BOILER INCIDENT DIRECTLY ATTRIBUTABLE TO PSM ISSUES

Process Safety Management (PSM) programs are expected to reduce the pr obability and severity of hazardous incidents. This paper presents a r eal life incident that occurred in a plant before a PSM program was pu t in place. A detailed description of the incident is provided with ap propriate discussions of noncompliance with the PSM rule. Finally, the paper provides a theoretical scenario where a fully operational PSM p rogram would have prevented the incident. The case history and discuss ion provided in this paper also reinforces the concept of maintaining process and equipment integrity through multiple barriers of safety. A fully operational PSM program represents such a multiple barrier safe ty system. The incident occurred in a high temperature boiler in a pro cess plant. The incident was caused by a sequence of four occurrences that combined to cause the boiler to lose water level and have serious internal and tube damage. The problem was not detected until a mechan ic who was going to work on the feed pump realized that there was flam es coming out of the boiler stack. The mechanic told the operator abou t the problem and boiler was manually tripped. The boiler feedwater pu mp was not blocked in until 30 minutes after the incident was over. If this pump was started during or directly after the incident, the addi tion of boiler feedwater to the over-heated boiler would have certainl y caused and explosion. At the time the incident was reported there we re 8-10 employees in the area of the boilers.