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Slide 1
Good afternoon Team

Before we begin, if you could kindly indicate on the chats who is attending today's session.

Indicate your brewery, name, surname and position. If you are in a leadership position, you are welcome
to list the names of all those attending today's session for your team.

Slide 2
Due to the severity of the boiler SIF incident that occurred in Ate Brewery, it was deemed necessary to
have dedicated training on understanding what happened and how to prevent this from happening at
any of our sites.

Slide 3
Let's go over the incident that occurred in Ate Brewery located in Peru.

Slide 4
A biogas boiler exploded on Christmas eve last year. The explosion was so severe that the rear cover was
found 10 meters away from where the boiler was originally installed.

The explosion resulted in damage to nearby utility pipework and a structural element.

A maintenance operator that was working nearby suffered 1st and 2nd degree burns to his arms and
face.

Based on the nature of this failure, the likely cause was a low water level condition. It appears the biogas
burner didn't trip despite the water reaching dangerously low levels.

So how can we prevent this from happening?

1. Above all, let's ensure our Boiler House Operators are appropriately qualified to operate our
boilers
2. We have to ensure that we have the necessary engineering and administrative mitigation
measures in place to prevent a low water level condition which I will detail shortly in the slides
to come

Slide 5
This is a picture of the biogas boiler before and after the explosion.

Slide 6
Just a few images of the surrounding damage after the explosion. Here we see some shattered windows
of a nearby room and damaged concrete beam due to the cover blown from the boiler

Slide 7
So this not a rare type of failure. Here are few examples of how a low water condition here in South
Africa have resulted in catastrophic losses
Slide 8
On this example and summarizing the red underlines, the water level dipped below the low water mark
and the alarm and trip functionality did not engage.

The boiler continued to run as heat energy continued to feed into the boiler.

Eventually the weld seam failed resulting in an explosion.

The Operator was not injured. He was trained and the records did suggest this.

There is a shiftly check to test the low water alarm and tripping safeties and his checklist did illustrate
that he did in fact do this.

Unfortunately, no OWD was done to validate his understanding on the matter and when asked how to
perform this check, he revealed his lack of understanding to the inspector.

If you read this section in particular on page 2, the Operator thought that in order to conduct this critical
check, he had to physically run the boiler dry which revealed his lack of understanding on carrying out
this task.

Ultimately his contract was terminated and the company had to purchase a new boiler.

I must stress the fact that if the supervisor just took the time to validate that the operator was
competent on this task via an OWD or even if an SOP was available for him to review, this incident could
have been prevented.

Do not assume that if someone is qualified and certified to operate a boiler that he/ she will facilitate
the expected tasks. Please ensure that there is an SOP and validate this critical check via OWD.

Slide 9
In this quick example, as you can see a similar incident led to the total destruction of the boiler and the
adjoining factory that ran 24 hours like us.

It was determined that the Operator fell asleep on night shift. He was dependent on the low water
safety alarm to wake him up and to trip the boiler however it did not work.

He did suffer injuries but recovered. His contract was not terminated however due to the monies
required to rebuild the factory, the business decided not to pursue that course and led to the
retrenchment of himself and his fellow colleagues.

Now the learning here is that if there was a safety checklist to prompt regular interlock inspections and
during these inspections it was found that there was problem perhaps earlier during the day, that boiler
could have been placed offline to rectify the fault.

Instead the fault failed to activate the interlock which resulted in a severe explosion.

Slide 10
What are systems should we have in place?
Slide 11
As many of you know, on all our fire tube boilers, we have a mobrey level switch that cuts the boilers
energy feed if the water level falls below the low low water level mark.

This is done to prevent the boiler from running dry bearing in mind that water within the boiler also
maintains the desired temperature of the fire tubes as it evaporates. If there is no water, those fire
tubes become malleable and could fail resulting in an explosion as steam expands violently.

This low level switch is a hard-coded device and is tested once a shift. This directive or regulation must
be enforced with all our teams.

If it fails to operate after testing, the boiler operator must feel empowered to place that boiler offline for
investigation and repairs. Please ensure that this directive is well cascaded to the front line team.

