SECCO98Incident20121118

1、SECCO HP Ethylene Gas Release Incident 8th September 20112011年9月8日賽科高壓乙烯氣體泄漏事故2006年年6月月50%30% 50%20%30%2006年年6月月2006年年6月月2006年年6月月賽科主要生產(chǎn)裝置賽科主要生產(chǎn)裝置 Main plants of SECCO119萬噸萬噸/年乙烯年乙烯50萬噸萬噸/年芳烴抽提年芳烴抽提9萬噸萬噸/年丁二烯年丁二烯65萬噸萬噸/年乙苯年乙苯/苯乙烯苯乙烯30萬噸萬噸/年聚苯乙烯年聚苯乙烯60萬噸萬噸/年聚乙烯年聚乙烯25萬噸萬噸/年聚丙烯年聚丙烯26萬噸萬噸/年丙烯腈年丙烯腈28萬噸萬噸

2、/年硫酸回收裝置年硫酸回收裝置賽賽 科科 生生 產(chǎn)產(chǎn) 裝裝 置置2006年年6月月2002, March2002, Oct2004, Dec2005, March2005, July2006年年6月月All accidents are preventable所有事故都是可以避免的所有事故都是可以避免的SECCO Commitment - 賽科的承諾賽科的承諾We try to achieve 我們力圖達(dá)到我們力圖達(dá)到No accidents 無事故、無事故、No harm to people 無人身傷害、無人身傷害、No damage to the environment 無對環(huán)境任何損害。無

3、對環(huán)境任何損害。Commitment to HSSE 我們對我們對HSSE的的承諾和承諾和責(zé)任責(zé)任 SECCO Vision & Values賽科的愿景和價值觀點擊播放視頻1 滅火現(xiàn)場 Brief Account of Incident 事故情況At 22:53 on Sep 8 a release of high pressure (HP) ethylene occurred at the gate valve (DN150) of the bypass line of flow meter for transferring HP ethylene from SECCO to Sha

4、nghai Petrochemical. The released ethylene was immediately ignited resulting in an ethylene leak and fire. 9月8日晚上10點53分，賽科到上海石化的高壓乙烯輸送管道的流量計的旁通管線上一臺閘閥（DN150）發(fā)生了高壓（HP）乙烯泄漏。釋放的乙烯立即起火，造成乙烯泄漏與火災(zāi)事故。Fire impacted the cryogenic ethylene tank farm pipe rack and HP ethylene transfer area, and resulted in dam

5、age and deformation of some pipe racks, 20 pipelines (Hydrocarbon/Utilities), power cables and instrument cables on the pipe rack. 火災(zāi)影響到低溫乙烯罐區(qū)的管架與高壓乙烯輸送區(qū)，部分管架、20條管線（烴類/公用工程）、以及管架上的電源線與儀表電纜遭到破壞或變形。The fire was brought under control at 1:30am on 9th September. In total, 70 tons of ethylene was release

6、d. There were no injuries in this incident, and no significant environmental pollution was caused. 9月9號凌晨1點30分火情得到控制?？偣册尫帕?0噸乙烯。事故沒有造成人員傷害，也沒有造成重大的環(huán)境污染。乙烯罐74-TK-0301丙烯罐74-TK-0401乙烯冷凍單元 過火區(qū)域過火區(qū)域氨罐74-TK-0401丙烯冷凍單元受損管廊管線受損管廊管線介質(zhì)介質(zhì)管線數(shù)量管線數(shù)量超臨界乙烯2乙烯2丙烯2氨1冷凍水2火炬管線1工廠風(fēng)1低壓蒸汽1低壓凝液1中壓氮氣1儀表風(fēng)1冷卻水2工業(yè)水1燃料氣1點火氣1Sup

7、ercritical Ethylene System 超臨界乙烯系統(tǒng)Rupture of bolts and fire accident螺栓斷裂與火災(zāi)事故螺栓斷裂與火災(zāi)事故SC ethylene to SPCsuper-critical ethylene from ethylene plant管線的清洗球收發(fā)器接口 Pipeline cleaning ball Transceiver connection 5M 2M 3M 2M 30M流量計 Flow meter破裂閥門 broken valve 火炬flareCryogenic liquid ethylene into vaporizer蒸

