﺭﺍﺟﻌﺔ ﻗﺑﻝ ﺍﻟﺗﺷﻐﻳﻝ ﻋﻠﻰ ﺍﻟﻐﻼﻳﺔ ﻭﻟﻛﻥ ﺍﻟﻣﺳﺗﻧﺩﺍﺕ ﻛﺎﻧﺕ ﻏﻳﺭ ﻣﺗﺎﺣﺔ ﻟﻣﺭﺍﺟﻌﺗﻧﺎ ﺍﺛﻧﺎء‬
‫ﺍﻟﺗﺣﻘﻳﻕ‬
‫ﺍﺛﺑﺕ ﻋﺩﻡ ﻭﺟﻭﺩ ﺍﻯ ﺍﺳﻼﻙ ﺍﺣﻛﺎﻡ ﻟﻠﻣﺣﺎﺑﺱ ﻋﻧﺩ ﺍﻟﺗﺷﻐﻳﻝ ﺍﻟﻣﺑﺩﺋﻰ ﻭﺍﺳﺗﺧﺩﺍﻡ ﺍﻟﻁﺭﻳﻘﺔ ﺍﻟﺗﺣﻭﻳﻠﻳﺔ‬
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

‫ﺍﻟﻣﻼﺣﻅﺎﺕ ﻭﺍﻟﺩﻻﺋﻝ‬
‫ﺍﻟﺗﺩﺭﻳﺏ ﻭﺍﻟﺧﺑﺭﺍﺕ‬

‫ ﺍﺷﻬﺭ ﻟﺑﺭﻧﺎﻣﺞ ﺷﺭﺡ ﻭﺗﺩﺭﻳﺏ ﻳﺗﺿﻣﻥ ﺍﻟﻧﺎﺣﻳﺔ ﺍﻟﺗﺩﺭﻳﺑﻳﺔ ﻭﻧﻅﺎﻡ ﺍﺩﺍﺭﺓ ﺍﻟﺳﻼﻣﺔ‬8 ‫ﻛﻝ ﺍﻟﻔﻧﻳﻳﻥ ﺗﻡ ﺣﺿﻭﺭﻫﻡ‬
‫ﺍﻟﺿﺣﻳﺗﻳﻥ ﻛﺎﻧﻭﺍ ﻓﻧﻳﻳﻥ ﻣﻌﺎﻟﺟﺔ ﻭﻟﻛﻧﻬﻡ ﻟﻳﺳﻭﺍ ﻣﻌﺗﻣﺩﻳﻥ ﻟﺩﺧﻭﻝ ﺍﻣﺎﻛﻥ ﺑﻬﺎ ﻏﻼﻳﺎﺕ ﻭﺍﻟﻣﺻﺎﺏ ﻛﺎﻥ ﻣﻌﺗﻣﺩ ﻟﺩﺧﻭﻝ‬
‫ﻏﻼﻳﺎﺕ ﺍﻟﺑﺧﺎﺭ ﺫﺍﺕ ﺍﻟﻣﺳﺗﻭﻯ ﺍﻻﻭﻝ‬
‫ ﺩﻳﺳﻣﺑﺭ‬9 ‫ﺍﻟﻣﺻﺎﺏ ﻗﺩ ﺍﺩﻟﻰ ﺑﺄﻧﻪ ﻟﻳﺳﺕ ﻋﻧﺩﻩ ﺩﺭﺍﻳﺔ ﻋﻥ ﻣﻭﺿﻭﻉ ﺍﺳﺗﺧﺩﺍﻡ ﺍﻟﻁﺭﻳﻘﺔ ﺍﻟﺗﺣﻭﻳﻠﻳﺔ ﻭﺍﻟﺗﻰ ﺍﺳﺗﺧﺩﻣﺕ ﻓﻰ‬
‫ﻭﻛﺫﻟﻙ ﺍﺩﻟﻰ ﺑﺎﻋﺗﻘﺎﺩﻩ ﺑﺎﻥ ﺍﻟﺗﺩﺭﻳﺏ ﺍﻟﺫﻯ ﻗﺩ ﺗﻡ ﻛﺎﻥ ﻏﻳﺭ ﻛﺎﻓﻰ ﺑﺎﻟﻧﺳﺑﺔ ﻟﻪ ﻟﺗﺷﻐﻳﻝ ﺍﻟﻐﻼﻳﺔ‬
Training & Experience
All technicians were given 8 months of orientation and training program.
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

