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REPORT CHARACTERISTICS:
DONOR: Office of the Chief Medical Examiner
JURISDICTION: ALBERTA
REPORT TITLE: REPORT TO THE ATTORNEY GENERAL, PUBLIC INQUIRY
INDIVIDUAL PRESIDING: H H AIME, PROVINCIAL COURT JUDGE
PLACE OF INQUIRY: FORT MCMURRAY
DATE OF INQUIRY : 1983-11-17
INFORMATION ABOUT DECEASED:
NAME: BALTAZAR BOLIMA
OCCUPATION: PETROLEUM WORKER
INDUSTRIAL SECTOR: PETROLEUM REFINING
ACCIDENT INFORMATION:
DATE OF ACCIDENT : 1982-03-27
PLACE OF ACCIDENT: SUNCOR PLANT, FORT MCMURRAY, ALBERTA
BRIEF CAUSE OF DEATH: SEVERE ACUTE BURNING OF BODY
BRIEF MANNER OF DEATH: ACCIDENTAL
ACCIDENT DESCRIPTION:
THERE ARE 3 SEPARATE LINES RUNNING TO THE HEATER - A CHARGE
LINE
CARRYING BITUMEN/NAPTHA, A VELOCITY AND SWEEPING STEAM LINE
CARRYING
STEAM AT 400 POUNDS PER SQUARE INCH, AND A SNUFFING STEAM LINE
CARRYING
STEAM AT 140 POUNDS PER SQUARE INCH. THE CHARGE LINE RUNS THROUGH
A
SYSTEM OF COILS WITHIN THE HEATER. GAS FIRES IN THE HEATER ARE
DESIGNED
TO SUBSTANTIALLY RAISE THE TEMPERATURE OF THE BITUMEN/NAPHTHA
IN THESE
COILS. THE SWEEPING SYSTEM IS USED TO CLEAN THE BITUMEN/NAPHTHA
FROM
THE LINES WITHIN THE HEATER AT TIMES OF SHUT DOWN OR START-UP.
SNUFFING
STEAM IS FOR THE PURPOSE OF EXTINGUISHING ANY UNCONTROLLED FIRE
OCCURRING WITHIN THE HEATER.
THERE WAS A JUMPER LINE BETWEEN THE CHARGE LINE AND THE SNUFFING
STEAM LINE WITH VALVES. IT WAS THE INTENT TO CLOSE OFF THE
BITUMEN/NAPHTHA LINE, ALSO THE SWEEPING STEAM LINE, AND RUN
THE LOWER
PRESSURE SNUFFING LINE THROUGH THE HEATER. THROUGH INADEQUATE
COMMUNICATIONS AND UNDERSTANDING OF THE SYSTEM, THE BITUMEN/NAPHTHA
LINE
WAS NOT CLOSED OFF AND SO THE HIGHER PRESSURE FED INTO THE SNUFFING
LINE
WHICH THEN FED INTO THE HOT HEATER CAUSING A FLASH EXPLOSION.
THE
DECEASED BALTAZAR APPARENTLY CLOSED A VALVE IN A BANK OF FOUR
BUT NOT
THE CHARGE LINE (BITUMEN/NAPHTHA).
THIS ACCIDENT WAS CAUSED BY THE CONTINUOUS EXISTENCE OF A JUMPER
LINE BETWEEN THE SNUFFING LINE AND CHARGE LINE, WHICH HAD NOT
BEEN
REMOVED ALONG WITH A MISUNDERSTANDING OF THE SYSTEM BY THE EMPLOYEES
THAT ALLOWED A SUDDEN GUSH OF BITUMEN/NAPHTHA INTO THE HEATER
(HOT
FURNACE).
RECOMMENDATIONS ISSUING FROM INQUIRY:
SUNCOR INCORPORATED HAVE PUT INTO EFFECT 13 RECOMMENDATIONS
FOR THE
START UP OR SHUT DOWN OF THE RECOVERY HEATER IN PLANT 5; THAT
IS TO
ELIMINATE A SIMILAR ACCIDENT. IT WOULD BE PRESUMPTUOUS ON THE
PART OF
THE COURT TO RECOMMEND COMPLICATED INDUSTRIAL PROCEDURES OTHER
THAN
GENERALIZE THE RECOMMENDATIONS AS AGREED UPON BY ALL PARTIES.
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