When I wrote the first entry in this blog, I did not expect it to be dormant for so long. Certain constraints from my retirement were partially to blame but even without that, time was very scarce and the blog probably would not have gotten updated. I wrote two short articles for the ISA Power Industry Division Spring 2011 Newsletter, one with the same title as this blog. Never being one to waste words, here is that article.
It does not seem possible that I have been retired for a little over a year now. As I had been warned, I have been busier than while I was working. Does not seem possible. Wish some of the work would have generated a positive cash flow.
Since the first of the year, I have been reading a number of reports written by government commissions and boards on a number of incidents that have occurred. While only one directly involved a power plant, they all offered lessons learned and warnings for the power industry.
First up was the January report from the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling; Deep Water: The Gulf Oil Disaster and the Future of Offshore Drilling which can be downloaded at http://www.oilspillcommission.gov/final-report. I must admit that I skimmed the sections of the 398 page report dealing with the cleanup and environmental impact. However, the sections on the time-line, process equipment and decisions were very interesting.
To me, the most interesting discussion in the report is “Complex Systems Almost Always Fail in Complex Ways”. The tendency after a incident is to try to identify the 'single' point of failure, decision, or activity that caused the incident. Believing that there is a magic silver bullet that will prevent a repeat of the incident just re-enforces the complacency that caused the incident. The report references “Complex Systems Almost Always Fail in Complex Ways” to the Shuttle Columbia Accident Investigation Board Report. The six volume report is available at http://caib.nasa.gov/news/report/default.html. The referenced discussion appears in Volume I.
Next came the Chemical Safety Board's report on the Bayer CropScience Pesticide Waste Tank Explosion (http://www.csb.gov/newsroom/detail.aspx?nid=361) in 2008. Factors cited in the investigation reports included attempting the process start-up with a new DCS system that was still being checked out, instrumentation not calibrated, totally different look to HMI displays due to change of DCS vendor, etc. Other factors identified are cognitive tunneling and not seeing the big picture, task-shedding due to the workload experienced during the re-start, interlocks that did not work on the old system being retained in the new system where they were also bypassed, missing valves and instruments, and operating procedures that were not updated to the new equipment that had been installed.
The final item reviewed is the Chemical Safety Board's Safety Video; “Deadly Practices” (http://www.csb.gov/newsroom/detail.aspx?nid=363) that focuses on the ConAgra and Kleen Energy explosions that resulted from the hazards of fuel gas releases. The video focuses on the dangers of what appears to be a cavalier attitude about the explosive potential from fuel gas releases when charging lines or doing gas blows to clean line. The CSB has recommended changes in codes, standards, recommended procedures and laws to prevent additional incidents. Some of the recommendations have been implemented in the year since the Kleen Energy explosion. From the number of house explosions and fires that have been making the local news this winter, I have concerns that everyone has become too complacent in handling natural gas and propane.
Even though only one of these incidents involved a power plant, I think everyone will recognize many of the factors cited from their personal experience. These reports are recommended reading and worth consideration for everyone, regardless of their experience.
Hopefully, the next blog entry will not take as long. I have been busy trying to grow the ISA Power Industry Division group on Linked In which was the subject of the other newsletter blog. I also have a technical paper being presented in the division's 54th POWID Symposium in Charlotte next month and it's time to submit another article for the Summer Newsletter. You would think that I like to write or was good at it.
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