High Potential Incident Safety Alert Issue No: HIPO-2024-25/01

Incident Date: 17.04.2024 Time: 05:35 PM

Brief Description of Incident:

A defect notification was raised by Operation Dept, on 04.04.2024 on noticing reduction of bleed flow of HPH-2 extraction
leading to efficiency loss. However, it was decided to attend the said defect during short shutdown of the unit. On 17.04.2024,
the unit-3 had to be taken into shut-down at about 3.12 PM to attend LP Heater bellow leakage. Then it was decided to attend
the notification defect in this shut down. Accordingly, TMD Engineer applied for Permit duly submitting the Job Safety Analysis
(JSA) for the job. Before issuing the PTW, the HP Heater-2 extraction line was drained and depressurrised and permit was
issued for 24 hours from the time of issue. The pressure and flow both are shown 0 (zero) in DCS system.

On obtaining the permit at 04.55 PM, a team of 3 workmen namely (1) Sh. YYY, Rigger, (2) Sh. ZZZ, Fitter and (3) Sh. LLL, Helper
of M/s. XXX were engaged for the job of inspection of QCNRV. Sh. OOO, Dy. Manager, Turbine Maintenance who has received
the Permit and supervising the work.

At about 5.35 PM, the above team started inspection after duly confirming the Pressure, flow and opening of drain Manual
Isolating Valve. During inspection, the fitter and the rigger went to the scaffolding platform provided at QCNRV, which is
located at 3 M above the working floor. Taking position on platform near the NRV duly anchoring the safety harness and
wearing leather handgloves & faceshield, together they opened the bolts of NRV bonnet. On trying to loosen the bonnet cover
by tapping, the cover opened up swiftly resulting in atmospheric air entering in the piping. Few seconds later a small quantity
of hot water suddenly ejected out from the bonnet cover and fell over the rigger who was nearer to the NRV.

Sh. YYY, Rigger,aged 54 yrs, working for M/s. XXX suffered superficial burn injuries on front of his body and under
treatment in nearest Hospital.

Observation Findings: Schematic Diagram of HPT Extraction to HP Heater-2

• The work was undertaken by the team after receiving a valid work
permit.
• There is a scaffold platform available there with safe ingress /egress
to safely perform the job at QCNRV.
• Job specific PPEs including Safety Harness, leather hand-gloves and
face shields were used by both the workers who were working on
platform.
• Both the drain lines beneath QCNRV and the loop between HP
Extraction point and QC NRV, are through and through, however
there is a chance of water accumulation (condensate) in the vertical
section of downstream piping (near HPH-2) as shown in the
schematic diagram given above.
• The flap of QCNRV was found detached from its position. (found
during inspection)
• There was a possibility of more than 1000C metal temperature at
the time of opening the bonnet cover.
• From the statements of the witness, it is revealed that while tapping
on the bonnet cover, atmospheric air stated gushing in to the system
piping

Preliminary Findings:
- On opening the bonnet nuts, the air ingress started causing pulling of the residual hot condensate (mixture
steam and water) from the downstream vertical line (as shown in the scheme above) which they have not
expected. (It might be due to phenomenon of Venturi effect, due to which the deposited hot condensate in
the downstream vertical line might have ejected out when atmospheric air entered in to the piping system).
- Existence of metal temperature above 1000 C at the time of work.
- Presence of very hot condensate water in the downstream vertical line.
- Attempt to open the bonnet cover by tapping instead of crack opening (i.e., by lifting jack bolts).

Lesson Learnt from Incident: JSA to be reviewed. Before starting the work complete condensate removal to be ensured .
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