8、發(fā)器vaporizer1、The result of the broken bolt test shows that the carbon content of all broken bolts are higher than as required in ASTM 193 for B8 (304 SS) bolt, and the solution treatment is not thorough enough. 螺栓斷裂的試驗結(jié)果顯示所有斷裂螺栓的碳含量都高于ASTM193 B8（304SS）標(biāo)準(zhǔn)，而且固溶處理也不夠徹底2、The environment contains corrosi

9、on medium such as SCI etc. and due to stress intercrystalline stress corrosion cracking occurred on the bear bar of the bolt. The crack deteriorated during normal use till it ruptured.環(huán)境中含有S/CI等腐蝕性介質(zhì)。還因為螺栓的受力桿發(fā)生了晶間應(yīng)力腐蝕開裂。正常使用時開裂擴大并最終斷裂。3、The valve bonnet blew off and touched the steel platform overh

10、ead causing spark and ignition of the leaked ethylene.閥帽沖出并砸到底部鋼制平臺，引發(fā)火化并引燃泄漏出來的乙烯。點擊播放視頻2 監(jiān)控視頻Valve Bonnet and Stem閥帽與閥桿Valve Body閥體Damaged Valve Site受損閥門現(xiàn)場4.5mValve bonnet separated from the valve body and hit the base of the platform above the valve. Valve bonnet was later found 4.5m from the val

11、ve body.閥帽與閥體分離，撞到閥門上面的平臺底部。后來在距閥體4.5米處找到了閥帽。Date日期日期Description (Event / Condition)說明（事件說明（事件/條件）條件）Information Source信息來源信息來源July 20042004年7月HAZOP of high pressure ethylene pipe was conducted.進(jìn)行了高壓乙烯管線HAZOP。2004 HAZOP report 2004年HAZOP報告May 20052005年5月Construction of the super critical ethylene pi

12、pe and distribution was completed based on super critical ethylene distribution design.根據(jù)超臨界乙烯配管設(shè)計，完成超臨界乙烯管線和配管施工。Conversation / slides provided by SECCO engineer談話/幻燈片SECCO工程師提供June 20052005年6月Preparation of commissioning of super critical ethylene pipe.超臨界乙烯管線準(zhǔn)備試車。Conversation / slides談話/幻燈片3 June

13、 20052005年6月3日Pressure test for Line 200-P-8201003 was done. The test pressure was done at 1.5 times design as per SECCO technical standard and the line passed the test.完成管線200-P-8201003壓力試驗。按照SECCO技術(shù)標(biāo)準(zhǔn)，以1.5倍設(shè)計壓力做了壓力測試，管線通過了測試。Pressure test report.壓力試驗報告。(The Pressure test report see Appendix 1.壓力試驗

14、報告參見附錄1)July 20052005年7月Commissioning of super critical ethylene pipe (Line 200-P-8201003) and started transfer of ethylene in gas phase to SPC (not super critical ethylene)The operating pressure range was 3.2-3.4 Mpa, ambient temperature.超臨界乙烯管線試車（管線200-P-8201003），開始向SPC輸送氣相乙烯（并非超臨界乙烯）操作壓力范圍處于3.2-3

15、.4Mpa,常溫。Review SOP & operating envelop at this time. 審核SOP和當(dāng)時的操作范圍(SOP see Appendix 2，SOP參見附錄2) 2007SECCO issued a procedure of leak detection and repair procedure requiring leak test for high risk items every 3 months.SECCO 發(fā)布泄漏檢測程序，及對高風(fēng)險項目每3個月進(jìn)行一次泄漏檢測的修訂泄漏檢測及修理(LDAR)程序Leak Detection and Repai

16、r (LDAR) Procedure June 2008A release of ethylene from a gate valve on gas ethylene line to Tianyuan happened due to failed SS304 bonnet bolts which are from different vendor. Causal analysis showed that stress corrosion cracking (SCC) caused the bolt to fail. High carbon content and no solution tre

