OSER For Utilities
OSER For Utilities
OSER For Utilities
Type of Incident
Report ID
OSER # 1
Date of Incident
02-Dec-13
Time
1239 hrs.
Title
Details of Incident
DG-2 & DG-4 were in service at 550 KW load (each) & running in synchronization
with STG-401 at 1000 KW load. During checking of Governor 505 E for LP extraction
by HTC TA (Mr. Cao JJ), load suddenly increased on STG-401 to 2100 KW. Due to
low load, DG-2 & 4 tripped. Electrical team was called in & emergency was efficiently
handled by the combined efforts of Utilities & Electrical maintenance team without
any electrical or production loss of plant.
Root Cause
1. Due to sudden load decrease on DG-2 & DG-4 system voltage decreased.(360
Volts, normal range is 400-415)
2. Along with voltage decrease generators tripped on Reverse Power which was
indicated on DG-2/4 digital modules.
Target Date
1. E&I
2. Production + Utility + E&I
3. E&I + Maintenance
05-Dec-13
Filled By
MAB
Approved By
Utility Manager
Responsibility
OPERATIONAL SKILL
ENRICHMENT REPORT FOR
UTILITIES
Report ID
All tractors (blades, buckets) were stopped can cause steam failure/ST-401 tripping due
to husk shortage
OSER # 2
Date of Incident
03-Dec-13
Time
0245 hrs.
Title
Husk Shortage
Type of Incident
HP Boiler and ST-401 were in service at 0245hrs, AM Utilities was on round and
found:
Details of Incident
1.
2.
3.
4.
Observer asked to drivers for feeding husk, and as result our system was not affected.
Root Cause
Post-3 FC sent Husk yard supervisor to start deep well turbine during this activity, no
one was there on supervision of drivers due to which they stopped tractors operation,
while FC did not accept his duties regarding operation of water turbine. Water turbine
operation is the responsibility of FC Post-3 not husk yard supervisor.
Recommendations
1. Husk yard supervisor should always be present in husk yard and should be vigilant.
2. Coaching of every boardman, FC and 3po staff to be done for acceptance of their
JD`s.
Responsibility
Target Date
To onwards
Filled By
MMA
Approved By
Utility Manager
OPERATIONAL SKILL
ENRICHMENT REPORT FOR
UTILITIES
Type of Incident
Water Spillage
Report ID
OSER # 3
Date of Incident
05-Dec-13
Time
1630 hrs.
Title
Details of Incident
1. Area operator operated the P-101-B at 1500hrs when its level was 21 feet.
2. T-100 over flow after maintaining its maximum level.
Root Cause
Area operator went to attend polisher operational training without informing to any
other area FC. Posts 3 FC also forget that water turbine was in service which cause
over -flow.
.
Recommendations
During operation, area FC must have complete focus in his responsibilities and in case
of another activities, charge must be hand over to other FC/TL.
Responsibility
Target Date
05-Dec-13
Filled By
MA
Approved By
Utility Manager
OPERATIONAL SKILL
ENRICHMENT REPORT FOR
UTILITIES
Type of Incident
Report ID
OSER # 4
Date of Incident
08-Dec-13
Time
0216 hrs.
Title
Details of Incident
RHF#1 motor tripped on overload due to iron bar (Diameter =10mm & length=
400mm Approximately) stuck in feeder causing decrease in boiler steam drum
pressure. Furthermore, this iron bar can damaged the husk carrier which leads to
shutdown of the SG-321 & STG-401 operation.
Root Cause
Recommendations
During operation, area FC must have complete focus in his responsibilities and in case
of another activities, charge must be hand over to other FC/TL.
Responsibility
Target Date
13-Dec-13
Filled By
SS/HMA
Approved By
Utility Manager
OPERATIONAL SKILL
ENRICHMENT REPORT FOR
UTILITIES
Type of Incident
Report ID
OSER # 5
Date of Incident
02-Jan-14
Time
1115 hrs.
Title
Details of Incident
SG-321 BFW Pump-B was in service, leakage was observed from its front side gland,
informed to maintenance team and cold work permit was handed over for gland
leakage removal. Maintenance team person tightened the gland pusher and after
completion of job, permit closing activity was in progress, suddenly, during this period,
gland pusher damaged into two pieces, one piece shoot away (approx.. 15 m) to ash
water pit side and warm water leaked from gland packing. Fortunately no person was
standing b/w this area.
