Root Cause Analysis Report CEP pit block 4 flooding

Incident Summary:
On November 1, 2023, an incident occurred where Block 4 of the CEP pit was
flooded by seawater. The root causes of this incident were identified as the open state of the
MOV discharge line A in Condenser Block 4, the concurrent condition of the open water box
A bottom side manhole, and the presence of seawater in the culvert outfall since August.
This incident also highlights the importance of PTW procedures in preventing such events.

Timeline of Events:
1. Since August, the culvert outfall had seawater inside, as a small leakage on a stop
log went unaddressed.
2. The culvert outfall stop log is not proper maintenance.
3. HK manpower has civil worked on block 4 culvert outfall which finish last week and
there are some electrical construction works on block 4 by doosan manpower
4. On November 1, 2023, the MOV discharge line A in Condenser Block 4 might be
open position by someone
5. As a result of the open MOV discharge line A, seawater was allowed to enter the
condenser.
6. Simultaneously, the bottom side manhole of water box A was left open, providing an
additional pathway for seawater to CEP pit block 4.
7. Over a period of time, a significant amount of seawater entered the cooling system
and subsequently overflowed into the CEP pit.
8. The flooding of the CEP pit was detected on November 1, 2023

Root Causes:

1. MOV Position: The primary root cause of the incident was improper maintenance for
stoplog block 4 and the MOV discharge line A in Condenser Block 4 might be opened
by someone, allowing seawater to enter the system.
2. Manhole Condition: The concurrent condition of the water box A bottom side
manhole being open.
3. Flange CW outlet : Flange CW outlet bolt not fully tighten
4. Failure to Address Leakage : The presence of seawater in the culvert outfall was due
to the failure to address a small leakage on a stop log because poor maintenance on
stop log

Contributing Factors:
Inadequate Supervision: Insufficient oversight and supervision of personnel
responsible for MOV operations, manhole inspections, and outfall maintenance may have
contributed to these errors.

PTW Applicability:
PTW procedures should have been applicable in this incident to isolate and secure
the MOV, manhole, and outfall to prevent seawater ingress.
Response After Flooding :

1. Doosan Informed HK to Install sump pump to remove water on CEP pit block 4
2. HK directly install sump pump to remove water on CEP pit block 4

Corrective Actions:
To prevent similar incidents in the future and address the PTW issue, the following
corrective actions are recommended:
1. Revised Procedures: Develop and strictly enforce revised standard installation
procedures for MOV operations to ensure keep closing, manhole inspections,
and outfall management. Include explicit instructions on the application of PTW
during maintenance and repair tasks.
2. Enhanced Training: Provide comprehensive training to personnel responsible for
MOV operations, maintenance tasks, and stop log maintenance to emphasize
the importance of procedural adherence, equipment integrity, and PTW
procedures.
3. Supervision and Monitoring: Implement a system of rigorous supervision and
monitoring to ensure that PTW is correctly applied during maintenance and that
equipment like manholes are properly maintained and closed, and stop logs are
inspected and repaired promptly.
4. Emergency Response Plan: Develop an effective emergency response plan to
mitigate the impact of such incidents and minimize potential damage to
equipment and the environment. such as Install permanent sump pump
immediately when flood coming at CEP pit block 4
Oufall block 4 condition in 29 August 2023
sea water level condition
FOR APPROVAL

22/10/2018

GRAPHIC SCALE
0 5 10 25 50 100 200m
 4. STEEL LADDER:
STAINLESS STEEL (ASTM A276 TYPE 316L)

22/10/2018

FOR APPROVAL

GRAPHIC SCALE
0 5 10 25 50 100 200m
8/21/2019
manhole still opening
cause water goes to
CEP PIT BLOCK 4
sea water level at MOV discharge
condenser