The Commonwealth of Massachusetts

Department of Public Safety

One Ashburton Place, Room 1301 Boston, Massachusetts 02108-1618 Phone (617) 727-3200 Fax (617) 727-5732
TTY (617) 727-0019 www.mass.gov/dps

Deval L. Patrick Governor Timothy P. Murray Lieutenant Governor

Kevin M. Burke Secretary Thomas G. Gatzunis, P.E. Commissioner

July 31, 2008

In addition to the incident investigation, the following is a summary of the steps taken by the Department of Public Safety (Department) in the wake of the boiler failure on November 6, 2007. 1. On November 19, 2007 the certificates of inspection for all four boilers were revoked. This action prohibited the boilers from restarting until an inspection by Department inspectors was performed and a new certificate was issued. The Department performed an assessment on all solid fuel fired boilers in the Commonwealth to ensure that other plants with solid fuel fired boilers were in compliance with the Code which required inspection and maintenance of the Dead Air Space in the boiler. The compliance action was carried out by all of the state District Engineering Inspectors on March 24, 2008. Based on this assessment, it was determined the other plants did comply with the Code in this regard. Before any repairs were allowed to be performed on any of the boilers at the Salem Harbor Plant: a. The Department reviewed/discussed the proposed non-destructive examination (NDE) and repair scope with DENE-Salem; b. The Engineer-in-charge Steve Dulong of Dominion Energy New England (DENE-Salem) stepped down from his responsibilities as the Engineer-in-charge; c. Daniel Girard assumed the position of Engineer-in-charge. The Department met with DENE-Salem management to review and discuss plant responsibilities with particular attention to the Engineer-in-charge. The Department met with the new Engineer-in-charge to review plant responsibilities. The Department requested DENE-Salem to perform operator training and create procedures to identify boiler tube leaks to ensure personnel safety in the event a leak is identified. The Department formed a Boiler Task Group to consider and submit proposed changes to the Board of Boiler Rules as a result of the incident. As boiler repairs and NDE proceeded, the Department discussed results on the NDE with DENE-Salem and in some cases increased the scope of NDE. It is noted that DENE-Salem also initiated decisions to increase the scope of NDE several times as well. A review of all the NDE and repairs are attached. The Department ordered pressure tests of the boilers and inspected each boiler before each boiler was allowed to return to service. On July 31, 2008, the Department revoked former Engineer-in-charge Steve Dulongs 1st Class Engineers License. On July 31, 2008, the Department advised Insurance Inspector Robert Maule that based upon the results of its investigation, it deemed him incompetent and untrustworthy to hold a Certificate of Competency to inspect boilers in the Commonwealth. Such finding may lead to the revocation of his Certificate of Competency.

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Commonwealth of Massachusetts
Department of Public Safety
INCIDENT REPORT

July 31, 2008 Dominion Energy New England - Salem Harbor Station Salem, MA Boiler #3 Failure - November 6, 2007

Investigating Inspectors Mark F. Mooney, Chief of Inspections Mechanical Edward S. Kawa, Manager of District Engineering Inspectors
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INCIDENT FACT SHEET

DATE AND TIME: LOCATION:

November 6, 2007, 0846 hours Dominion Energy New England Salem Harbor Generating Station 24 Fort Avenue Salem, MA 01970 (978) 740-8234 Mathew Ideglia (deceased)

VICTIMS / FATAL:

Philip Robinson (deceased)

Mark Mansfield (deceased) et

OBJECT UNDER INVESTIGATION: MANUFACTURER:

1957 B & W Boiler, NB #19517 The Babcock & Wilcox Company 800 Main Street, 4th Floor Lynchburg, VA 24505 U.S.A. 1-800-BABCOCK (1-800-222-2625) See Supplemental Interview List Mark F. Mooney (lead inspector) Edward S. Kawa Detective John Doyle, Salem Police Department Trooper Anthony LoPilato, Mass. State Police

WITNESSES: INSPECTORS:

INVESTIGATING LOCAL POLICE: INVESTIGATING STATE POLICE:

INVESTIGATING OSHA INSPECTORS: John Nesbitt, Industrial Hygienist Alan Burbank, Compliance Safety and Health Officer Lee Hathon, Mechanical Engineer

