徐理
不当隔离造成S1103B发生严重安全事故Serious HSSE Incident at S-1103B as Result of Inadequate System Isolation
Customer Communication Package
Agenda 内容
1.Incident Description
事故描述
2.Incident Classification and Analysis
事故分类和分析
3.Key Learning
主要教训
4.System Isolation Standard
系统隔离标准
Incident Description事故描述
1.Timing时间: Dec. 2009
2.Venue地点: SCGP Licene 某客户
银的真假辨别方法3.What happened事故: Explosion occurred to S1103 B 3h after S/U开车后3小时S1103 B发生爆炸
4.Immediate actions当即措施: operator emergently shut down gasifier 紧急手动停车。
5.Conquences事故后果:
①S1103B fully damaged 布袋除尘器S1103B完全损坏
②Large amount of coal powder poured onto the ground 大量煤粉抛向地面
③if somebody had been clo to the bag filter then injury or wor could easily have happened幸好现场无人，
否则会发生伤亡。
窗帘品牌排行前十名6.Preliminary findings 初步查证
四面都是山①When client switched the syngas to the shift unit the syngas flew into the LP N2 system becau the LP N2 system
was not properly isolated from the shift unit. Then the syngas flew back to unit 1100 though LP N2 line and caud the explosion of the S-1103B bag filter. 全场低压氮气与变换及制粉系统联通。因为低压氮气与变换系统隔离不当，合成气导入变换系统后，合成气流入低压氮气系统，然后进入磨煤系统而导致布
袋除尘器爆炸。
②Client did not add blind between the LP N2 system and the shift unit but relied on a single valve to isolate the
systems. 在低压氮气和变换系统之间未加盲板，仅靠单一阀门隔离。
③Syngas and coal powder formed an explosive mixture to the explosive limit due to H2 prence. Most likely a static
electricity spark built up in this solid handling system ignited the mixture. 合成气进入布袋除尘器后，合成气里的氢、一氧化碳与煤粉及系统内的氧气形成爆炸物。氢气易燃，其混和物的爆炸下限很低，
煤粉输送系统很容易形成静电，很可能是静电火花点燃了可燃粉尘/气体爆炸物。
父爱无言
Incident Classification and Analysis事故分类和分析
1.Type of Incident 事故类别:Explosion &Ast Damage 爆炸及资产损坏
2.Incident RAM Rating –High Risk Potential: P4D, E2D, A3C, R4D; Actual: P0, E1, A3, R4
事故分级–高风险潜在风险：人员4D，环境2D, 资产3C，声誉4D；实际：无伤亡
，环境1，资产3，声誉4
无伤亡，
3.Immediate Caus直接原因:
①Syngas ingress into S1103B from the shift unit via LP N2 line formed an explosive mixture with the coal
dust inside S1103 B变换装置里的合成气进入低压氮气系统后，又进入S1103B，与煤粉形成
爆炸粉尘/气体混和物。
②Prence of static electricity during solids handling ignited the explosive mixture inside S1103B
固体输送形成的静电点燃了S1103B里的爆炸混和物。
4.Underlying Caus间接原因:
①Isolation of the LP N2 system from the shift unit/syngas system relied on a single valve instead of using
blinds or removal of spool piece
低压氮气与变换系统的隔离未采用盲板或断开的方式，而仅仅依靠单一阀门。
②The N2 fire fighting system relying on O2 and CO monitoring escalated the fire and explosion process in
this incident since more syngas instead of pure N2 was kept feeding to S1103 B once high CO content was detected.氮气消防系统根据测量到的布袋内的氧含量和一氧化碳含量的高低来决定氮气消
防流量。此次事故中，一氧化碳含量高，氮气消防流量增加，但此时消防系统送入的恰
恰是导致火灾和爆炸事故的合成气，而非纯氮，导致事故升级。
励志歌曲有哪些4
Key Learning 主要教训
1.All valves leak. HP medium will leak to LP system if they are connected and isolated with valves
only. Never rely on valves for system isolation. Air gapping is recommended.
所有阀门都存在内漏。如果高压系统与低压系统相连，而仅用阀门隔离，高压介质会流向低压系统。所以不能依靠阀门担当系统隔离。建议采用断开的隔离方式。2.Procedures need be adopted to ensure that whenever a unit is started, the systems not in u are
properly isolated, for example the LP nitrogen system is positively isolated from the shift unit by dropping the spool piece.需要建立管理程序，当装置开车时，不用的系统需要可靠隔离，比如对于低压氮气系统，应拿掉短节，以确保与变换系统可靠隔离。
霞蔚云蒸
3.Correct rating and installation of the rupture discs are crucial. The bag filter need be airtight and O2
content to be kept below 8% or 6%, depending on the coals.The system shall also have a PSV.
防爆片的定值和安装非常重要，布袋除尘器气密要合格，根据不同煤种，氧量保持在8%或6%以下。该系统也应考虑设置泻压阀。
补中益气汤的标准配方
4.The bag filter area is also a high risk area when CMD is in operation and requires barricading. A
long term solution is required.
布袋除尘器区域是高风险区域，需要区域隔离。需要考虑长期解决放案。
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