Slide 12
So in the spirit of learning from previous incidents, let's use an example even closer to home in one of
our breweries here in South Africa that occurred a little over a year ago.

There were mitigation measures in place however none failed to avert a low water level condition on
Boiler 2.

We started our investigation on the evening of the incident where there was tube sheet leak and we
found that the water level reduced below the safety mark. The mobrey level switches failed and was
known to be offline and our other forms of defense in the hierarchy of control also failed which includes
other engineering and administrative measures which I will detail shortly.

Slide 13
When we pulled trends we observed the water level reducing to 0% and in response, the boiler feed
water supply valve peaked to 100% open however upstream to this control valve, is an isolation valve
and that was found closed. We are not sure why that manual valve was isolated.

To further validate our hypothesis that the boiler ran dry, we observed a rise in flue gas temperature to
indicate that no heat transfer was taking place with the water and hot flue gas.

Slide 14
There were three engineering mechanisms to protect against a low water level condition namely the
mobrey level switch, level transmitter and a level proxy sensor on the sight glass.

The mobrey switch which is the main form of defense and the level sensor on the sight glass was
damaged and offline. The level transmitter appeared to be purely indicative with no alarm functionality
to alert the operator on SCADA.

Slide 15
There were four administrative mechanisms that can be used to reveal a fault namely three inputs on a
logbook and one SIC input.
The strange thing noticed is that the boiler operator marked that he tested the mobrey switch on this
boiler knowing that he cannot do so since it had failed and had failed for some time.

The boiler water level input is done too far in between at a frequency of 4 hours. It must be done at
least every two hours taking reference from the OEM. It was marked at 41% at 14:00 which is below the
low low water level mark but didn't prompt any investigation.

Lastly two inputs for flue gas temperature didn't reveal the correlation of low water to high flue gas
temperature link.

In this case study, there were multiple mechanisms available to preempt or diagnose a low water level
condition and this tube sheet leak could have been prevented which rendered the boiler offline for
months.

Slide 16
What are the expectations of leadership and when I mean leadership I mean our team leaders, our E&F
engineers and our GMR 2.1 appointments?

Slide 17
1. Ensure we go over this training with each and every boiler house operator
2. Ensure our OWS features an SOP on how to conduct a low water level trip including a blow
down to clear debris that could obscure the true level within the boiler
3. Leaders as we have learnt from the previous case study in South Africa, we must conduct an
OWD when our boiler operators conduct this check and the steps taken should be validated
against the Standard operating procedure
4. Once this critical check is completed by the Boiler House Operator, it must be signed off either
on a checklist or a logbook
5. Leaders you then need to validate this check by routinely reviewing this logbook or checklist.
Failure to adhere to this shiftly check is an opportunity to coach and must be investigated as to
why it did not occur. We need to ensure the Operator is aware that failure to conduct this check
can lead to dire consequences
6. Let's ensure we have other means of monitoring the water level that is to have a level indicator
with alarming functionality and or a proximity sensor on the sight glass also with alarming
functionality
7. Ensure that the water level is monitored and formally recorded on the logbook every two hours.
If you need to amend your logbook frequency as a result, please do so.
8. Lastly ensure that the boiler operator can link other PIs to a possible low water level condition. A
good example is a low to nil flow rate into the boiler over a period of time or the flue gas
temperature rising due to minimal heat transfer. If the flue gas temperature increases it
suggests that minimal heat transfer is taking place between the flue gas and remaining water
within the boiler due to a lack of water

Slide 18
We developed a health dashboard with 8 checks in 2022 that was filled out in Q1.
Any question marked as a No will constitute as a gap that needs to be addressed immediately.

This dashboard was completed last year and this was the representation as of Week 14 in 2022. The
request is to reinvigorate this dashboard that can be accessed via this SharePoint link. Please validate
that these systems are in place and aim to change any No's to Yes's.

Please print this training material and have it available for our operators coming on shift. Alternatively,
they are welcome to join more sessions in the week.

The success of this training is if the FLT have a talking knowledge of what happened in Ate Brewery and
what they can do to prevent it from happening in their boiler house.

Slide 19
Thank you. Any questions/ thoughts of clarification?