When the staff of ethylene oxide plant heard the abnormal sound of air discharge, they immediately carried out emergency treatment for the tower, cut off the feed, cut off the heating steam and other measures, and rushed to the site for inspection and confirmation, and found that the top safety valve of the ethylene oxide refined tower t-430 tower jumped. 5:37 tower kettle reboiler head accessories have white smoke. A fire broke out near the upper head of the reboiler. Fire was put out and a fire alarm was raised at 6:03 am. 6:04 there was an explosion in the refining tower.
The indirect reason
Failure to carry out the responsibility of the post leads to misjudgment, incorrect operation and improper disposal of abnormal working conditions.
There are defects in the design of the instrument pressure guide tube. The pressure interlock of the t-430 tower shares a pressure guide with the pressure control transmitter and the field pressure gauge.
Technology management is not in place. The risk of abnormal working condition of ethylene oxide refining tower is not well understood.
The production and operation management is not in place, the workshop has not strictly implemented the company's management system, has not recorded and handed over abnormal working conditions, and has not reported abnormal working conditions to the plant scheduling and plant leaders.
The investigation and control of hidden dangers are ineffective. Although the same kind of t-410 tower newly added in the device has adopted independent source point, it has not conducted hazard identification and risk assessment for the setting of the source point of the t-430 tower, and design hidden dangers have not been discovered and rectified in time.
Personnel training is not in place, and the ability to judge and deal with abnormal working conditions is not high.