BO CO S C - INCIDENT ALERT
BO CO S C - INCIDENT ALERT
(NEAR MISS, FIRST AID, RECORDABLE INCIDENT, SPILL )
Report date: Oct-24-2013Report by: Tran Minh PhongDepartment:
HSE
NH MY
PLANT:SSTVN
LOI S C
INCIDENT TYPE:Near miss: Furnace Explosion
S c sut xy ra
S TH T S C
INCIDENT NUMBER:
KHI NO?
WHEN?12:16
M T S C
WHAT?The back-up generator which powers the evaporative coolers
and pumps did not engage. About ten minutes after the power failed
he went down and killed the disconnect switch and immediately the
generator kicked in and the pumps re-started. Although the shoe
shorting out on the hot-track did not cause the power failure it
did keep the generator from starting.
NI XY RA?
WHERE?Furnaces Monorail cooling tower generator
MC THNG TT
EMPLOYEE INJURY:N/A
NHM IU TRA
INCIDENT INVESTIGATION TEAM :Joe, Manh, Thanh, Khang,
Phong.Tran
TN HI TI SN
EQUIPMENT / FACILITY DAMAGE: A carbon brush of the monorail was
burnt.
TNH TRNG IU TRA
INVESTIGATION STATUS:Completed
TI SAO?
Why?Why was there a possibility of the impending danger of
furnace explosion?Due to the power loss, the cooling towers could
not supply the water to the furnaces
TI SAO?
Why?Why did the power fail?The main CB & generator could not
be on
Why could not they be on?
The power was leaked , but the CB used in the monorail system
had no function to detect this whereas the main CB and generator
could and automatically dropped . A carbon brush on one hoist was
burned during running.
Why did the electrical leakage cause the power failure?
No ELCB used in the equipment.
NGUYN NHN GC
ROOT CAUSE Earth leakage occured in the monorail system
NGUYN NHN GP PHN
CONTRIBUTING CAUSESNo backup water for the furnaces when the
power was lost.
HNH NG KHC PHC
CORRECTIVE ACTIONSinstall a disconnect panel between the
generator and all systems except the evaporative coolers and the
cooling pumps Thanh-MA
Due date: Oct-28-2013
install a "city water" or fresh water bypass that will cool the
furnaces in the event of a catastrophic failureThanh-MA
Due date: Nov-04-2013
