Hoot Lake OSHA Hoot Lake OSHA Citation 2005/06Citation 2005/06

Otter Tail Power Company Otter Tail Power Company Hoot Lake Plant MNOSHA Hoot Lake Plant MNOSHA Hoot Lake Plant MNOSHA Hoot Lake Plant MNOSHA Citation ReviewCitation Review

O fO fOrder of EventsOrder of EventsHoot Lake Plant OSHA CitationChronological Order of Events

11-9-05: MNOSHA is in the neighbor hood. Inspector states, "she's an OSHA Industrial Hygienist, saw the stack, & would like go into the boiler and test our Sub bituminous Ash for lead, cadmium, and arsenic." We are on-line and let her know we can't test on-line. She requests some information and then leaves.

12-5-05: We send her the requested information; 300 Log for the last two years, MSDS for Sub bituminous Ash.

12-21-05: I contact MNOSHA in the morning telling them they're welcome to test, but next scheduled outage is Spring 2006.

12-21-05: MNOSHA leaves me a voice mail in the afternoon stating that they received a call from Hoot Lake telling them the plant will be off line tomorrowbe off line tomorrow.

12-22-05: MNOSHA calls me @ 7:30 a.m. requesting to meet at the plant in 30 minutes. We conduct opening conference but inspector is very evasive and is asked 3 times before admitting to being a compliance officer.

OSHA Protocol? Credentials, employee contact, scope of inspection., p y , p p

2-8-06: We receive OSHA Citation. The contest begins.

Q ???Q ???Questions ???Questions ???

Bronco StationArc Flash IncidentMIOSHA Citation AbatementMIOSHA Citation Abatement

August 23, 2007

Incident SummaryIncident Summary

On February 21, 2006, the Senior Engineering Technician was performing a high y , , g g p g gvoltage (13.2kV) phase verification test utilizing an Avistar AP-10 (GPS) Phase Verification test set. This test device is new to Detroit Edison and was under evaluation at the time of the incident. As part of the overall evaluation process only two Sr. Technicians were provided on-site training directly by the vendor on the proper use of this device and only these technicians had been performing p p y p gthe field evaluations of this device. During the vendor’s training the instruction book and actual field use of the device was reviewed. This device had been used/tested by these technicians successfully on six previous high voltage phasing jobs over the last eight months without incident. This was another field test of this test device which immediately followed a successful TV Phasing test, y g ,page 5 & 8.

High Voltage Phasing tests have been performed at Detroit Edison for many years as outlined in the existing Job Procedure #300-025. The purpose of thisyears as outlined in the existing Job Procedure #300 025. The purpose of this procedure is to describe a method of phasing between two systems to verify, by observation of voltage measurements, that there is zero or virtually zero voltage between the points (buses, conductors, lines) that will be tied together. Testing of this nature is necessary to assure that no faults, due to incorrect phasing between the two ‘systems’, occur when the systems are tied together.

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between the two systems , occur when the systems are tied together.

Incident SummaryIncident Summary

There are several different types of high voltage phasing test equipmentThere are several different types of high voltage phasing test equipment available for use: high voltage phasing sticks, high voltage TV phasing test sets and the AP-10 Global Positioning System test set (under field test/evaluation).

Th f th hi h lt h i t t j b F b 21 2006 tThe purpose of the high voltage phasing test job on February 21, 2006, was to verify correct phase relationships existed between Bronco Station, (new equipment) and Grayling Station, (an existing substation).

The HV phase verification test was being performed in the 13.2 kV switchgear cubicle position L3, Bus 13 for the in-commissioning of Transformer – 4 and associated equipment, under shutdown request # C11149.

Following the successful completion of the TV Phasing test, a phase to ground 13.2kV arc flash occurred while field testing the Avistar AP-10. The Senior Engineering Technician sustained second degree arc flash burns to his face, neck and arms

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neck, and arms.

High Voltage Phasing Test Set-upHigh Voltage Phasing Test Set-up

Bronco GraylingBronco station

Grayling station

Crew at Bronco Station: Crew at Grayling Station:

Sen Engrg TechEMJ 1st ClassAA OperatorSystem Supervisor (Training)

Sen Engrg Tech

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Citation and Notification of PenaltyCitation and Notification of Penalty

• Citation 1 Item 1– No Training, instruction, or procedures had been conducted to open the grounded metalNo Training, instruction, or procedures had been conducted to open the grounded metal

shutter guards and provided to employees. Recent changes in the construction of the switchgear that included aluminum shutter guards. No shutter guard position indicator.