‫ﻣﺎ ﻭﺟﺩ ﺑﺎﻟﻣﻭﻗﻊ‬

‫ ﻭﻫﺫﺍ ﻳﺅﻛﺩ‬%50 ‫ﺍﻟﺗﺣﻘﻳﻕ ﺑﺎﻟﻣﻭﻗﻊ ﺑﻌﺩ ﺍﻟﺣﺎﺩﺙ ﺍﻛﺩ ﺍﻥ ﻣﺣﺑﺳﻰ ﺍﻟﺗﺣﻭﻳﻝ ﻛﺎﻧﺎ ﻣﻔﺗﻭﺣﻳﻥ ﺟﺯﺋﻳﺎ ﺑﻧﺳﺑﺔ‬
‫ﺍﻥ ﺍﻟﻁﺭﻳﻘﺔ ﺍﻟﻣﺳﺗﺧﺩﻣﺔ ﻫﻰ ﺍﻟﻁﺭﻳﻘﺔ ﺍﻟﺗﺣﻭﻳﻠﻳﺔ ﺍﺛﻧﺎء ﺍﻋﺎﺩﺓ ﺍﻟﺗﺷﻐﻳﻝ‬
‫( ﻛﺎﻥ‬LPG ) ‫ﻭﺑﻔﺣﺹ ﻣﺳﺟﻝ ﻣﻌﻠﻭﻣﺎﺕ ﺍﻟﺗﺷﻐﻳﻝ ﺗﺄﻛﺩ ﺍﻥ ﻣﺣﺑﺱ ﺍﻟﺗﺣﻛﻡ ﻟﻠﻐﺎﺯ ﺍﻟﺑﺗﺭﻭﻟﻲ ﺍﻟﻣﺳﻳﻝ‬
ً ‫ ﻫﺫﺍ ﻗﺑﻝ ﺍﻻﻧﻔﺟﺎﺭ ﻣﺑﺎﺷﺭﺗﺎ‬% 66 ‫ﻣﻔﺗﻭﺡ ﺑﻧﺳﺑﺔ‬
‫ﻣﺣﺎﺑﺱ ﺍﻟﻌﺯﻝ ﻗﺑﻝ ﻭﺑﻌﺩ ﺑﻠﻑ ﺍﻟﺗﺣﻛﻡ ﻛﺎﻧﻭﺍ ﻣﻔﺗﻭﺣﻳﻥ ﻛﻠﻳﺗﺎ‬
‫ ( ﻟﻠﻣﺭﻭﺭ ﺩﺍﺧﻝ ﺻﻧﺩﻭﻕ ﺍﻟﺣﺭﻳﻕ ﻣﻣﺎ ﺳﺑﺏ ﻓﻰ ﺍﻻﻧﻔﺟﺎﺭ‬LPG )‫ﺑﻁﺭﻳﻘﺔ ﻣﺑﺎﺷﺭﺓ ﻗﺩ ﺗﻡ ﺍﻟﺳﻣﺎﺡ ﻟﻠﻐﺎﺯ‬
•Site investigations after the accident confirmed that the 2 bypass
valves were 50% open. This confirmed that the bypass method
was utilized 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

Fuel Flow Line after accident
2 ‫ ﻣﺣﺑﺱ ﺍﻟﺗﺣﻭﻳﻝ‬2nd bypass valve
1 ‫ﻣﺣﺑﺱ ﺍﻟﺗﺣﻭﻳﻝ‬1st bypass valve
50% open

