SECCO98Incident20121118

1、SECCO HP Ethylene Gas Release Incident 8th September 20112011年9月8日赛科高压乙烯气体泄漏事故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月月赛科主要生产装置赛科主要生产装置 Main plants of SECCO119万吨万吨/年乙烯年乙烯50万吨万吨/年芳烃抽提年芳烃抽提9万吨万吨/年丁二烯年丁二烯65万吨万吨/年乙苯年乙苯/苯乙烯苯乙烯30万吨万吨/年聚苯乙烯年聚苯乙烯60万吨万吨/年聚乙烯年聚乙烯25万吨万吨/年聚丙烯年聚丙烯26万吨万吨/年丙烯腈年丙烯腈28万吨万吨

2、/年硫酸回收装置年硫酸回收装置赛赛 科科 生生 产产 装装 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 - 赛科的承诺赛科的承诺We try to achieve 我们力图达到我们力图达到No accidents 无事故、无事故、No harm to people 无人身伤害、无人身伤害、No damage to the environment 无对环境任何损害。无

3、对环境任何损害。Commitment to HSSE 我们对我们对HSSE的的承诺和承诺和责任责任 SECCO Vision & Values赛科的愿景和价值观点击播放视频1 灭火现场 Brief Account of Incident 事故情况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点53分，赛科到上海石化的高压乙烯输送管道的流量计的旁通管线上一台闸阀（DN150）发生了高压（HP）乙烯泄漏。释放的乙烯立即起火，造成乙烯泄漏与火灾事故。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. 火灾影响到低温乙烯罐区的管架与高压乙烯输送区，部分管架、20条管线（烃类/公用工程）、以及管架上的电源线与仪表电缆遭到破坏或变形。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号凌晨1点30分火情得到控制。总共释放了70吨乙烯。事故没有造成人员伤害，也没有造成重大的环境污染。乙烯罐74-TK-0301丙烯罐74-TK-0401乙烯冷冻单元 过火区域过火区域氨罐74-TK-0401丙烯冷冻单元受损管廊管线受损管廊管线介质介质管线数量管线数量超临界乙烯2乙烯2丙烯2氨1冷冻水2火炬管线1工厂风1低压蒸汽1低压凝液1中压氮气1仪表风1冷却水2工业水1燃料气1点火气1Sup

7、ercritical Ethylene System 超临界乙烯系统Rupture of bolts and fire accident螺栓断裂与火灾事故螺栓断裂与火灾事故SC ethylene to SPCsuper-critical ethylene from ethylene plant管线的清洗球收发器接口 Pipeline cleaning ball Transceiver connection 5M 2M 3M 2M 30M流量计 Flow meter破裂阀门 broken valve 火炬flareCryogenic liquid ethylene into vaporizer蒸

8、发器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. 螺栓断裂的试验结果显示所有断裂螺栓的碳含量都高于ASTM193 B8（304SS）标准，而且固溶处理也不够彻底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.环境中含有S/CI等腐蚀性介质。还因为螺栓的受力杆发生了晶间应力腐蚀开裂。正常使用时开裂扩大并最终断裂。3、The valve bonnet blew off and touched the steel platform overh

10、ead causing spark and ignition of the leaked ethylene.阀帽冲出并砸到底部钢制平台，引发火化并引燃泄漏出来的乙烯。点击播放视频2 监控视频Valve Bonnet and Stem阀帽与阀杆Valve Body阀体Damaged Valve Site受损阀门现场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.阀帽与阀体分离，撞到阀门上面的平台底部。后来在距阀体4.5米处找到了阀帽。Date日期日期Description (Event / Condition)说明（事件说明（事件/条件）条件）Information Source信息来源信息来源July 20042004年7月HAZOP of high pressure ethylene pipe was conducted.进行了高压乙烯管线HAZOP。2004 HAZOP report 2004年HAZOP报告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.根据超临界乙烯配管设计，完成超临界乙烯管线和配管施工。Conversation / slides provided by SECCO engineer谈话/幻灯片SECCO工程师提供June 20052005年6月Preparation of commissioning of super critical ethylene pipe.超临界乙烯管线准备试车。Conversation / slides谈话/幻灯片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.完成管线200-P-8201003压力试验。按照SECCO技术标准，以1.5倍设计压力做了压力测试，管线通过了测试。Pressure test report.压力试验报告。(The Pressure test report see Appendix 1.压力试验