– GENERAL RULES, PART 1, RULE 114(2)(b) – SERIOUS VIOLATION

• Citation 1 Item 2Citation 1 Item 2– No inspections of the Powercon switchgear and the compatibility of the Avistar AP-10.– GENERAL RULES, PART 1, RULE 114(2)(c) – SERIOUS VIOLATION

• Citation 1 Item 3Employer did not furnish an environment which is free from recognized hazards– Employer did not furnish an environment which is free from recognized hazards.

– ACT 154 PUBLIC ACT OF 1974, 408.1011(a) SERIOUS VIOLATION

• Citation 1 Item 4– Face and eye protection shall be used where a hazard or risk of injury exist.y p j y– PERSONAL PROTECTIVE EQUIPMENT, PART 6, RULE 624(1) – SERIOUS VIOLATION

• Citation 1 Item 5– Inadequate body protection for electrical arc blasts and flashes have been provided to

employees performing phase verification.

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employees performing phase verification.– PERSONAL PROTECTIVE EQUIPMENT, PART 6, RULE 626(5)

Proposed Penalty for the five items was $10,000

Citation AbatementCitation Abatement

• Citation 1 Item 1a– No Training, instruction, or procedures had been conducted to open the grounded metalNo Training, instruction, or procedures had been conducted to open the grounded metal

shutter guards and provided to employees. Recent changes in the construction of the switchgear that included aluminum shutter guards. No shutter guard position indicator.

– GENERAL RULES, PART 1, RULE 114(2)(b) – SERIOUS VIOLATION

• Citation 1 Item 1bCitation 1 Item 1b– No inspections of the Powercon switchgear and the compatibility of the Avistar AP-10.– GENERAL RULES, PART 1, RULE 114(2)(c) – SERIOUS VIOLATION

• Citation 1 Item 3Employer did not furnish an environment which is free from recognized hazards– Employer did not furnish an environment which is free from recognized hazards.

– ACT 154 PUBLIC ACT OF 1974, 408.1011(a) SERIOUS VIOLATION

• Citation 1 Item 4– Face and eye protection shall be used where a hazard or risk of injury exist.y p j y– PERSONAL PROTECTIVE EQUIPMENT, PART 6, RULE 624(1) – SERIOUS VIOLATION

• Citation 1 Item 5– Inadequate body protection for electrical arc blasts and flashes have been provided to

employees performing phase verification.

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employees performing phase verification.– PERSONAL PROTECTIVE EQUIPMENT, PART 6, RULE 626(5)

Proposed Penalty for the five items was $10,000

Citation AbatementCitation Abatement

DTE Energy successful argued the proposed penalty and the five citable itemsDTE Energy successful argued the proposed penalty and the five citable items from the initial MIOSHA Citation and Notification of Penalty. Groups involved in developing the argument were: Corporate Safety; Distribution Operations (PERT Group); Safety specific legal council.

– Citation # 1 Item # 3 and # 5 were dismissed– Item # 1 and # 2 were renumbered and grouped together as Item # 1a and #

1b for penalty purposes and the fine was reduced from $4000 to $2000.– Citation 1 Item 4 were uncontested and amended as follows:Citation 1, Item 4 were uncontested and amended as follows:

• Inadequate face protection for electric arc blasts and flashes provided to employees performing and assisting in the phase verification activities in breaker cabinets with a potential of 13.kV . During this work activity, the employees were only provided with and wore Z87.1 glasses for eye protection.

Thi l lt d i d ti f fi f $2000 t $1400– This also resulted in a reduction of fine from $2000 to $1400.

DTE Energy’s arguments were accepted on July 12, 2007. DTE Energy wasable to demonstrate existing practices and corrective measures, which

t d b MIOSHA P d P lt f $10 000 d d t

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were accepted by MIOSHA. Proposed Penalty of $10,000 was reduced to$3,400.