INCIDENT SUMMARY
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On November 6, 2007 at approximately 0800 hours, two (2) operations employees (Mathew Indeglia, and Philip Robinson) and one maintenance employee (Mark Mansfield) were working to tag out a pulverizer seal air fan under boiler #3. At 0846 hours, a series of division wall tubes catastrophically failed within the east furnace lower slope dead air space. The steam boiler was operating at 1900 PSI at the time of the failure. The furnace lower slope dead air space was normally under a slight negative pressure. The failure of tubes within the furnace lower slope dead air space caused that space to become rapidly pressurized resulting in a secondary explosive rupture of the boiler casing around that space. It is believed that the tubes failed in a pattern and manner as shown in this report as apparent pattern of failure. The failure caused ash and steam/hot water, at a temperature of approximately 600F, to be released toward the immediate area where the three employees were standing. Based on witness accounts, the three (3) employees were able to leave the area of the failure on their own, however, they all suffered extensive burn injuries. All 3 died within 24 hours of the explosion. Autopsies on Matthew Indeglia, Mark Mansfield, and Phil Robinson were performed by Dr. John Parker of the Office of the Chief Medical Examiner. Dr. Parker determined that all three victims drowned in their own secretions as a result of damage to the bronchi, trachea and lungs. Dr. Parker also determined that each victim suffered significant burns. As a result of the boiler failure, the boiler was immediately shut down and the facility managers began the process of shutting down the remaining 3 boilers. Due to the massive release of asbestos caused by the failure, the area was sealed off in accordance with the Division of Occupational Safety requirements. On November 19, 2007, the Department revoked the certificate of inspection for boilers #1 through #4 in accordance with Massachusetts General Law Chapter 146. (See appendix 5)

Point of failure

Dead Air Space (full of ash) Primary direction of casing failure Location of victims Location of seal air fans

Graphic representation of failure area

BACKGROUND INFORMATION
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Based on information gathered in the investigation, Dominion Energy New England Salem Harbor (DENE) is located at 24 Fort Avenue, Salem, Massachusetts. The facility is a 680 megawatt coal / oil fired power generating facility. The facility has 4 high pressure boilers, 3 of which can burn coal or oil and a 4th boiler which burns oil. Each boiler supplies steam to 4 individual steam turbines. Boilers #1 and #2 are Babcock and Wilcox water tube steam boilers capable of producing 625,000 pounds of steam per hour. These boilers provide steam to a General Electric and a Westinghouse turbine generating a total of 120 megawatts. Boiler #4 is a Riley Stoker water tube steam boiler which burns oil or natural gas, capable of producing 3,250,000 pounds of steam per hour. This boiler provides steam to a General Electric turbine generating a total of 436 megawatts. Boiler #3, where the failure occurred, is a 1957 Babcock & Wilcox (B & W) water tube steam boiler, capable of producing 1,000,060 pounds of steam per hour. This boiler provides steam to a General Electric turbine generating a total of 125 megawatts. Boiler #3 was manufactured for the New England Power Company, and was placed into service on June 8, 1958. The boiler has been operating on a continuous basis since that time, being brought off line only for required inspections, maintenance and repair. Based on information obtained from previous inspection reports, as of November 2007, the boiler had been in service for an estimated 433,000 hours with approximately 364,000 hours in actual operation.

Salem Harbor Generating Capacity

Boiler #3 was designed and erected by the Babcock & Wilcox Company in accordance with the
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requirements of Section I of the American Society of Mechanical Engineers (A.S.M.E.) Boiler and Pressure Vessel Code as well as Massachusetts Regulation 522 CMR at the time of construction. (See appendix 2 Manufacturers Data Report) Based on statements from plant managers and supervisors, the facility was purchased by Pacific Gas and Electric Corporation (PG & E) from New England Power Company. In 2005, Dominion Resources Inc. Virginia purchased the facility and it is now under the control of DENE. The boiler is a natural circulation watertube boiler designed with a divided furnace, an economizer, a reheater and a radiant and convection superheater. The boiler was designed to fire coal but had an approximate ten (10) year period of firing oil in the 1970s until it returned to coal firing in the 1980s. It is equipped with 4 pulverizers that feed 4 fuel elevations that are located on the furnace front wall. Each elevation contains 4 burners. The boiler is rated at 1,000,060 pounds per hour steam flow with a maximum allowable working pressure of 2,275 PSI. Based on witness accounts from Salem Harbor operations personnel interviewed, the boiler has seen increased boiler cycling from minimum load to full load since the mid 1990s. Several witnesses stated that the boiler outages were reduced from 6 week outages down to 2 - 4 week outages. Witness accounts indicated that this made it difficult for the plant to take care of all the outstanding maintenance items and the plant went from a preventive maintenance mentality to putting out fires. Plant personnel indicated that they believed that deregulation reduced the parts inventory, which also had a negative impact on plant maintenance. A review of DENEs outstanding work orders demonstrated a large backlog of approximately 2,500 work orders on plant equipment.

