Document pme2G9B6XV21VGvVXbZLq7wXw

B. F. Goodrich Chemical Company Inter-Organization Correspondence fO~' a To D. L. Dowell Location Cleveland Deitnrtmeut From _ J. W. Gressler Location _.., Pedricktown Department Subject NEAR MISS - GAS ESCAPE, BUILDING 513, PEDRICKTOWN Date July 7, 1971 On July I, 1971, at 2*09 a.m. a gas release was experienced in the pearl-paste polymerization building. The drain line on pearl poly No. 7 was open when blowdown recovery started. Approximately ha,lf of the charge was drained to the trench. FACTS BEFORE RELEASE OCCURRED 1. On the previous charge, it was noted that a bad contact existed on Poly No. 7 sewer valve. The console technician had properly set the faulty bit and went on to charge the poly. Everything was normal with the charge up to the clean logic. 2. Poly ,No. 7 went to hold because the sewer valve would not function properly. At this point, day shift console technician, left the poly in hold, bypassed the computer and opened the yarway and sewer valve. 3. The poly was not looked at again until 3*15 p.m. on June 30, 1971.(approxi mately 2-1/2 hours after going to hold.) The poly should not have been left in hold, it should have been put back into normal clean logic. 4. At 3:15 p.m., the poly was taken out of hold and put to schedule, at which time the computer cleared the faulty bits. 5. Poly No. 7 went back to hold because the sewer valve contact was reading in correctly. The poly was taken out of hoHand put back into schedule. Once again, it went to hold because of the sewer valve. 6. At this time, if.... set the faulty bits improperly. Rather than just by passing the one bad contact, he bypassed both contacts on the valve. 7. He should have checked with the building technician to determine the position of the valve, however, this was not done. Before the charge is started, the building technician checks the poly. 8. The computer switch was put into the computer position by building technician, Ernest Kidd. 9. The poly is then checked. (Manhead, air connected, etc.) 10. He then checked the meter and charge station before going to the first floor. 11 Note: If the poly had been in the normal clean logic rather than hold, all computer valves would have gone to their proper position when the computer switch was put into the computer position (yarway closed, sower closed, etc.) REDACTED NGC 15692 JUL i 41971 NEAR MISS - GAS ESCAPE, BUILDING 513 <Cont.) Page 2 12. The building technician then checks the yarway and sewer valve* 13. At this point, the air line to the sewer valve is disconnected* Because the poly was still in hold and not in the clean logic, the yarway and sewer valve had remained pperu 14. Once the poly was scheduled and went to hold, the yarway closed* 15* The sen the sewer valve didn't elese was because the faulty bit had been set. The air had been disconnected from the sewer valve with it being in the open position. 16. The run button was hit and the poly again went to hold because of the sewer valve. 17. It was at this point bits improperly. bypassed the sewer valve by setting the faulty 18. The run button was hit again* From that point on, charging and reaction were normal FACTS AT TIME OF RELEASE 1. At 2:09 a.xn. blowdown began. 2. At this same time. Poly No. 1 had a heel which was being transferred to the blend tank, i building technician, with 5 weeks experience, was on the first floor* Via two-way radio, he contacted , console technician, and told him that the heel was going to the trench* 3. immediately checked the sewer valve; it was closed* 4* However, insisted that the heel was being drained to the trench. 5. ; , building technician, reported to the first floor* He saw that Poly 7 was being blown to the floor. 6. ------- _ immediately called No. 7. and told him to close the yarway on Poly 7. " closed the yarway and put the poly to hold. tion correctly. handled the situa 8. Neither the gas alarm nor the fog system were activated. The emergency fans were turned on. 9. They did not activate the gas alarm or fog system because they thought they had the situation under control. A Board of Inquiry was conducted on July 6, 1971. The following people attended: J, W. Gressler E.'s. Kidd E. C. Martinelli J. A. Miller S. Lodge NGC 15693 NEAR MISS - GAS ESCAPE BUILDING 513 (Cont.) Page 3 With one exception, all of the facts are correct as presented. The only discrep ancy is that was thoroughly convinced that the sewer valve was closed when he checked it* The pre-charge check sheet could not be located. CONCLUSION: 1* We have concluded that all o the facts, as presented, are correct. 2. It was proven that the sewer valve could not have been closed before the air was disconnected* CORRECTIVE ACTION: 1* r reprimanded for his mistakes* 2. was reprimanded for disconnecting the air with the valve open. Note: is one of our most conscientious employees. There is no doubt in any of our minds that the pre-charge check sheet was completed. We also feel that he honestly thought the valve was closed before he disconnec ted the air. However, the computer printouts do not verify that fact. 3. All console technicians have been instructed to follow the computer logic. 4. We do have a good preventive maintenance program on bad contacts. However, every effort will be made to improve the program. 5. This incident will be discussed in all departmental meetings. Emphasis will be placed on checking the poly out thoroughly and if a situation does arise, the fog system and emergency fans must be activated. J. W. Gressler cc: 0. F. Beckmeyer J. L. Nelson - R. D. Scott E* w. Harrington - P. H. Lawrence G. Pow W. E. Brodine W. L. Cato E. E. Mitchell - P. D. Terry A. R. Webber H. T. Evans J. w. Goetsch - S. M. Evans - E. C. Martinelli W. A. Reed *GC 15694