2nd Trip valve

50% open
‫ﻣﺣﺑﺱ ﺍﺗﻭﻗﻑ‬1st Trip valve

‫ ﻣﺣﺑﺱ ﺍﺗﻭﻗﻑ‬100% close

100% closed

‫ﻣﺣﺑﺱ ﺍﻟﺗﺣﻛﻡ‬
Control valve
‫ﻣﺣﺑﺱ ﺍﻟﻌﺯﻝ‬

66% open

Block valve
100% open

‫ﻣﺣﺑﺱ ﺍﻟﻌﺯﻝ‬
Block valve

‫ﻣﺣﺑﺱ ﺍﻟﻌﺯﻝ‬

100% open

Block valve
100% open

CAUSE OF ACCIDENT ‫ﺳﺑﺏ ﺍﻟﺣﺎﺩﺙ‬
‫ﺍﺳﺗﺧﺩﺍﻡ ﺍﻟﻁﺭﻳﻘﺔ ﺍﻟﺗﺣﻭﻳﻠﻳﺔ ﺍﻟﻣﺅﻗﺗﺔ ﻹﻋﺎﺩﺓ ﺗﺷﻐﻳﻝ ﺍﻟﻐﻼﻳﺔ ﺑﻌﺩ ﺍﻥ ﺗﻭﻗﻔﺕ ﺍﺿﻁﺭﺍﺭﻳﺎ‬
‫ﻣﺣﺑﺳﻲ ﺍﻟﺗﺣﻭﻳﻝ ﻟﻛﻝ ﻣﺣﺑﺱ ﺗﻭﻗﻑ ﺍﺿﻁﺭﺍﺭﻯ ﺗﻡ ﻓﺗﺣﻳﻬﻣﺎ ﻗﺑﻝ ﻏﻠﻕ ﻣﺣﺑﺳﻰ ﺍﻟﻌﺯﻝ ﺍﻭﻻً ﺑﻌﺩ ﻣﺣﺑﺱ ﺍﻟﺗﺣﻛﻡ‬
( LPG ) ‫ﻓﻰ ﺍﻟﻐﺎﺯ ﺍﻟﺑﺗﺭﻭﻟﻰ ﺍﻟﻣﺳﻳﻝ‬
‫ﻋﺩﻡ ﺍﺗﺑﺎﻉ ﻣﺗﻁﻠﺑﺎﺕ ﻧﻅﺎﻡ ﺍﺩﺍﺭﺓ ﺍﻟﺳﻼﻣﺔ ﺑﺎﻟﺷﺭﻛﺔ‬
‫•ﺍﺳﺗﺧﺩﺍﻡ ﻧﻅﺎﻡ ﺍﻟﺗﺣﻭﻳﻝ ﺍﻟﻣﺅﻗﺕ ﺍﻟﻐﻳﺭ ﻣﻌﺗﻣﺩ‬
‫•ﺍﺯﺍﻟﺔ ﺳﻠﻙ ﺍﺣﻛﺎﻡ ﺍﻟﻐﻠﻕ ﻋﻠﻰ ﻣﺣﺑﺱ ﺍﻟﺗﺣﻭﻳﻝ‬
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 unauthorized temporary bypass method
- The removal of sealed wire on the bypass valves.

CONCLUSION

Air (Oxygen)