14、报告参见附录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.超临界乙烯管线试车（管线200-P-8201003），开始向SPC输送气相乙烯（并非超临界乙烯）操作压力范围处于3.2-3

15、.4Mpa,常温。Review SOP & operating envelop at this time. 审核SOP和当时的操作范围(SOP see Appendix 2，SOP参见附录2) 2007SECCO issued a procedure of leak detection and repair procedure requiring leak test for high risk items every 3 months.SECCO 发布泄漏检测程序，及对高风险项目每3个月进行一次泄漏检测的修订泄漏检测及修理(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. 天原一条乙烯输送管线，因为一个闸阀上的SS304螺栓断裂而造成乙烯泄漏的事故。该阀门从另外供应商购买。经过根本原因分析发现，是由于应力腐蚀断裂造成螺栓断裂。较高的含碳量以及没有进行退火处理，是造成应力性腐蚀的原因之一。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.天原事故后对相关阀门的实际材料进行了鉴定，结果发现全部正常没有保留报告。 July 20082008年7月A MAR study was started for the 6 pipeline transfer from Secco OSBL to SPC and not completed 进行了从SECCO到SPC6根管线的MAR研究，但没有完成。 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乙烯系统改造项目完成，向SPC输送超临界乙烯。项目完成以后可以向SPC输送更多的乙烯。Project document 项目文件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项目HAZOP，对从OL装置到OSBL界区的超临界乙烯管线进行了回顾。2009 HAZOP report2009年HAZOP报告Early 20092009年初PSSR was done for the SC pipeline and actions progressed.超临界乙烯管线完成PSSR，并且采取了行动。PSSR reportPSSR报告July 20092009年7月SECCO ethylene system modification project completed.SECCO乙烯系统改造项目完工。PSSR and Commissioning documentsPS

21、SR和试车文件18 August 20092009年8月18日Pre-commissioning of super critical ethylene line from Olefin (OL) plant commenced.烯烃（L）装置出来的超临界乙烯管线预试车开始。PSSR and Commissioning documentsPSSR和试车文件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.用管线200-P-82011201将超临界乙烯（作为一种密相气体）从烯烃（OL）输送到SPC。PSSR and Commissioning documentsPSSR和试车文件16 October 20092009年10月16日Conducted one calibration of the flow meter (82FQ01001).对流量计（82FQ01001）进行了一次校准。Calibration record校准记录 The bypass valve that failed during the incident was not in use duri

23、ng the calibration of this flow meter.at this time校对该流量计时，该旁通阀（事故中损坏的）未使用。PI trend and calibration recordPI趋势和校准记录 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.事故中损坏的旁路阀门2011年5月进行过微小测

24、漏检测，未发现问题。confirmed by ES TeamES确认 The bypass valve that failed during the incident was not operated during this period.事故中损坏的旁路阀在此期间没有被操作。Interview面谈August 20112011年8月2011 site wide Turnaround (TAR).2011年全厂大检修。 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年大检修期间，超临界乙烯区域没有维修工作。大检修期间，该管线处于使用状态，将超临界乙烯从低温罐输送到SPC。There was no maintenance work required on this valve during the 2011 turnaround 2011年大修期间该阀门不需要检修。Interview面谈Several days before the date of incident事件发生之日前几

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。超临界乙烯管道的操作压力为7.1-7.5 Mpa处于操作范围。操作温度30-36,处于操作范围。Nothing abnormal related to the SC- ethylene pipe was found from Boardman and shift superviso

27、r handover logs.从内操和值班长交接班记录中未发现任何与超临界乙烯管线相关的异常情况。Shift handover logsDCS trend交接班记录DCS趋势赛科现场着火区域摄像机位置现场照片受损现场现场的合金成份分析Metal component analysis断裂的螺栓Broken bolt多处管道爆开 Multiple pipes broken管廊受损情况Pipe rack damaged相关运行参数 Operating parameters进行泵切换时的正常流量波动。Normal flow rate fluctuation during pump switchove

28、r事故前一周内，超临界乙烯输送系统工艺参数正常。包括温度、压力、流量。Within 1 week before incident, SC-C2 transfer system process parameters were normal, including T, P, F.PI trend PI 趋势趋势监控录像截屏 Video camera screenFire Video事故发生过程推测 Deduce what happened阀盖螺栓断裂bonnet bolt broken泄露leaking撞击火花hit and spark静电火花static electric spark闪爆expl