M ki Ri Pl t Muskingum River Plant Hydrogen Explosion

January 8, 2007y ,Update

Presenter: Gary Hatcher,Regional Manager Safety and Health

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Review of Events Leading to the Explosion

– Unit 5 is a 565 Mw coal fired supercritical unit– Unit 5 is a 565 Mw coal fired supercritical unit– In operation since 1968– On January 8, 2007, plant operating status was normal– Hydrogen supplier was making routine delivery– Premature failure of the Upper Tube, west relief device’s rupture

disc– Explosion killed hydrogen truck driver.– Ten others were injured

Damage easily visible from opposite side of Muskingum River– Damage easily visible from opposite side of Muskingum River– The rupture discs were designed to relieve at approximately 3700

PSI

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Rupture Disc Relief Device

Weather Membrane

Shear RingRupture DiscCopper WasherCopper Washer

Relief Device Body

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iRupture Discs

Rupture disc after being pressurized

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Rupture disc after being pressurizedExample of a failed rupture disc

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Enforcement ActionsOSHA enforcement action consisted 9 citations, one willful

and 8 serious. The dollar amount of the citations was $94 500 Most of the citations were directed at the$94,500. Most of the citations were directed at the design of the hydrogen system.

Vendor had similar number of citations. Total fines were $9 150 Similar items cited but one was a “5 (a)(1)”$9,150. Similar items cited, but one was a 5 (a)(1) citation.

After the informal conference the willful citation was reducedAfter the informal conference the willful citation was reduced and one citation dropped leaving a total of eight. The fine was lowered to $55,600.

The vendor also attended an informal conference with similarThe vendor also attended an informal conference with similar results. They had one citation dropped and fine reduced to $5,310.

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New Hydrogen System

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Corrective ActionsThe plant took immediate corrective action by decommissioning

the damaged hydrogen system and setting up a temporary t C t ti b t tsystem. Construction began on a permanent system

Developed unloading procedures, Job Hazard Analysis (JHA), a d il b i ( ) d l di i idaily Job Site Assessment (JSA) and unloading training

All AEP hydrogen systems were reviewed against a safe design basis. Included in the design basis:

• Must be 50 feet from any occupied structure• All rupture discs replaced with spring loaded relief valvesp p p g• Standard design for vents and piping• Standard manifold cabinet design• No “tube trailer” style systems are permitted

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• No tube trailer style systems are permitted

Still to Come:Priority was to replace the rupture discs

• Not all locations have completed the change out of hydrogen systems… major task

• Now completing the standardized training for those unloading hydrogen

• Re bidding hydrogen suppliers and maintenance• Re-bidding hydrogen suppliers and maintenance providers

• Developing materials for OSHA publicationDeveloping materials for OSHA publication• Plant has undertaken compliance with ISO 14001 /

OHSAS 18001 and begun the OSHA VPP process

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North Wall of the Muskingum River Unit 5 as it Looks Today.

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Shoring Incident11/06

O A Gas crew was working on repairing a gas main leak.

M h i i i i l 7 f dO Mechanic was in excavation approximately 7 feet deep without shoring.

Shoring IncidentShoring Incident11/0611/0611/0611/06

Gas main with clamp partially applied.

O An OSHA inspector walked up on the job.

Shoring IncidentShoring Incident11/0611/0611/0611/06

Overall view of jobsite. Note spoil pile less than 2 feet from edge of excavation.

O Crew had noted on their tailboard briefing sheet that gshoring would be required.

O Shoring was on jobsite, but not installed.

Shoring IncidentShoring Incident11/0611/06

O The crew’s response to the inspector was that they took

Shoring being installed.

p p ya short cut.

Shoring IncidentShoring Incident11/0611/06

O OSHA decided not to cite the company at this time.

O OSHA noted that a second incident of Company failing to use

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shoring will result in citation.

O OSHA expressed concern that employees did not fully appreciate potential risks.appreciate potential risks.

O Avenues to address OSHA’s concerns;

a.) Involved employees could not work in the field until ) p yretrained in shoring, with an emphasis on the risks.

b.) All employees read and sign that they reviewed and understood the shoring procedureunderstood the shoring procedure.

c.) Company to circulate a Safety Alert on shoring, including OSHA’s photos of the shoring violation, direction on proper h i d th t ti l lt f i l ti l tishoring and the potential results of violating regulations.

Questions?????