17、atment were the contributing factors of SCC. 天原一條乙烯輸送管線，因為一個閘閥上的SS304螺栓斷裂而造成乙烯泄漏的事故。該閥門從另外供應(yīng)商購買。經(jīng)過根本原因分析發(fā)現(xiàn)，是由于應(yīng)力腐蝕斷裂造成螺栓斷裂。較高的含碳量以及沒有進(jìn)行退火處理，是造成應(yīng)力性腐蝕的原因之一。Following the Tianyuan incident related valves were checked for positive material identification and all valves were found to be normal however, t

18、he report was not kept.天原事故后對相關(guān)閥門的實際材料進(jìn)行了鑒定，結(jié)果發(fā)現(xiàn)全部正常沒有保留報告。 July 20082008年7月A MAR study was started for the 6 pipeline transfer from Secco OSBL to SPC and not completed 進(jìn)行了從SECCO到SPC6根管線的MAR研究，但沒有完成。 May 20092009年5月SECCO ethylene system modification project completed to allow transfer of super criti

19、cal ethylene to SPC. The project allowed the transportation of higher volume of ethylene to SPC. SECCO乙烯系統(tǒng)改造項目完成，向SPC輸送超臨界乙烯。項目完成以后可以向SPC輸送更多的乙烯。Project document 項目文件2009年The SC-ethylene pipe work from Olefins plant to OSBL Battery Limit was being reviewed based on Olefin DB Project HAZOP in 2009.基于

20、OL DB項目HAZOP，對從OL裝置到OSBL界區(qū)的超臨界乙烯管線進(jìn)行了回顧。2009 HAZOP report2009年HAZOP報告Early 20092009年初PSSR was done for the SC pipeline and actions progressed.超臨界乙烯管線完成PSSR，并且采取了行動。PSSR reportPSSR報告July 20092009年7月SECCO ethylene system modification project completed.SECCO乙烯系統(tǒng)改造項目完工。PSSR and Commissioning documentsPS

21、SR和試車文件18 August 20092009年8月18日Pre-commissioning of super critical ethylene line from Olefin (OL) plant commenced.烯烴（L）裝置出來的超臨界乙烯管線預(yù)試車開始。PSSR and Commissioning documentsPSSR和試車文件15 October 20092009年10月15日Use of Line 200-P-82011201 for the transfer of super critical ethylene (as a dense gas) from Ole

22、fin (OL) to SPC.用管線200-P-82011201將超臨界乙烯（作為一種密相氣體）從烯烴（OL）輸送到SPC。PSSR and Commissioning documentsPSSR和試車文件16 October 20092009年10月16日Conducted one calibration of the flow meter (82FQ01001).對流量計（82FQ01001）進(jìn)行了一次校準(zhǔn)。Calibration record校準(zhǔn)記錄 The bypass valve that failed during the incident was not in use duri

23、ng the calibration of this flow meter.at this time校對該流量計時，該旁通閥（事故中損壞的）未使用。PI trend and calibration recordPI趨勢和校準(zhǔn)記錄 The bypass valve that failed was included in LDAR (Leak Detection and Repair) inspection program and was last inspect during May, 2011. No problem was identified.事故中損壞的旁路閥門2011年5月進(jìn)行過微小測

24、漏檢測，未發(fā)現(xiàn)問題。confirmed by ES TeamES確認(rèn) The bypass valve that failed during the incident was not operated during this period.事故中損壞的旁路閥在此期間沒有被操作。Interview面談August 20112011年8月2011 site wide Turnaround (TAR).2011年全廠大檢修。 There was no maintenance work in the super critical ethylene area during the 2011 TAR. T

25、he line was in use during the TAR to transfer SC-ethylene from cryogenic tank to SPC.2011年大檢修期間，超臨界乙烯區(qū)域沒有維修工作。大檢修期間，該管線處于使用狀態(tài)，將超臨界乙烯從低溫罐輸送到SPC。There was no maintenance work required on this valve during the 2011 turnaround 2011年大修期間該閥門不需要檢修。Interview面談Several days before the date of incident事件發(fā)生之日前幾