29、osion持续加热管道continuous heating up pipe管道强度降低pipe strength reduced压力增高pressure increased超临界乙烯裂解SC-C2 decomposition管道破裂爆炸pipe broken and explosion温度降低Temp. decreased压力降低Pressure decreased信号破坏signal damaged积会增加约1500倍volume can expand by 1500 times中国石油化工股份有限公司青岛安全工程研究院中国石油化工股份有限公司青岛安全工程研究院QDRISE 2011 版权所

30、有版权所有 No.2011-PPT-SBS相关运行参数进行泵切换时的正常流量波动。事故前一周内，超临界乙烯输送系统工艺参数正常。包括温度、压力、流量。中国石油化工股份有限公司青岛安全工程研究院中国石油化工股份有限公司青岛安全工程研究院QDRISE 2011 版权所有版权所有 No.2011-PPT-SBS监控录像截屏中国石油化工股份有限公司青岛安全工程研究院中国石油化工股份有限公司青岛安全工程研究院QDRISE 2011 版权所有版权所有 No.2011-PPT-SBS事故发生过程推测阀盖螺栓断裂泄露撞击火花静电火花闪爆持续加热管道管道强度降低压力增高超临界乙烯裂解管道破裂爆炸温度降低压力降低

31、信号破坏积会增加约1500倍中国石油化工股份有限公司青岛安全工程研究院中国石油化工股份有限公司青岛安全工程研究院QDRISE 2011 版权所有版权所有 No.2011-PPT-SBS阀盖螺栓失效初步分析1.金相检测：金相检测：晶粒度78级,沿晶裂纹2.硬度测试硬度测试:HRC 20.83.化学成份分析化学成份分析元素元素CSiMnSPCrNi事故阀盖螺栓（M27170）Wt%0.110.511.100.0120.03117.378.49DN100阀螺栓（M24170）0.100.441.280.0090.02817.308.14供货文件0.0740.551.220.0210.02918.09

32、8.05中国石油化工股份有限公司青岛安全工程研究院中国石油化工股份有限公司青岛安全工程研究院QDRISE 2011 版权所有版权所有 No.2011-PPT-SBS4.SEM及及 EDX 分析分析:S、Cl的来源：环境？消防水和泡沫？中国石油化工股份有限公司青岛安全工程研究院中国石油化工股份有限公司青岛安全工程研究院QDRISE 2011 版权所有版权所有 No.2011-PPT-SBS中国石油化工股份有限公司青岛安全工程研究院中国石油化工股份有限公司青岛安全工程研究院QDRISE 2011 版权所有版权所有 No.2011-PPT-SBS材料环境应力管道内压力阀杆作用力螺栓残余应力 ClS奥

33、氏体不锈钢开裂阀盖螺栓失效初步分析中国石油化工股份有限公司青岛安全工程研究院中国石油化工股份有限公司青岛安全工程研究院QDRISE 2011 版权所有版权所有 No.2011-PPT-SBS初步结论螺栓断裂为沿晶型应力腐蚀开裂，发生该类型的开裂主要是螺栓化学成份中碳含量高于标准上限，而铬含量又是低于标准下限，同时固溶处理不充分。引起螺栓SCC的介质是硫化物及氯离子的共同作用。中国石油化工股份有限公司青岛安全工程研究院中国石油化工股份有限公司青岛安全工程研究院QDRISE 2011 版权所有版权所有 No.2011-PPT-SBS建议措施1. 开展地毯式排查不锈钢螺栓裂纹，对于一定要采用开展地毯

34、式排查不锈钢螺栓裂纹，对于一定要采用304不锈钢材质的，不锈钢材质的，可使用固溶充分的可使用固溶充分的304L不锈钢，增加晶间腐蚀检验。不锈钢，增加晶间腐蚀检验。2.事故发生时应保护好现场事故发生时应保护好现场,如如:将搜集的螺栓编号匹对将搜集的螺栓编号匹对.3.给不锈钢管道及紧固件防腐刷漆保护。给不锈钢管道及紧固件防腐刷漆保护。4. 对高压部位的管件应定期检查。对高压部位的管件应定期检查。5.紧固应采用力矩扳手，控制好预紧力。紧固应采用力矩扳手，控制好预紧力。6.重新论证超临界乙烯输送安全性及风险识别。重新论证超临界乙烯输送安全性及风险识别。7.对易爆炸的烃类管线布管时考虑隔离措施？对易爆炸