Root Cause
Recommendations
Responsibility
Target Date
05-Jan-14
Filled By
MA
Approved By
Utility Manager
OPERATIONAL SKILL
ENRICHMENT REPORT FOR
UTILITIES
Type of Incident
Report ID
OSER # 6
Date of Incident
03-Jan-14
Time
1517 hrs.
Title
Details of Incident
BFW Pump A was in service, at 1517 hrs. boiler area FC opened common circulation
valve FWP A & B, during this activity, BFW Pump-A pressure and flow dropped which
caused the SG-321 boiler water level drop and tripped the boiler.
Root Cause
Recommendations
1. Refresher training about SG-321 field operation & proper communication in b/w
team is required, Daily monitoring of mechanical machinery parts by operation &
maintenance team.
2. Strictly cautions board required at designated place in area for working.
3. Arrange proper pumps with specifications as compare with boiler specifications
according to ASME code.
Responsibility
Utilities, Maintenance
Target Date
20-Jan-14
Filled By
MA
Approved By
Utility Manager
OPERATIONAL SKILL
ENRICHMENT REPORT FOR
UTILITIES
Type of Incident
Report ID
OSER # 7
Date of Incident
18-Jan-14
Time
2025 hrs.
Title
Details of Incident
At 2025hrs, when area FC tried to take left side GLG in service, LT-324 showed low
water level which was less than 35%, which caused SG-321 tripping.
Root Cause
Recommendations
4. Refresher training about SG-321 field operation & proper communication in b/w
team is required, Daily monitoring of mechanical machinery parts by operation &
maintenance team.
5. Strictly cautions board required at designated place in area for working.
6. Arrange proper pumps with specifications as compare with boiler specifications
according to ASME code.
Responsibility
Utilities, Maintenance
Target Date
20-Jan-14
Filled By
MA
Approved By
Utility Manager
OPERATIONAL SKILL
ENRICHMENT REPORT FOR
UTILITIES
Type of Incident
Report ID
OSER # 8
Date of Incident
18-Jan-14
Time
2120 hrs.
Title
Details of Incident
At 2120hrs, sudden abnormal sound create from ash conveyer of SG321 immediately
stopped the conveyer and inform to maintenance team.
Root Cause
1. Due to Ash continuous collecting in ash conveyer which caused minimizing the
upper and down plate distance, plates hit to each other and chain de-tracked.
2. Due to continuous operation, chain loose and de-tracked.
3. Miss-alignment.
Recommendations
Responsibility
Utilities, Maintenance
Target Date
19-Jan-14
Filled By
MA
Approved By
Utility Manager
OPERATIONAL SKILL
ENRICHMENT REPORT FOR
UTILITIES
Type of Incident
Report ID
OSER # 9
Date of Incident
21-Jan-14
Time
1015 hrs.
Title
Details of Incident
At around 1015hrs, field operator observed high magnitude of abnormal sound from
the husk elevator. So to avoid any further damage, field operator abruptly stopped husk
elevator and called maintenance team. During continuous inspection, it was observed
that the plate installed between chains to move husk was separated from the chain and
was stuck in the return duct outlet. So the plate was removed. Boiler Box up and
ST-401 safe shutdown at 1050hrs.
Root Cause
The bolts were opened from one side of the plate in the initial step. After sticking into
the return discharge duct, the free end of the plate applied back force on the fix end. In
the result of this force, the chain misaligned and broke the angle of the connection
point installed over the chain link to mount plate on it.
Recommendations
Preventive Maintenance
Responsibility
Utilities, Maintenance
Target Date
05-Feb-14
Filled By
MAB
Approved By
Utility Manager
OPERATIONAL SKILL
ENRICHMENT REPORT FOR
UTILITIES
Type of Incident
Report ID
OSER # 10
Date of Incident
22-Jan-14
Time
1045 hrs.
Title
Details of Incident
At 1045 hrs. Main ash conveyer de-tracked due to plate missing and supports then after
that chain loosed and miss alignment cause de tracking of ash conveyer. Our teams try
to complete the Maintenance job in time but in vain at last we safe shut down the
Steam turbine at 1324 hours and Safe shut down of Boiler at 1340. After that Boiler
restart the SG-321 at 1650 hours and ST-401 on Electric load sync at 1840.