BOILER #3 OVERVIEW
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Boiler #3 was constructed in 1957 by the Babcock and Wilcox Company. The boiler is considered a high pressure (operating at 2,000 PSI) water tube boiler, which utilizes coal as the primary source of fuel. The boiler is approximately 130 feet high, and hangs from the top of the building structure and expands down. The boiler is equipped with an economizer, which is a bank of tubes located in the boiler flue gas path designed to increase the boiler feedwater temperature before it enters the boiler. It also has a primary and secondary superheater that takes saturated steam from the steam drum, located at the top of the boiler, in order to supply high quality dry steam to the steam turbine. The boiler also has a reheat superheater, which takes steam from a stage in the steam turbine and reheats it. It is then returned back to the turbine. The boiler has 4 waterwalls (tubes that are lined up to cover each of the 4 furnace walls). The boiler has 4 coal burner levels, each of which contain 4 burners (16 burners total). The boiler is equipped with 4 coal pulverizers. Each pulverizer supplies coal to 4 burners. Each burner mixes air with the coal, which is ignited as it exits the burner. The products of combustion heat the water in the waterwalls and then flow through the secondary superheater, reheat superheater, primary superheater and finally past the economizer and out through components that reduce plant air emissions. The steam produced in the boiler supplies steam to a steam turbine that drives a generator, which generates electricity. After the steam has passed throught the turbine, the steam is condensed. The condensate is heated and pumped back into the boiler in one large steam/water loop. The boiler water is treated with chemicals to prevent component corrosion and to ensure that a high quality steam is produced. The boiler runs under a balanced draft (the furnace pressure in the boiler is slightly negative). In order to maintain a balanced draft, the boiler is equipped with a forced draft fan that supplies air to the boiler, and an induced draft fan, which is located between the boiler and the stack. Fan dampers are used to maintain proper draft. Because excess air results in improper combustion, tramp air (uncontrolled air entering the boiler from unintended locations) is minimized by a wet ash system. The waterwalls bend toward the bottom of the boiler to form a slope that directs the ash to a water filled hopper. The configuration of the waterwalls create a space within the boiler where there is no combustion. If properly maintained, the waterwalls are designed to minimize the amount of ash that accumulates in this space. This space is commonly referred to as a dead air space. If the spaces between the tubes are not tight or filled with a refractory material, boiler ash can fill the void space. DENE, like most plants, use water to wash boilers down before an internal inspection. The dead air space is a location where water from water washing can enter and combine with the ash. This combination can become corrosive to metal if not cleaned or maintained periodically. The following page gives a pictoral overview of this boiler.

