psim南沙站调压撬路起跳事件报告

1、DPLNG Incident Report Form Minor Incident3. INCIDENT DESCRIPTION2012 年 03 月 07 日 11：26 时，南沙站调压撬A 路的 SSV3051 阀因出站压力（最高至 4.55MPa）出现起跳关闭，调压撬自动切换至B 路，没有造成中断供气。事情经过如下：3 月 7 日，维修一行到南沙站进行加热炉橇四孔法兰加装防雷跨接铜片工作。操作员按正常程序首先对A 加热炉进行了放空，维修开始安装防雷跨接片。此时加热炉的流程为：A 炉，B 炉畅通；为确保正常供气，操作员将旁路调温阀 TV3062 手动全开。维修安装完A 炉的防雷跨接片后，操

2、作员开始A 炉工艺流程恢复工作，操作员关闭了A 炉放空阀，打开A 炉上游手动球阀 BA63062 的 1 寸旁通开始给A 炉升压。升压完成后，操作员未及时打开A 炉上游手动主球阀，操作员随后在站控室打开了 A 炉出口阀 XV3041。操作员紧接着对B 加热炉进行了，维修开始安炉的防雷跨接片。此时加热炉的流程为：A 炉上游手动球阀 BA63062 关闭，1 寸旁路全开，出口阀全开；B 炉；旁路调温阀TV3062 手动全开。B 炉维修工作中，操作员回到站控室，操作员回到站控室时发现出站温度已经低报，便关闭加热炉旁通阀TV3062 让气通过A 加热炉加热试图以提高出口气体温度。此时天然气仅由A 炉上

3、游球阀 BA63062 的 1 寸旁通阀通过，不能完全满足下游用气的需要，很快造成出站压力低。调压阀自动开大到了 30%左右。操作员马上手动将 TV3062 的开度由 0 开至 50%，接着再开至 100%。此举造成两个：下游出站压力冲高，造成A 路 SSV 联锁关闭，B 路自动接管；上游过滤撬与加热炉之间的压力降低，与过滤撬上游瞬间形成了 209Kpa 的偏差，导致过滤撬自动切换。接到 后，北区 和主管先后赶到南沙站进行原因分析，并通报 。经过检查事件 和趋势图，初步认为是过滤撬堵塞切换造成的，经与维修沟通，当天下午安排了过滤撬B 路的开盖 工作，发现一些油脂类杂物。3 月 8 日，由于观察

4、趋势图和事件 中还存在一些疑点，相关 再次到南沙站 ，最终查明造成本次事件的主要原因为人为 。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南沙分输站调压撬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程序执行，没有根据程序要求打开加热炉A 上游主阀。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 走捷径 1-

9、10 short cut能源 程序执行 。操作员在同一系统依次进行的能源 工作时，没有遵循完成一路，恢复一路，再进行另一路能源 的原则。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/意识缺乏：2、lack of awareness4-1 决定欠妥或缺乏判断 4-1 poor

10、decior no judgement工作方面不能合理把握。操作员在对 TV3062 的开0-50%-100%时，动作过快过急；也缺乏对该操作会 的 的考虑。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、行为：1、action5-8 雇员5-8 st

11、aff precipitancy操作员在紧急情况下处理事情不冷静。当温度低于 1.5时，完全有时间检查原因再进行流程操作。Operator was precipitancy. He had enough time to deal with the problem of low outlet temperature properly.2、技术水平:2、skill level6-2 缺乏技术实践 6-2 lack of technical practice未遵循平稳、缓慢的操作原则。即使需要使用温控阀调节温度，也不能急开急关操作。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 工作中无确认步骤 no double confirming step on the pros energy isolation工艺上”恢复”一栏只有操作员签名,而没有”复核人”签名栏，少一道确认就会多一份意外发生的可能(在盲板上就有恢复时的双签栏)。 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.进行事故。Chen, Tiger Lin WeiDing Bella Hong Deng Yuanming22012-03-08对当班操作员进行能源程序再培训和维修教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在管线运营此次事故教训。42012-04-30事件事件未按时间进行排序，同时在中控未能显示全部，需要检查原因。Events record is not line upZhu Lijian剑by time, and there is no same events record in CCR.52012-06-30建议对工艺进行更新完善，增加流程恢复时的Ding Bella Hong双确认栏（参考盲板）。To update the and add doublepros energy isolationsign column on it.6Luo Jesse Ziyuan2012-06-30站场操作员经常需要在行维修较长时间，为加强中控及其他和站场的便捷沟通，建议尽快采购防爆。Sion operators usually need to monitor maenance work outside, and the EX mobile shouldbe dispatched comm