Root Cause
No preventive maintenance
Recommendations
Preventive maintenance
Responsibility
Utilities, Maintenance
Target Date
10-Feb-14
Filled By
RM
Approved By
Utility Manager
OPERATIONAL SKILL
ENRICHMENT REPORT FOR
UTILITIES
Type of Incident
Report ID
OSER # 11
Date of Incident
25-Jan-14
Time
1350 hrs.
Title
Details of Incident
Air compressor K-701 motor tripped due to over load. Immediately, K-702 was taken
in service and informed to E&I team for rectification of problem of K-701. During this
period, air supply cut from mill and CDP while supply continuous to utilities
equipment after 15 minutes, K-701 took back in service when problem rectify by E&I
team.
Root Cause
Recommendations
1. Preventive maintenance
2. Cleaning must be on daily, weekly & monthly basis.
3. Should be compressor separate houses & avoid dirty environment.
Responsibility
Target Date
15-Feb-14
Filled By
MA
Approved By
Utility Manager
OPERATIONAL SKILL
ENRICHMENT REPORT FOR
UTILITIES
Type of Incident
Right side ID fan abnormal sound and vibration due to coupling bolts loses.
Report ID
OSER # 12
Date of Incident
25-Jan-14
Time
1350 hrs.
Title
Right side ID fan abnormal sound and vibration due to coupling bolts loses.
Details of Incident
At 1830 hrs. Abnormal sound observed & vibration in right side ID fan due to coupling
bolts loosen. Area operator informed to board-man and left side ID fan took in service
in the presence of TL & AM. Inform & problem discussed with maintenance team.
Root Cause
Recommendations
Responsibility
Target Date
27-Jan-14
Filled By
MA
Approved By
Utility Manager
OPERATIONAL SKILL
ENRICHMENT REPORT FOR
UTILITIES
Type of Incident
Report ID
OSER # 13
Date of Incident
14-Feb-14
Time
1000 hrs.
Title
Details of Incident
At around 10:00 a.m., field operator observed that raw water pumps (P-102A-C) were
not meeting the pressure requirement. Mechanical team was called to check the pump.
Their suction valves were checked, found ok. Also, their strainers cleaning were done
but still the problem persists. Eventually, when the rotation of motor was checked it
was found that pumps motor rotation was opposite (Clock-wise).
Root Cause
Maintenance job was carried out on pumps breaker during plant shut down and at that
time, due to insufficient load margin, checking of pumps rotation was not done at that
time.
Recommendations
1. Proper training session for troubleshooting.
2. Pumps operational instructions to be placed in area.
Responsibility
Utilities
Target Date
22-Feb-14
Filled By
MHH/AM
Approved By
Utility Manager
OPERATIONAL SKILL
ENRICHMENT REPORT FOR
UTILITIES
Type of Incident
DG # 2 startup problem
Report ID
OSER # 14
Date of Incident
17-Feb-14
Time
0750 hrs.
Title
DG # 2 Startup problem
Details of Incident
At around 7:30 am, field operator started DG#2 to warm up, after warming up
shutdown DG#2 but its starting motor didn't stop. Operator stopped it manually from
DG local control Key and informs E & I team. E&I team started DG#2 about 11:50AM
but it fails to start, and starting motor started prior to DG. E&I team consult Allied
team(CAT engine service provider) for the issue, they advised to disconnect DC power
supply of EMC module and do cleaning of its contacts. After cleaning, DC power
restored to EMC and DG#2 started again, DG#2 starts successfully. Issue has been
resolved.
Root Cause
EMC Malfunctioning
Recommendations
1. Preventive Maintenance
2. Monitoring of DC Battery system on daily basis.
Responsibility
Utilities, Maintenance
Target Date
26-Feb-14
Filled By
IH
Approved By
Utility Manager
OPERATIONAL SKILL
ENRICHMENT REPORT FOR
UTILITIES
Type of Incident
Report ID
OSER # 15
Date of Incident
17-Feb-14
Time
0750 hrs.
Title
Details of Incident
At around 11:30 am, field operator started DG#1 and successfully synchronized with
STG-401. After synchronization DG#1 share 1000KW load from STG-401 in 1 minute
and tripped at overload protection. Field operator informed utility team. Utility team
investigated the issue and found DG#1 no load rpm (1503~1504) little higher than
rated rpm (1500rpm). Than utility team inform E&I team to rectify the rpm problem.