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East Side

Sketch #1 Boiler #3 Overview

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INCIDENT INVESTIGATION On November 6, 2007 at 0846 hours, a catastrophic boiler failure occurred at the Salem Harbor Generating Station located at 24 Fort Avenue, Salem, Massachusetts. Within two hours, Massachusetts Emergency Management Agency Director Don Boyce notified the Department of a boiler explosion at the above location. A preliminary investigation was immediately started by Chief of Inspections-Mechanical Mark Mooney (Mooney) and assisted by Manager Edward S. Kawa (Kawa) and District Engineering Inspector Steve Bakas. The victims of the incident, Mr. Mathew Indeglia, Mr. Mark Mansfield, and Mr. Philip Robinson were given medical treatment on the scene and transported to local hospitals where they died from their injuries. The scene was secured by the Salem Police Department, and the State Police in conjunction with the Essex County District Attorneys Office (District Attorneys Office), OSHA and the Department of Public Safety. The failure occurred in an area of the boiler that was insulated with asbestos. The failure dispersed the asbestos insulation and a large volume of ash throughout the boiler building. As a result, access to the failure location required specialized training and equipment. To assist in gaining immediate access to the point of failure, the State Fire Marshal, in cooperation with the Salem Fire Department, activated the hazardous material response unit in support of the Department of Public Safetys (DPS) investigation. The Massachusetts Division of Occupational Safety began working with the DENE Salem Harbor personnel to develop an asbestos abatement plan. An initial observation of the failure was performed by Mooney and Kawa. It was determined that there were two short lengths of tube (tube stubs) missing from the ends of Tube #10 and Tube #11. These stubs were short sections of tube that were fitted into the lower division wall header and attached to the division wall tubes by a full penetration butt weld. These tube stubs separated from the tube and header adjacent to circumferential welds. The search of the missing tube stubs began shortly thereafter by the DPS in conjunction with the District Attorneys office, OSHA, and DENE. After an exhaustive search, the tube stub to tube #10 was located, buried in ash, in the approximate area where the victims tool box was situated under the boiler. The tube stub to tube #11 has not been located as of the date of this report. Following the initial inspection of the failed components, a large section of the header and the failed tube components were sent to a metallurgical lab (Structural Integrity Associates, Inc) for testing in Austin, Texas, under the oversight of the DPS. DENE produced volumes of documents requested by the DPS, OSHA and the District Attorneys office. Thirty nine individuals were brought in for questioning over the following months. (See Interview List in appendix). Based on the interviews and documentation obtained in the investigation, it was determined that at approximately 08:00 a.m., two maintenance mechanics (Mark Mansfield and Dan Connolly) were working to lock out pulverizer seal air fan #3-1. They determined that this seal air fan could not be isolated for repair until a common discharge valve on seal air fan #3-2 was repaired. Mr. Mansfield went to the control room to get the proper lockout tags for seal air fan #3-2, while Mr. Connolly made a visit to the restroom. Two operators (Mathew Indeglia and Philip Robinson) then went down with Mr. Mansfield to lock out Seal Air Fan #3-2. As Mr. Connolly was leaving the restroom, the plant alarm sounded indicating a boiler failure. As the failure occurred, Mr. Mansfield, Mr. Indeglia and Mr. Robinson were in the area immediately below it. These men were able to exit the building, but had suffered serious and ultimately fatal burns from the failure.
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Witness accounts gave no indication of any noticeable audible changes that could have warned adjacent operators or maintenance people in the area of a tube leak. It was determined, by both the discharge of the ash on the floor around the failure and the amount of ash buildup in the dead air space opposite the area where the failure occurred, that ash was packed in the space where the failure occurred. Further, several witnesses stated that it was common knowledge that the area was packed with ash. Ash can have a muffling effect on an adjacent tube leak, which are typically very loud. In addition, the area of the failure also had high operating noises caused by the coal pulverizers, which may have also affected the victims ability to hear the leak. Witness accounts and boiler operation trends show that Boiler #3 was routinely operated at a capacity above the rated steam flow for the boiler. Operating boilers above rated capacity can have a negative effect on the life of the boiler. As part of the investigation, corrosion was considered as a possible cause. Based on witness testimony, it was the common practice to water wash the waterwalls when the unit was taken off line. The water would cascade to the lower section of the boiler including the lower dead air spaces. Water and ash are known to create a highly corrosive environment for boiler components. The boiler also has an injection system that sprays a liquid chemical, Urea, into the furnace in an effort to reduce nitrous oxide emissions. Urea can mix with sulfur oxides to form ammonium bisulfates or ammonium sulfate compounds, which, based on my training and experience, is known to enhance corrosion and plugging in boiler air heaters. Based on several witness accounts from the Salem Harbor operations personnel interviewed, it was common for the urea injection ports to overspray following a boiler trip. It was noted however that the substance was not present at the time of the first observation of the failed components several days following the failure. Further, when the west side dead air space was opened, these tubes did not have any obvious signs of urea contamination. It was determined that the ash acted as an insulator from any excessive urea slip (urea overspray). Combined with the large volume of ash that was in the dead air space, and the time it takes for the Urea to leak down to the dead air space if not restricted by ash, the presence of the Urea was discounted as a significant factor in the failure. Mooney and Kawa determined that the corrosion of the tubes and header within the dead air space was caused primarily from the interaction of the boiler metal with the ash and water (from boiler washing). As the investigation proceeded, Mooney made a determination that all 4 boilers at the Salem Harbor Station were in a dangerous condition. Upon this determination, on November 19, 2007, Mooney revoked the certificate of inspections from all 4 boilers at the plant. Massachusetts General Law Chapter 146 requires that a state inspection and pressure test must be performed on each boiler before a new certificate of inspection is issued. (See appendix 5). Since the shutdown, all the Boilers have undergone substantial non-destructive examination and/or repairs. They have been inspected by the DPS and have been issued new certificates of inspection. Boilers #1 and #2 were placed back into operation in May 2008 and Boiler #3 and #4 were placed back into service in July 2008.

