Some thoughts on the near-miss incident involving the 103-B high-pressure steam coil

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On the night shift on February 20, 2009, after taking over the shift and checking the meters, it was found that the temperature indicated for TI-04130 was 176°C, which is significantly different from the normal operating temperature of 480°C. At the same time, the checks showed that FI-04104 read 0, while TI-04121b was at 684°C, which is nearly 100°C higher than normal. Therefore, the instrumentation staff was contacted promptly for inspection and verification; after checking the instruments, it was confirmed that the readings were accurate. Emergency measures were taken; after slightly opening HCV-04106 for venting, all parameters returned to normal. The relevant personnel in the back office analyzed that it was due to a large pressure difference between the two steam drums, which caused steam in 122-F to be trapped and unable to flow freely, thereby leading to dry burning of the high-pressure steam coil in 103-B. It belongs to a near-miss incident involving equipment. The department has decided to impose a fine of 200 yuan on our class. The summary of this incident is as follows: 1. The pre-shift inspection was not conducted in a timely manner upon taking over the shift. During the pre-shift inspection, due to the shutdown of Unit 4, only units 103-J and 105-J were shut down; the upstream system had its load reduced, and there were no significant fluctuations in other operating conditions. Therefore, only some key parameters were briefly checked, and no abnormalities were detected. This reveals a lack of thoroughness in pre-shift inspections, as well as insensitivity to abnormal changes in various parameters. 2. After detecting abnormal changes in various parameters, although it was noted in the shift log, it was not accurately recorded in the reports. Although this is related to the department’s requirement that process parameters be recorded within normal ranges, in abnormal situations, the parameter records should still be kept accurate and valid, or notes should be added alongside them. Actually, when I noticed the abnormality that day, I didn’t record those data at the time; I only entered them after everything returned to normal, just before leaving work. This reveals a lack of my operational experience, as I have not fully understood the various rules and regulations that govern production. Because if the handling is not effective and an accident occurs, and someone reviews the reports, the consequences will be extremely severe. Therefore, in the future, records of abnormal parameters under abnormal operating conditions must be accurate; one can also seek advice from experienced colleagues or departmental technical staff. 3. Upon discovering an accident, it is necessary to report it promptly to the department’s technical staff and relevant supervisors, as well as inform the production scheduler. We didn’t handle things well in this regard that day; it was right to get in touch and take action as soon as the accident was discovered, but it’s also important not to fail to report it, nor to delay reporting it. In case something goes wrong and it isn’t reported, the matter is kept under one’s own control. As long as it is reported, as for how to handle it, one can follow the instructions of the supervisor or technical staff. After all, that’s what technicians are supposed to do. As a frontline operator, one only needs to carry out all the instructions given by technicians and managers in a way that ensures quality and quantity. 4. The dry chemical industry should adhere to the principle of avoiding accidents at all costs, and must not focus on obtaining rewards. Actually, if we hadn’t asked our supervisor for a reward that day, we wouldn’t have had our pay deducted, because there were indeed some areas in which we fell short in handling this matter – for example, we didn’t detect the problem during the pre-shift inspection, and the data at that time wasn’t recorded accurately. If it hadn’t been brought up by myself, this matter would likely have gone unaddressed, as no one would have known about it. Everyone’s attention is focused on restoring the system and getting back to driving. 5. Some leaders have extremely poor management skills. If it weren’t for a certain leader who actively encouraged us to apply on our own, we probably wouldn’t have faced this deduction this time. Some leaders should not speak rashly if they don’t have the authority to make decisions; a single word can kill someone. Of course, such a leader still has nothing to say when it comes to social skills and interpersonal relationships. At the very least, one should understand the principles of being a decent person; in other words, their character is sound. And some leaders are rigid and dogmatic, unable to adapt; after decades of hard work, things remain exactly as they were. They always think their skills are outstanding, but I don’t necessarily agree. It feels like the device can’t be turned on without me around; with my head held high, no one will pee. It’s almost ridiculous. 6. In the future, when encountering issues, one should report them promptly, wait for instructions, and act according to those instructions; this is also the essence of learning from the Western Pacific region and of embracing a mindset of controlled production. Under no circumstances should one handle things blindly, thinking they are great and then demanding rewards. Remember, in the chemical industry, it’s not about being great – it’s just about ensuring nothing goes wrong. This is a wise saying from experienced professionals who have worked in the chemical industry for many years; it is also the goal that every chemical operator strives to achieve throughout their lives. It’s already considered fortunate if nothing goes wrong throughout one’s life; but once something does happen, it’s not just a matter of losing money. At meetings big and small, people will use that incident as an excuse to criticize you, and your life is then ruined. Take this accident for example; we failed to report it in a timely manner. If, during the handling process, the coils were damaged or a severe explosion occurred, things would have turned out very badly. Because during the processing, TI-04130 rose very rapidly – in less than ten minutes, it increased from over 100°C to 629°C. Think about 100 kilograms of pressure – what material would not fail under prolonged exposure to high temperatures? Therefore, timely reporting is essential. This post was last edited by Huang Xinhui on 2009-2-27 at 12:41.]