26、天The operating pressure of the SC-ethylene pipeline is 7.1-7.5 Mpa within the operating envelope.The operating temperature 30-36 within the operating envelope。超臨界乙烯管道的操作壓力為7.1-7.5 Mpa處于操作范圍。操作溫度30-36,處于操作范圍。Nothing abnormal related to the SC- ethylene pipe was found from Boardman and shift superviso

27、r handover logs.從內(nèi)操和值班長交接班記錄中未發(fā)現(xiàn)任何與超臨界乙烯管線相關(guān)的異常情況。Shift handover logsDCS trend交接班記錄DCS趨勢賽科現(xiàn)場著火區(qū)域攝像機位置現(xiàn)場照片受損現(xiàn)場現(xiàn)場的合金成份分析Metal component analysis斷裂的螺栓Broken bolt多處管道爆開 Multiple pipes broken管廊受損情況Pipe rack damaged相關(guān)運行參數(shù) Operating parameters進(jìn)行泵切換時的正常流量波動。Normal flow rate fluctuation during pump switchove

28、r事故前一周內(nèi)，超臨界乙烯輸送系統(tǒng)工藝參數(shù)正常。包括溫度、壓力、流量。Within 1 week before incident, SC-C2 transfer system process parameters were normal, including T, P, F.PI trend PI 趨勢趨勢監(jiān)控錄像截屏 Video camera screenFire Video事故發(fā)生過程推測 Deduce what happened閥蓋螺栓斷裂bonnet bolt broken泄露leaking撞擊火花hit and spark靜電火花static electric spark閃爆expl

29、osion持續(xù)加熱管道continuous heating up pipe管道強度降低pipe strength reduced壓力增高pressure increased超臨界乙烯裂解SC-C2 decomposition管道破裂爆炸pipe broken and explosion溫度降低Temp. decreased壓力降低Pressure decreased信號破壞signal damaged積會增加約1500倍volume can expand by 1500 times中國石油化工股份有限公司青島安全工程研究院中國石油化工股份有限公司青島安全工程研究院QDRISE 2011 版權(quán)所

30、有版權(quán)所有 No.2011-PPT-SBS相關(guān)運行參數(shù)進(jìn)行泵切換時的正常流量波動。事故前一周內(nèi)，超臨界乙烯輸送系統(tǒng)工藝參數(shù)正常。包括溫度、壓力、流量。中國石油化工股份有限公司青島安全工程研究院中國石油化工股份有限公司青島安全工程研究院QDRISE 2011 版權(quán)所有版權(quán)所有 No.2011-PPT-SBS監(jiān)控錄像截屏中國石油化工股份有限公司青島安全工程研究院中國石油化工股份有限公司青島安全工程研究院QDRISE 2011 版權(quán)所有版權(quán)所有 No.2011-PPT-SBS事故發(fā)生過程推測閥蓋螺栓斷裂泄露撞擊火花靜電火花閃爆持續(xù)加熱管道管道強度降低壓力增高超臨界乙烯裂解管道破裂爆炸溫度降低壓力降低

31、信號破壞積會增加約1500倍中國石油化工股份有限公司青島安全工程研究院中國石油化工股份有限公司青島安全工程研究院QDRISE 2011 版權(quán)所有版權(quán)所有 No.2011-PPT-SBS閥蓋螺栓失效初步分析1.金相檢測：金相檢測：晶粒度78級,沿晶裂紋2.硬度測試硬度測試:HRC 20.83.化學(xué)成份分析化學(xué)成份分析元素元素CSiMnSPCrNi事故閥蓋螺栓（M27170）Wt%0.110.511.100.0120.03117.378.49DN100閥螺栓（M24170）0.100.441.280.0090.02817.308.14供貨文件0.0740.551.220.0210.02918.09

