psim南沙站調(diào)壓撬路起跳事件報(bào)告

1、DPLNG Incident Report Form Minor Incident3. INCIDENT DESCRIPTION2012 年 03 月 07 日 11：26 時(shí)，南沙站調(diào)壓撬A 路的 SSV3051 閥因出站壓力（最高至 4.55MPa）出現(xiàn)起跳關(guān)閉，調(diào)壓撬自動(dòng)切換至B 路，沒有造成中斷供氣。事情經(jīng)過如下：3 月 7 日，維修一行到南沙站進(jìn)行加熱爐橇四孔法蘭加裝防雷跨接銅片工作。操作員按正常程序首先對A 加熱爐進(jìn)行了放空，維修開始安裝防雷跨接片。此時(shí)加熱爐的流程為：A 爐，B 爐暢通；為確保正常供氣，操作員將旁路調(diào)溫閥 TV3062 手動(dòng)全開。維修安裝完A 爐的防雷跨接片后，操

2、作員開始A 爐工藝流程恢復(fù)工作，操作員關(guān)閉了A 爐放空閥，打開A 爐上游手動(dòng)球閥 BA63062 的 1 寸旁通開始給A 爐升壓。升壓完成后，操作員未及時(shí)打開A 爐上游手動(dòng)主球閥，操作員隨后在站控室打開了 A 爐出口閥 XV3041。操作員緊接著對B 加熱爐進(jìn)行了，維修開始安爐的防雷跨接片。此時(shí)加熱爐的流程為：A 爐上游手動(dòng)球閥 BA63062 關(guān)閉，1 寸旁路全開，出口閥全開；B 爐；旁路調(diào)溫閥TV3062 手動(dòng)全開。B 爐維修工作中，操作員回到站控室，操作員回到站控室時(shí)發(fā)現(xiàn)出站溫度已經(jīng)低報(bào)，便關(guān)閉加熱爐旁通閥TV3062 讓氣通過A 加熱爐加熱試圖以提高出口氣體溫度。此時(shí)天然氣僅由A 爐上

3、游球閥 BA63062 的 1 寸旁通閥通過，不能完全滿足下游用氣的需要，很快造成出站壓力低。調(diào)壓閥自動(dòng)開大到了 30%左右。操作員馬上手動(dòng)將 TV3062 的開度由 0 開至 50%，接著再開至 100%。此舉造成兩個(gè)：下游出站壓力沖高，造成A 路 SSV 聯(lián)鎖關(guān)閉，B 路自動(dòng)接管；上游過濾撬與加熱爐之間的壓力降低，與過濾撬上游瞬間形成了 209Kpa 的偏差，導(dǎo)致過濾撬自動(dòng)切換。接到 后，北區(qū) 和主管先后趕到南沙站進(jìn)行原因分析，并通報(bào) 。經(jīng)過檢查事件 和趨勢圖，初步認(rèn)為是過濾撬堵塞切換造成的，經(jīng)與維修溝通，當(dāng)天下午安排了過濾撬B 路的開蓋 工作，發(fā)現(xiàn)一些油脂類雜物。3 月 8 日，由于觀察

4、趨勢圖和事件 中還存在一些疑點(diǎn)，相關(guān) 再次到南沙站 ，最終查明造成本次事件的主要原因?yàn)槿藶?。On March 07,2012,SSV3051 shut down due to high outlet pre re at Nansha OTS. The stand-by loop took over automatically, and no influence to ga pply.Below is the i e content:Ma enance team went to Nansha OTS to do adding sheet cooper on the flange of four

5、 bolts on March 07.Operator did the normal energy isolation work, and ma enance team started their work.Right now the heater skid pros was: Heater A isolated, Heater B was normally running, bypass loop (TV3062) was opened.After maenance team finished their work on Heater A, operator started pros rec

6、overy work of Heater A. He closed the venting valves, slowly opened the upstream 1 inch bypass valves of Heater A to prerize.After finished prerizing, operator fot to open the upstream main valve.Aftert, operator isolated Heater B, and maenance team started their work on Heater B.2. CONSEQUENCEParti

7、es InvolvedInjuryProperty DamageGDLNGNoneNoneContractorNoneNoneThird PartyNoneNone1. GENERAL INFORMATIONREPORT NO.Report Title南沙分輸站調(diào)壓撬A 路起跳事件Loop A of prere regulator trip ie at Nansha OTSWork Pros Involved能源程序Energy isolation procedureType of Incident未遂事件Near missDate of Incident07-Mar-20124. CRITI

8、CAL FACTORS, CAUSEYSISCritical Factors程序執(zhí)行，沒有根據(jù)程序要求打開加熱爐A 上游主閥。The energy isolation procedure was not followed strictly,t is, the Heater “A” upstream main valve was not open as required by the procedure.Immediate CausesNote (briefly list supporting evidence)1、工作程序遵守方面：1、procedure follow: 1-10 走捷徑 1-

