Less than Adequate Configuration Control of Boiler Drain

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Type:  Lessons Learned

Publisher:  Los Alamos National Laboratory, Los Alamos, NM (LANL)

Published As:  Public


Topics:  Occupational Safety and Health, Operations, Maintenance, Work Management/Planning, Hazardous Energy Control

A Los Alamos National Laboratory pipefitter sustained a burn injury to his left ankle when he was sprayed with scalding water while performing blow down activities on a boiler. Boiler operators were in the process of blowing down a boiler that had unexpectedly shut down during the weekend and had been restarted on the following Monday morning. The boiler was in a cold state and had to be drained prior to restart. The low drain valve was opened to drain the boiler and was inadvertently left in the open position on Monday morning. On Monday afternoon, boiler operators attempted to perform the required blow down operation. As the pipefitter actuated a fast acting valve and began opening a slow acting gate valve, hot water at a temperature of 320 degrees from the low point drain valve located at floor level was discharged directly towards the pipefitters foot/ankle and resulted in a seconddegree burn to the ankle. The pipefitter was able to close the fast action valve and subsequently closed the slow action valve to stop the flow of hot water.

Lessons Learned Workers should verify the valve configuration(s) of boiler/steamcondensate systems prior to start-up or troubleshooting operations to identify drain pipe openings that can potentially expose them to injury from the inadvertent flow of hot water, steam or condensation. Work control documents or operating procedures that relate to pressure systems must specifically address these configuration control hazards and controls.

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