32、8.05中國石油化工股份有限公司青島安全工程研究院中國石油化工股份有限公司青島安全工程研究院QDRISE 2011 版權(quán)所有版權(quán)所有 No.2011-PPT-SBS4.SEM及及 EDX 分析分析:S、Cl的來源：環(huán)境？消防水和泡沫？中國石油化工股份有限公司青島安全工程研究院中國石油化工股份有限公司青島安全工程研究院QDRISE 2011 版權(quán)所有版權(quán)所有 No.2011-PPT-SBS中國石油化工股份有限公司青島安全工程研究院中國石油化工股份有限公司青島安全工程研究院QDRISE 2011 版權(quán)所有版權(quán)所有 No.2011-PPT-SBS材料環(huán)境應(yīng)力管道內(nèi)壓力閥桿作用力螺栓殘余應(yīng)力 ClS奧

33、氏體不銹鋼開裂閥蓋螺栓失效初步分析中國石油化工股份有限公司青島安全工程研究院中國石油化工股份有限公司青島安全工程研究院QDRISE 2011 版權(quán)所有版權(quán)所有 No.2011-PPT-SBS初步結(jié)論螺栓斷裂為沿晶型應(yīng)力腐蝕開裂，發(fā)生該類型的開裂主要是螺栓化學(xué)成份中碳含量高于標(biāo)準(zhǔn)上限，而鉻含量又是低于標(biāo)準(zhǔn)下限，同時固溶處理不充分。引起螺栓SCC的介質(zhì)是硫化物及氯離子的共同作用。中國石油化工股份有限公司青島安全工程研究院中國石油化工股份有限公司青島安全工程研究院QDRISE 2011 版權(quán)所有版權(quán)所有 No.2011-PPT-SBS建議措施1. 開展地毯式排查不銹鋼螺栓裂紋，對于一定要采用開展地毯

34、式排查不銹鋼螺栓裂紋，對于一定要采用304不銹鋼材質(zhì)的，不銹鋼材質(zhì)的，可使用固溶充分的可使用固溶充分的304L不銹鋼，增加晶間腐蝕檢驗。不銹鋼，增加晶間腐蝕檢驗。2.事故發(fā)生時應(yīng)保護(hù)好現(xiàn)場事故發(fā)生時應(yīng)保護(hù)好現(xiàn)場,如如:將搜集的螺栓編號匹對將搜集的螺栓編號匹對.3.給不銹鋼管道及緊固件防腐刷漆保護(hù)。給不銹鋼管道及緊固件防腐刷漆保護(hù)。4. 對高壓部位的管件應(yīng)定期檢查。對高壓部位的管件應(yīng)定期檢查。5.緊固應(yīng)采用力矩扳手，控制好預(yù)緊力。緊固應(yīng)采用力矩扳手，控制好預(yù)緊力。6.重新論證超臨界乙烯輸送安全性及風(fēng)險識別。重新論證超臨界乙烯輸送安全性及風(fēng)險識別。7.對易爆炸的烴類管線布管時考慮隔離措施？對易爆炸

35、的烴類管線布管時考慮隔離措施？中國石油化工股份有限公司青島安全工程研究院中國石油化工股份有限公司青島安全工程研究院QDRISE 2011 版權(quán)所有版權(quán)所有 No.2011-PPT-SBS旁邊閥門的螺栓中國石油化工股份有限公司青島安全工程研究院中國石油化工股份有限公司青島安全工程研究院QDRISE 2011 版權(quán)所有版權(quán)所有 No.2011-PPT-SBS下一步工作1.補充試驗補充試驗(晶間腐蝕敏感性試驗等晶間腐蝕敏感性試驗等)2.補充數(shù)據(jù)補充數(shù)據(jù)(大氣監(jiān)測數(shù)據(jù)、大氣監(jiān)測數(shù)據(jù)、 .螺栓規(guī)格、泡沫成份、閥門法蘭厚度螺栓規(guī)格、泡沫成份、閥門法蘭厚度)3.討論、論證討論、論證 4. 報告提交報告提交C

36、ritical Factor 關(guān)鍵因素Critical Factor 1關(guān)鍵因素1Due to bolts failure from the DN150 valve bonnet, stem and gate separated from the valve body resulting in the release of super-critical ethylene 由于螺栓斷裂，閥門的閥蓋、閥桿和閥閘與閥體分離，導(dǎo)致超臨界乙烯從由于螺栓斷裂，閥門的閥蓋、閥桿和閥閘與閥體分離，導(dǎo)致超臨界乙烯從DN150閥閥門中法蘭處泄漏門中法蘭處泄漏-The Material of the bolts w