9、10 short cut能源 程序執(zhí)行 。操作員在同一系統(tǒng)依次進(jìn)行的能源 工作時(shí)，沒有遵循完成一路，恢復(fù)一路，再進(jìn)行另一路能源 的原則。Energy isolation procedure was not followed strictly. When ng two energy isolation work on one system, it must ensure one loop isolated after another loop has been recovered fully.2、疏忽/意識缺乏：2、lack of awareness4-1 決定欠妥或缺乏判斷 4-1 poor

10、decior no judgement工作方面不能合理把握。操作員在對 TV3062 的開0-50%-100%時(shí)，動(dòng)作過快過急；也缺乏對該操作會(huì) 的 的考慮。No reasonable judgement when something happened. Wrong valve operating action for TV3062, and no proper judgement for the operating consequence.System CausesNote (briefly list supporting evidence)1、行為：1、action5-8 雇員5-8 st

11、aff precipitancy操作員在緊急情況下處理事情不冷靜。當(dāng)溫度低于 1.5時(shí)，完全有時(shí)間檢查原因再進(jìn)行流程操作。Operator was precipitancy. He had enough time to deal with the problem of low outlet temperature properly.2、技術(shù)水平:2、skill level6-2 缺乏技術(shù)實(shí)踐 6-2 lack of technical practice未遵循平穩(wěn)、緩慢的操作原則。即使需要使用溫控閥調(diào)節(jié)溫度，也不能急開急關(guān)操作。Not follow stably and slowly opera

12、ting principle. TV3062 could be operated slowly and stably not open and close fully.3、工作 PSP：3、PSP14-3 工作中無確認(rèn)步驟 no double confirming step on the pros energy isolation工藝上”恢復(fù)”一欄只有操作員簽名,而沒有”復(fù)核人”簽名欄，少一道確認(rèn)就會(huì)多一份意外發(fā)生的可能(在盲板上就有恢復(fù)時(shí)的雙簽欄)。 There are no double check lists of pros recovery on the pro s energy is

13、olation(there are double check lists on the blind isolation.)Right now the heater skid pros was: Heater A was running only used by upstream 1 inch bypass line, Heater B isolated , and bypass loop (TV3062) was opened.During Heater B maaining, operator back to control room, he found the outlet tempera

14、ture was low, and he closed TV3062 to let NG through Heater A to raise the outlet temperature.Now all NG took by customer were only passed through upstream 1 inch bypass line of Heater A, and it is not enough to supply current flow. Soon, the outlet prere dropped down and alarm. The prere control va

15、lve opened to 30% automatically. Operator was aware of the problem, and he opened TV3062 to 50% at once. Thiion caused two problems:as the outlet prere went up too high immediay, and SSV3051 tripped, lotook over automatically. The second wast the prere betn filter skid and heater skid dropped down,

16、the prere difference raised to 209kpa betn upstream and downstream filter B which was running, and theerlock acted and filter A opened.After received report, supervisor and senior operator went to Nansha OTS to investigate the initial cause immediay, and reported to prior leader. According to the ev

17、ents record and pros trend, the problem of filter B was regarded to the main reason att time. After communicated with maenance team, filter B was arranged to clean on afternoon, and some grease material were found.On March 08, related people went to Nansha OTS tonvestigation again because some doubt

18、s existed. The final result showedt human error is the main cause of this ie.1.ACTION TRACKINGNoActionResponsibleDate1CompletedIncident investigation.進(jìn)行事故。Chen, Tiger Lin WeiDing Bella Hong Deng Yuanming22012-03-08對當(dāng)班操作員進(jìn)行能源程序再培訓(xùn)和維修教Ding Bella Hong育。Provide energy isolation re-training to and maenan

19、ce team.operator3Share this incident in OPS Trunkline team.2012-03-09Chen, Tiger Lin WeiDing Bella Hong在管線運(yùn)營此次事故教訓(xùn)。42012-04-30事件事件未按時(shí)間進(jìn)行排序，同時(shí)在中控未能顯示全部，需要檢查原因。Events record is not line upZhu Lijian劍by time, and there is no same events record in CCR.52012-06-30建議對工藝進(jìn)行更新完善，增加流程恢復(fù)時(shí)的Ding Bella Hong雙確認(rèn)欄（參考盲板）。To update the and add doublepros energy isolationsign column on it.6Luo Jesse Ziyuan2012-06-30站場操作員經(jīng)常需要在行維修較長時(shí)間，為加強(qiáng)中控及其他和站場的便捷溝通，建議盡快采購防爆。Sion operators usually need to monitor maenance work outside, and the EX mobile shouldbe dispatched comm