An explosion in the Midwestern United States destroyed the boiler of a 450 MW coal and gas fired power plant, resulting in physical damages and lost revenues exceeding $0.5 billion. Through the years that the conditions leading to the explosion developed, the disaster might have been averted by any number of reasonable interventions by plant maintenance personnel, plant operators, or plant management. Many lessons may be gleaned through a careful retrospective analysis of the circumstances and events that led to the catastrophic explosion. The intent of this paper is to present a case study emphasizing the importance of operations and maintenance, with the appropriate coordination and oversight by management. In this particular case, operations failed to enforce requisite lockout/tagout procedures and to observe and understand the alarms that annunciated when a wastewater accident inundated the fuel safety system. Maintenance failed to employ proper cleanup and troubleshooting techniques. Management failed to assign repair responsibilities to the most qualified maintenance personnel and to ensure proper communication between the personnel in the various plant departments. The catastrophic result of these failures was an inadvertent release of a substantial quantity of natural gas that ultimately exploded, completely destroying the boiler and other plant systems. This case study does not focus on the implementation of new operations or maintenance technologies, rather the emphasis is on reinforcing the implementation of existing codes, procedures and protocols and strengthening communications among plant personnel.

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