LPG
FIRE
TRIANGLE

Hot Furnace Wall

LESSONS LEARNT ‫ﺍﻟﺩﺭﻭﺱ ﺍﻟﻣﺳﺗﻔﺎﺩﺓ‬
‫ﺍﻟﺗﺯﺍﻡ ﻛﻝ ﺍﻟﻌﺎﻣﻠﻳﻥ ﺑﺗﺷﻐﻳﻝ ﺍﻟﻐﻼﻳﺔ ﺑﺈﺗﺑﺎﻉ ﺍﺟﺭﺍءﺍﺕ ﺍﻟﺗﺷﻐﻳﻝ ﺍﻵﻣﻥ‬
‫ﺍﻟﺣﺻﻭﻝ ﻋﻠﻰ ﺍﻟﺗﻔﻭﻳﺽ ﻗﺑﻝ ﻋﻣﻝ ﺃﻯ ﺗﻐﻳﻳﺭ ﻟﻧﻅﺎﻡ ﺗﺷﻐﻳﻝ ﺍﻟﻐﻼﻳﺔ‬
‫ﺍﻟﺗﺄﻛﺩ ﻣﻥ ﺣﺻﻭﻝ ﻛﻝ ﺍﻟﻌﺎﻣﻠﻳﻥ ﺑﺎﻟﻐﻼﻳﺔ ﻋﻠﻰ ﺗﺩﺭﻳﺏ ﻛﺎﻓﻰ ﻭﺍﻥ ﻳﻛﻭﻧﻭﺍ ﻗﺎﺩﺭﻳﻥ ﻋﻠﻰ ﻋﻣﻠﻳﺎﺕ ﺍﻻﺷﺭﺍﻑ‬
‫ﺍﻟﺗﺄﻛﺩ ﻣﻥ ﻭﺟﻭﺩ ﺍﻟﻣﺳﺗﻧﺩﺍﺕ ﺍﻟﻣﻧﺎﺳﺑﺔ‬
• All personnel who are operating boiler must follow Safe
Operating Procedures.
• Authorization 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 ‫ﺍﻹﺟﺭﺍءﺍﺕ ﺍﻟﻣﺗﺧﺫﺓ‬
‫ﺗﻡ ﺍﻟﺗﻧﺑﻳﻪ ﻋﻠﻰ ﺍﻟﺷﺭﻛﺔ ﻋﻠﻰ ﻋﻣﻝ ﺗﻔﺗﻳﺵ ﻭﺍﺧﺗﺑﺎﺭ ﻛﺎﻣﻝ ﻋﻠﻰ ﺍﻟﻐﻼﻳﺔ ﺍﻟﻣﺗﺑﻘﻳﺔ ﻭﺃﺟﺭﺍء ﻛﻝ ﺍﻋﻣﻝ‬
‫ﺍﻟﺗﺻﺣﻳﺣﺎﺕ ﺍﻟﻼﺯﻣﺔ ﻹﻋﺎﺩﺓ ﺍﻟﻐﻼﻳﺔ ﻟﻠﻌﻣﻝ ﺑﻁﺭﻳﻘﺔ ﺁﻣﻧﺔ‬
‫( ﻭﻋﻣﻝ ﺍﻟﺗﺻﺣﻳﺣﺎﺕ ﺍﻟﻼﺯﻣﺔ ﻟﺗﺣﺳﻳﻥ ﺍﻟﻧﻅﺎﻡ‬BMS ) ( ‫ﺗﻡ ﻣﺭﺍﺟﻌﺔ ﺷﺎﻣﻠﺔ ﻟﻛﻝ ) ﻧﻅﺎﻡ ﺍﺩﺍﺭﺓ ﺍﻟﻣﻭﺍﻗﺩ‬
‫ﻭﺃﻳﺿﺎ ﺗﻡ ﻣﺭﺍﺟﻌﺔ ﻧﻅﺎﻡ ﺍﺩﺍﺭﺓ ﺍﻟﺳﻼﻣﺔ ﻟﻠﺗﻌﺭﻑ ﻋﻠﻰ ﻧﻘﺎﻁ ﺍﻟﺿﻌﻑ ﻭﺳﺩ ﻣﺛﻝ ﻫﺫﻩ ﺍﻟﻔﺟﻭﺍﺕ‬
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
‫ﻻ ﺗﺘﺠﺎﻫﻞ ﻧﻈﺎﻡ ﺗﺸﻐﻴﻞ ﺍﻟﻐﻼﻳﺎﺕ ﻟﻤﺠﺮﺩ ﺍﻧﻬﺎ ﺗﻌﻤﻞ‬
‫ﺍﺗﻮﻣﺎﺗﻴﻜﻴﺎ‬

‫ﺷﻛﺭﺍ‬
THANK YOU

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