35、的烃类管线布管时考虑隔离措施？中国石油化工股份有限公司青岛安全工程研究院中国石油化工股份有限公司青岛安全工程研究院QDRISE 2011 版权所有版权所有 No.2011-PPT-SBS旁边阀门的螺栓中国石油化工股份有限公司青岛安全工程研究院中国石油化工股份有限公司青岛安全工程研究院QDRISE 2011 版权所有版权所有 No.2011-PPT-SBS下一步工作1.补充试验补充试验(晶间腐蚀敏感性试验等晶间腐蚀敏感性试验等)2.补充数据补充数据(大气监测数据、大气监测数据、 .螺栓规格、泡沫成份、阀门法兰厚度螺栓规格、泡沫成份、阀门法兰厚度)3.讨论、论证讨论、论证 4. 报告提交报告提交C

36、ritical Factor 关键因素Critical Factor 1关键因素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 由于螺栓断裂，阀门的阀盖、阀杆和阀闸与阀体分离，导致超临界乙烯从由于螺栓断裂，阀门的阀盖、阀杆和阀闸与阀体分离，导致超临界乙烯从DN150阀阀门中法兰处泄漏门中法兰处泄漏-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, -螺栓材质没有达到规定指标（高碳含量，低螺栓材质没有达到规定指标（高碳含量，低Cr含量），不充分的固溶热处理。暴含量），不充分的固溶热处理。暴露环境的氯应力腐蚀露环境的氯应力腐蚀 Critical Factor 2关键因素关键

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.倒流到着火点的超临界乙烯管线内存量乙烯未被隔离，持续约倒流到着火点的超临界乙烯管线内存量乙烯未被隔离，持续约2小时，在此过程中优小时，在此过程中优先考虑防护低温罐和压力罐区，到先考虑防护低温罐和压力罐区，到 9月月9日日00

39、:30被有效隔离。被有效隔离。 Critical Factor 1 :关键因素关键因素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 由于螺栓断裂，阀门的阀盖、阀杆和阀闸与阀体分离，导致超临界乙烯从由于螺栓断裂，阀门的阀盖、阀杆和阀闸与阀体分离，导致超临界乙烯从DN150阀门中法兰处泄漏。阀门中法兰处泄漏。-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. -螺栓材质没有螺栓材质没有达到规定指标（高碳含量，低达到规定指标（高碳含量，低Cr含量），不充分的固溶热处理，暴露氯化物含量），不充分的固溶热处理，暴露氯化物的环境中造成应力腐蚀断裂。的环境中造成应力腐蚀断裂。System causes 系统原因No. 序号Possi

41、ble Cause可能原因Description 说明Recommends 建议16.7lessons learnt not embedded未吸取学到的教训Previous incident follow up issue. 2008.6.18 bolt incident lesson learnt.对以往事故的跟踪问题。2008.6.18螺栓事故学到的教训Review all previous bolt failure lesson learnt to determine specific actions or any common themes.回顾以往所有螺栓断裂事故中学到的教训，确定

42、具体行动或任何共同问题。 To review the secco system for incident investigation and improve the process for capturing lessons learned from prior incidents.回顾SECCO事故调查和改进流程，以从以往的事故中吸取教训。 20.2Incorrect item received收货错误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金属专家对青岛安工院和华理事故分析报告/螺栓分析报告的审核，螺栓材质没有达到规定指标（高碳含量，低Cr含量），固溶热处理不充分，导致暴露氯环境中造成应

44、力腐蚀，。 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. 审核供货商资格保障流程以及QA/QC程序，尤其是对新的项目，保证供货商理解SECCO规格要求，提供品质完好的货品。 System causes 系统原因21.6No preventative maintenance p

45、rogram预防性维护方案不完善No preventative maintenance program for the manual valves 对手动阀门开展预防性维护活动不完善Review and implement a preventative maintenance program for the critical manual valves.针对关键手动阀进行回顾并实施预防性维护流程22.2 Development of SPP not effective标准/规范/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月进行了LDAR，没有发现泄漏。到目前为止，只进行过一次泄漏检测。基于SECCO LDAR程序，对事故中损坏的阀门检测周期为3个月。SECCO should review implementation of LDAR program comparing to pr