37、ere not to specification (high carbon, low Chrome) and inadequate heat treatment, resulted in the bolts being less resistant to stress corrosion due to exposure to atmospheric chlorides, -螺栓材質(zhì)沒有達(dá)到規(guī)定指標(biāo)（高碳含量，低螺栓材質(zhì)沒有達(dá)到規(guī)定指標(biāo)（高碳含量，低Cr含量），不充分的固溶熱處理。暴含量），不充分的固溶熱處理。暴露環(huán)境的氯應(yīng)力腐蝕露環(huán)境的氯應(yīng)力腐蝕 Critical Factor 2關(guān)鍵因素關(guān)鍵

38、因素2The back flow from the SC ethylene pipeline inventory was not isolated until 00:30 Sept 9, approx.2 hours. Priority was given to protection of the cryogenicand pressurized storage area.倒流到著火點的超臨界乙烯管線內(nèi)存量乙烯未被隔離，持續(xù)約倒流到著火點的超臨界乙烯管線內(nèi)存量乙烯未被隔離，持續(xù)約2小時，在此過程中優(yōu)小時，在此過程中優(yōu)先考慮防護(hù)低溫罐和壓力罐區(qū)，到先考慮防護(hù)低溫罐和壓力罐區(qū)，到 9月月9日日00

39、:30被有效隔離。被有效隔離。 Critical Factor 1 :關(guān)鍵因素關(guān)鍵因素1 Due to bolts failure from the DN150 valve bonnet, stem and gate separated from the valve body resulting in the release of super-critical ethylene 由于螺栓斷裂，閥門的閥蓋、閥桿和閥閘與閥體分離，導(dǎo)致超臨界乙烯從由于螺栓斷裂，閥門的閥蓋、閥桿和閥閘與閥體分離，導(dǎo)致超臨界乙烯從DN150閥門中法蘭處泄漏。閥門中法蘭處泄漏。-The Material of the b

40、olts is not to specification (high carbon, low chrome), and inadequate heat treatment resulted in stress corrosion cracking due to exposure to atmospheric chlorides. -螺栓材質(zhì)沒有螺栓材質(zhì)沒有達(dá)到規(guī)定指標(biāo)（高碳含量，低達(dá)到規(guī)定指標(biāo)（高碳含量，低Cr含量），不充分的固溶熱處理，暴露氯化物含量），不充分的固溶熱處理，暴露氯化物的環(huán)境中造成應(yīng)力腐蝕斷裂。的環(huán)境中造成應(yīng)力腐蝕斷裂。System causes 系統(tǒng)原因No. 序號Possi

41、ble Cause可能原因Description 說明Recommends 建議16.7lessons learnt not embedded未吸取學(xué)到的教訓(xùn)Previous incident follow up issue. 2008.6.18 bolt incident lesson learnt.對以往事故的跟蹤問題。2008.6.18螺栓事故學(xué)到的教訓(xùn)Review all previous bolt failure lesson learnt to determine specific actions or any common themes.回顧以往所有螺栓斷裂事故中學(xué)到的教訓(xùn)，確定

42、具體行動或任何共同問題。 To review the secco system for incident investigation and improve the process for capturing lessons learned from prior incidents.回顧SECCO事故調(diào)查和改進(jìn)流程，以從以往的事故中吸取教訓(xùn)。 20.2Incorrect item received收貨錯誤Based on the review by BP metallurgist of the investigation reports from Qing Dao safety institu

43、te And East China Technology University. The Material of the bolts is not to specification (high carbon, low chrome), and inadequate heat treatment resulted in stress corrosion due to exposure to atmospheric chlorides, . 基于BP金屬專家對青島安工院和華理事故分析報告/螺栓分析報告的審核，螺栓材質(zhì)沒有達(dá)到規(guī)定指標(biāo)（高碳含量，低Cr含量），固溶熱處理不充分，導(dǎo)致暴露氯環(huán)境中造成應(yīng)

