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Preliminary Investigation Report Incident Investigation:: Preventive Action

On March 4th at 9:20 pm, a noodle charging operator heard a sound from the furnace oil (FO) tank farm and alerted the shift officer. The officer discovered that Tank 751A, storing furnace oil, was on fire and its top had been dismantled, damaging nearby pipelines and instruments. The boiler operator shut down the boiler and the electrician isolated the boiler and tank farm power supply. The fire brigade was notified and extinguished the fire by 9:29 pm. An investigation found the root causes were overheating of an electrical immersion heater now exposed below the low FO level, and the boiler operator failing to follow procedures for oil transfers. Corrective action removed the electrical heater

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Ashish Mishra
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49 views

Preliminary Investigation Report Incident Investigation:: Preventive Action

On March 4th at 9:20 pm, a noodle charging operator heard a sound from the furnace oil (FO) tank farm and alerted the shift officer. The officer discovered that Tank 751A, storing furnace oil, was on fire and its top had been dismantled, damaging nearby pipelines and instruments. The boiler operator shut down the boiler and the electrician isolated the boiler and tank farm power supply. The fire brigade was notified and extinguished the fire by 9:29 pm. An investigation found the root causes were overheating of an electrical immersion heater now exposed below the low FO level, and the boiler operator failing to follow procedures for oil transfers. Corrective action removed the electrical heater

Uploaded by

Ashish Mishra
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Preliminary Investigation Report

Incident Investigation :

On 4th Mar B shift, at 9:20 pm , noodle charging operator heard sound from FO tank farm
and he informed TSP 1 shift officer. Shift officer reached the FO tank farm and observed
Tank no. 751 A storing furnace oil caught fire and tank top got dismantled from tank
damaging the nearby pipelines and instruments. Boiler operator acted fast and shut down
the boiler. Shift officer instructed the electrician to isolate the boiler and tank farm power
supply and also informed the fire brigade. The fire blew off at 9:29 pm and fire fighters
cooled down the tank using foam water. The tank stored 2.5 kl furnace oil.

Meantime, as a precautionary measure all the persons assembled in their respective


assembly points and head count was matched and instructed to proceed for production.

Root cause:
1) Overheating of electrical immersion heater as the furnace oil level has gone below
the electrical immersion heater which in normal operation is immersed in furnace
oil.
2) Boiler operator failed to follow the standard operating procedure which specifically
mentions that transfer from main to day tank should be only done if level is greater
than 35 cm .

Preventive Action:
Corrective action has been taken by activating steam coil heating and removing the
electrical immersion heater

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