E&I team adjust its rpm from governor module and synchronize DG#1 with STG-401
& DG#2 successfully with a base load of 300KW. DG#2 stopped to check DG#1
behavior with STG-401. DG#1 took compressor load during loading of compressor and
didn't decrease it to base load (300KW). Issue communicated to E&I and they are
working on it.
Root Cause
DG # 1 load sharing problem
Recommendations
Responsibility
Target Date
25-Feb-14
Filled By
IH
Approved By
Utility Manager
OPERATIONAL SKILL
ENRICHMENT REPORT FOR
UTILITIES
Type of Incident
Report ID
OSER # 16
Date of Incident
18-Feb-14
Time
1052 hrs.
Title
SG-321 steam drum Pressure decreased from 61 to 56 bar g while STG was in service
at 600 Kwh
Details of Incident
Driven sprocket & shaft welding crack of husk carrier, stopped husk carrier and
elevator at 1052 hrs. After filling husk bin to 100 %, also synch DGs with STG and this
job completed at 1128 hrs. during this job once husk carrier started to fill again husk
bin.
Root Cause
1. Solid particle come through husk which cause welding damage of sprocket and
shaft.
Recommendations
Responsibility
Utilities, Maintenance
Target Date
05-Mar-14
Filled By
RM/AR
Approved By
Utility Manager
OPERATIONAL SKILL
ENRICHMENT REPORT FOR
UTILITIES
Type of Incident
Report ID
OSER # 17
Date of Incident
14-Mar-14
Time
1900 hrs.
Title
Details of Incident
At 1900 hrs. Boiler pressure was dropped to 43 bar (g) despite increasing husk feeder
motor rpm. On investigation, it was found that boiler assistant left the field without
giving charge to incoming person, also his co-assistant left the field without giving
charge, moreover, husk yard supervisor also showed negligence due to which husk
feeding shortage occurred.
Root Cause
1. On investigation, it was found that boiler assistant left the field without giving
charge to incoming person.
2. His co-assistant left the field without giving charge, he communicated wrong that
he gave charge to incoming person at LP boiler but actually, he gave charge at gate.
3. Husk yard supervisor also showed negligence due to which husk feeding shortage
occurred.
Recommendations
Responsibility
Utilities
Target Date
15-Mar-14
Filled By
MHH/KM
Approved By
Utility Manager
OPERATIONAL SKILL
ENRICHMENT REPORT FOR
UTILITIES
Type of Incident
Report ID
OSER # 18
Date of Incident
15-Mar-14
Time
0230 hrs.
Title
Details of Incident
At 0230hrs, sudden abnormal sound create from ash conveyer of SG321& due to
continuous collection of ash in ash conveyer, caused minimizing the upper and down
plate distance as a result plates hit to each other and chain de-tracked. Immediately
stopped the conveyer and called the maintenance team.
Root Cause
1. Due to continuous collection of ash in ash conveyer, it caused minimizing the upper
and down plate distance, plates hit to each other and chain de-tracked.
2. Due to continuous operation, chain loose and de-tracked.
3. Miss-alignment.
Recommendations
Responsibility
Utilities, Maintenance
Target Date
16-Mar-14
Filled By
MHH
Approved By
Utility Manager
OPERATIONAL SKILL
ENRICHMENT REPORT FOR
UTILITIES
Type of Incident
Report ID
OSER # 19
Date of Incident
21-Mar-14
Time
1115 hrs.
Title
Details of Incident
At 1115 hrs. Main ash conveyer de-tracked due to plate missing and supports then after
that chain loosed and miss alignment cause de tracking of ash conveyer. Maintenance
team was called and after checking, they communicated that the rectification will be
completed after 5 hours. So, safe shut down of Steam turbine done at 1130 hours after
shifting load on DG`s and boiler was operated at low pressure till 1545 hrs. After that,
boiler (SG-321) pressure was increased at 1600 hrs. Load on STG-401 was taken from
DG`s at 1915 hrs.
Root Cause
No preventive maintenance
Recommendations
Preventive maintenance
Responsibility
Utilities, Maintenance
Target Date
25-Mar-14
Filled By
MHH
Approved By
Utility Manager