44、力腐蝕，。 Review the vendor qualification assurance process, and QA/QC process. For new projects, ensure vendors understand SECCO specifications requirement and provide goods with sound quality. 審核供貨商資格保障流程以及QA/QC程序，尤其是對新的項目，保證供貨商理解SECCO規(guī)格要求，提供品質(zhì)完好的貨品。 System causes 系統(tǒng)原因21.6No preventative maintenance p

45、rogram預(yù)防性維護(hù)方案不完善No preventative maintenance program for the manual valves 對手動閥門開展預(yù)防性維護(hù)活動不完善Review and implement a preventative maintenance program for the critical manual valves.針對關(guān)鍵手動閥進(jìn)行回顧并實施預(yù)防性維護(hù)流程22.2 Development of SPP not effective標(biāo)準(zhǔn)/規(guī)范/程序 制定欠妥The LDAR was implemented since May 2011. No leak wa

46、s detected. Only one leak inspection was conducted so far. Per SECCO LDAR procedure, the inspection frequency of the bypass valve which failed is every 3 months.在2011年5月進(jìn)行了LDAR，沒有發(fā)現(xiàn)泄漏。到目前為止，只進(jìn)行過一次泄漏檢測?；赟ECCO LDAR程序，對事故中損壞的閥門檢測周期為3個月。SECCO should review implementation of LDAR program comparing to pr

47、ocedure and consider the inspection frequency and the criticality of equipment.SECCO應(yīng)對照程序回顧LDAR計劃的實施，并考慮檢測頻率和設(shè)備關(guān)鍵性。 Immediate causes直接原因No. 序號Possible Cause可能原因Description 說明Recommendations 建議5.5warning systems not effective報警系統(tǒng)未有效報警Gas detector didnt alarm during the initial leak, because the conce

48、ntration didnt reach the alarm set point. Investigation found that the gas detectors were calibrated by CH4, this might result in the lower explosion limit (LEL) reading being lower than the actual value because LEL of CH4 is lower than ethylene. 由于濃度未達(dá)報警值，氣體檢測器在最初泄漏時未報警。調(diào)查發(fā)現(xiàn)氣體探測儀由CH4校驗，這可能導(dǎo)致了低于爆炸限值

49、LEL讀數(shù)比實際底，因為CH4的LEL比乙烯低1. Check the area 82 gas detector set points and calibration gas standard. Verify the LEL is representative for ethylene. to ensure the warning system is effective. 審核82區(qū)域氣體檢測器設(shè)定值和校準(zhǔn)用標(biāo)準(zhǔn)氣體（驗證測試用甲烷氣體濃度），保證警告系統(tǒng)有效。2. Review the layout of detector placement in the area 82 and the r

50、equired number of gas detectors Due to the wind direction, the detector which registered the trace quantity hydrocarbon is 20 meters away from the leak source.審核82區(qū)域氣體檢測器的布置和需要數(shù)量，由于風(fēng)向的原因，距泄漏點20米遠(yuǎn)的氣體探測儀才檢測到微量的碳?xì)浠衔铩?7.5Bolt composition and heat treatment螺栓材質(zhì)和熱熔處理High carbon and low chrome with inadeq

51、uate heat treatment resulted in bolt fracture.高碳低鉻熱熔處理不充分造成螺栓斷裂。Immediately inspect other bolts from the same vendor and take necessary corrective action. 立即檢驗同一供貨商的其它螺栓，采取必要的糾正行動。Review the process to classify the valves and management procedure including inspection. 回顧流程，對閥門和管理程序進(jìn)行分類包括檢查。Review th

52、e process to manage the high risk area valves to prevent similar failure. 回顧高風(fēng)險區(qū)域閥門的管理流程，以防發(fā)生類似故障。 7.9Corrosion 腐蝕Based on SECCO previous research report of bolt breaking in 2008, potential cause of Stress corrosion cracking, SCC, was found 基于SECCO以往對2008年螺栓斷裂的研究報告，考慮可能的應(yīng)力腐蝕開裂（SCC）原因。Review previous