47、ocedure and consider the inspection frequency and the criticality of equipment.SECCO应对照程序回顾LDAR计划的实施，并考虑检测频率和设备关键性。 Immediate causes直接原因No. 序号Possible Cause可能原因Description 说明Recommendations 建议5.5warning systems not effective报警系统未有效报警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. 由于浓度未达报警值，气体检测器在最初泄漏时未报警。调查发现气体探测仪由CH4校验，这可能导致了低于爆炸限值

49、LEL读数比实际底，因为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. 审核82区域气体检测器设定值和校准用标准气体（验证测试用甲烷气体浓度），保证警告系统有效。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.审核82区域气体检测器的布置和需要数量，由于风向的原因，距泄漏点20米远的气体探测仪才检测到微量的碳氢化合物。 7.5Bolt composition and heat treatment螺栓材质和热熔处理High carbon and low chrome with inadeq

51、uate heat treatment resulted in bolt fracture.高碳低鉻热熔处理不充分造成螺栓断裂。Immediately inspect other bolts from the same vendor and take necessary corrective action. 立即检验同一供货商的其它螺栓，采取必要的纠正行动。Review the process to classify the valves and management procedure including inspection. 回顾流程，对阀门和管理程序进行分类包括检查。Review th

52、e process to manage the high risk area valves to prevent similar failure. 回顾高风险区域阀门的管理流程，以防发生类似故障。 7.9Corrosion 腐蚀Based on SECCO previous research report of bolt breaking in 2008, potential cause of Stress corrosion cracking, SCC, was found 基于SECCO以往对2008年螺栓断裂的研究报告，考虑可能的应力腐蚀开裂（SCC）原因。Review previous

53、 similar lesson learnt reports of bolts failure incidents and take action where common themes exist. 审核以往类似螺栓断裂教训报告，查找SCC的共同问题。Develop and implement a preventive program to prevent SCC.制定并实施SCC预防活动。 Critical Factor 2:关键因素关键因素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.倒流到着火点的超临界乙烯管线内存量乙烯未被隔离，持续约倒流到着火点的超临界乙烯管线内存量乙烯未被隔离，持续约2小时小时，直到，直到9月月9日日00：50被隔离。被隔离。Immediate causes直接原因No. 序号Possible Cause可能的原因Description 说明Recommends 建议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现有的应急响应程序中缺乏具体针对高压乙烯管线的泄漏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.审核并完善现有标准操作规程中的应急程序（ERP）来处理超临界乙烯管线的泄漏，并进行演习。这一建议同样适用于其他SECCO输送SPC的管线。 No. 序号Possible Cause可能的原因Description 说明Recommends 建议15.5Other其它No specific drill for this SC ethylene pipeline.对此超临界乙烯管线没有具体的演习Refer to

57、22.2参见22.2 18.3incorrect ergonomic or human factor design不正确的人机工程或人为因素设计Operators have to climb up to close the CBI solation valve. 操作工不得不爬着上去关闭CBI 隔离阀 SECCO need to consider which additional valves require remote isolation in the emergency events to reduce impact on all pipes and plantsSECCO需要考虑增加哪

58、些阀门进行事故情况下的远程隔离，以减少对管线和装置的影响。18.7technical analysis for risk not effective风险技术分析无效The previous risk assessments conducted didnt cover this incident.以往的风险评估中未包括此类事故。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. 考虑在生产区域及管廊实施涵盖二次影响的其它风险评价方法，如QRAMARFault treeBow TieCOMMUNITY EMERGENCY RESPONSE社区紧急响应社区紧急响应 PLANT EMERGENCY RESPONSE工厂紧急响应工厂紧急响应 PHYSICAL PROTECTION (DIKES)物理保护物理保护(围堰围堰) PHYSICAL PROTECTION (RELIEF DEVICES)物理保护物理保护(释放装置释放装置)AUTOMATIC A

60、CTION SIS OR ESD自动操作自动操作, SIS 或或 ESD CRITICAL ALARMS, OPERATOR SUPERVISION,关键报警，操作工监督关键报警，操作工监督 AND MANUAL INTERVENTION与手动干预与手动干预BASIC CONTROLS, PROCESS ALARMS, 基本控制，工艺报警基本控制，工艺报警AND OPERATOR SUPERVISION与操作工监督与操作工监督 PROCESSDESIGN LAH1IWhat worked well on 9/8 and prevented incident escalation经过经过9/8事件验证并防止事故