53、 similar lesson learnt reports of bolts failure incidents and take action where common themes exist. 審核以往類似螺栓斷裂教訓(xùn)報告，查找SCC的共同問題。Develop and implement a preventive program to prevent SCC.制定并實施SCC預(yù)防活動。 Critical Factor 2:關(guān)鍵因素關(guān)鍵因素2The back flow from the SC ethylene pipeline inventory was not isolated unt

54、il 00:50 Sept 9, approx. 2 hours. Priority was given to protection of the cryogenic and pressurized storage area.倒流到著火點的超臨界乙烯管線內(nèi)存量乙烯未被隔離，持續(xù)約倒流到著火點的超臨界乙烯管線內(nèi)存量乙烯未被隔離，持續(xù)約2小時小時，直到，直到9月月9日日00：50被隔離。被隔離。Immediate causes直接原因No. 序號Possible Cause可能的原因Description 說明Recommends 建議22.2Development of SPP not effe

55、ctive 程序制定欠完善The existing emergency response procedure lacks detail for the high pressure ethylene pipeline isolation現(xiàn)有的應(yīng)急響應(yīng)程序中缺乏具體針對高壓乙烯管線的泄漏Review and improve the existing emergency response procedure (ERP) within the standard operation procedure for handling SC Ethylene pipeline leakage and provi

56、de relevant drills. This recommendation also applies to the other pipelines from SECCO to SPC.審核并完善現(xiàn)有標(biāo)準(zhǔn)操作規(guī)程中的應(yīng)急程序（ERP）來處理超臨界乙烯管線的泄漏，并進(jìn)行演習(xí)。這一建議同樣適用于其他SECCO輸送SPC的管線。 No. 序號Possible Cause可能的原因Description 說明Recommends 建議15.5Other其它No specific drill for this SC ethylene pipeline.對此超臨界乙烯管線沒有具體的演習(xí)Refer to

57、22.2參見22.2 18.3incorrect ergonomic or human factor design不正確的人機工程或人為因素設(shè)計Operators have to climb up to close the CBI solation valve. 操作工不得不爬著上去關(guān)閉CBI 隔離閥 SECCO need to consider which additional valves require remote isolation in the emergency events to reduce impact on all pipes and plantsSECCO需要考慮增加哪

58、些閥門進(jìn)行事故情況下的遠(yuǎn)程隔離，以減少對管線和裝置的影響。18.7technical analysis for risk not effective風(fēng)險技術(shù)分析無效The previous risk assessments conducted didnt cover this incident.以往的風(fēng)險評估中未包括此類事故。Consider carrying out other risk assessment methodologies e.g QRA, MAR, Fault Tree, Bow Tie, that will consider hazardous conditions as

59、an impact from initial fire in the operating plant/ pipe rack. 考慮在生產(chǎn)區(qū)域及管廊實施涵蓋二次影響的其它風(fēng)險評價方法，如QRAMARFault treeBow TieCOMMUNITY EMERGENCY RESPONSE社區(qū)緊急響應(yīng)社區(qū)緊急響應(yīng) PLANT EMERGENCY RESPONSE工廠緊急響應(yīng)工廠緊急響應(yīng) PHYSICAL PROTECTION (DIKES)物理保護(hù)物理保護(hù)(圍堰圍堰) PHYSICAL PROTECTION (RELIEF DEVICES)物理保護(hù)物理保護(hù)(釋放裝置釋放裝置)AUTOMATIC A

60、CTION SIS OR ESD自動操作自動操作, SIS 或或 ESD CRITICAL ALARMS, OPERATOR SUPERVISION,關(guān)鍵報警，操作工監(jiān)督關(guān)鍵報警，操作工監(jiān)督 AND MANUAL INTERVENTION與手動干預(yù)與手動干預(yù)BASIC CONTROLS, PROCESS ALARMS, 基本控制，工藝報警基本控制，工藝報警AND OPERATOR SUPERVISION與操作工監(jiān)督與操作工監(jiān)督 PROCESSDESIGN LAH1IWhat worked well on 9/8 and prevented incident escalation經(jīng)過經(jīng)過9/8事件驗證并防止事故