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BOILER #3 INSPECTIONS Massachusetts General Law Chapter 146 section 6 states that all steam boilers and their appurtenances shall be thoroughly inspected externally and internally at least once a year. In 2000, Massachusetts Board of Boiler Rules adopted the 1998 National Board Inspection Code (NBIC) with 1999 addenda, and incorporated them into 522 CMR. Massachusetts commissioned Insurance Inspectors are required to perform their inspections in accordance with the NBIC. The NBIC is the standard that Massachusetts licensed engineers are required to use to ensure their boilers are being maintained, repaired and inspected properly. As demonstrated further in this report, the boiler was not properly inspected in accordance with the NBIC code, nor was it inspected in accordance with the Manufacturers manual. Following a first inspection by a State District Engineering Inspector, the annual inspection is performed by an inspector of an insurance company. The responsibility of the insurance inspector is to make a proper internal and external inspection of the boiler, in accordance with Massachusetts regulations and the NBIC. If no discrepancies or unsafe conditions are found, the inspector shall issue a certificate of inspection. In April 2007, Boiler #3 was brought down for annual inspection and maintenance. On April 10, 2007, Insurance Inspector Robert Maule (Maule), of National Union Fire Insurance Company, signed a certificate of inspection that he had performed the required inspection on Boiler #3 (See appendix 3). However, the lower dead air spaces containing the division wall headers were not opened for inspection at that time, and Maules report made no reference to the condition of the furnace lower slope dead air space. (See appendix 11) Based on statements made by Maule to Mooney and Kawa, on July 17, 2008, Maule stated that he did not inspect the dead air spaces on Boiler #3. He further stated that he did not inspect these spaces based on the fact that his personal past experiences never indicated these areas to be problem areas. He also stated that he looked in all boiler spaces early in his career but stopped this practice as his experience increased. Maule stated that since the failure, he has resumed inspecting all boiler spaces. In April 2007, DENE also hired a second inspector (Dennis Nygaard of Alstom Power) to perform a private non-jurisdictional inspection as well. Mr. Nygaard indicated in his report that no inspection was completed to the furnace lower slope dead air space this outage since it was not opened. (See appendix 4) All evidence demonstrates that the furnace lower slope dead air space had not been opened. During the entire interview process, no one could recall ever seeing, or having had seen evidence, that the furnace lower slope dead air spaces were opened. Engineer-in-charge Steve Dulong (Dulong) reported seeing documents that demonstrated that work had been performed in the furnace lower slope dead air space in approximately 1999, but did not actually recall seeing it open or anyone entering the space. He stated that the space had not been opened since he was the Engineer-in-charge. Another witness stated that he recalled seeing a report indicating that it had been opened in 1998, When questioned regarding the failure to inspect the lower dead air spaces, Dulong stated that the space was not opened because Maule did not request the space to be opened.
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Based on (1) the volume of ash that emptied into the area below the failure, (2) the volume of ash in the west side dead air space, (3) the level of corrosion on the tubes and header in the lower dead air space, and (4) the number of witnesses that confirmed the existence of ash in the lower dead air space, we determined that the lower dead air space was full of ash prior to the failure. To determine the volume of ash that was in the east dead air space in relation to the space, the DPS gained access to the dead air space opposite the space the failure occurred in. This space was virtually a mirror image of the area in which the failure occurred and was under the same operating conditions. This space (west side dead air space) could not be entered because of the heavily packed ash filling the space and blocking the entrance. The DPS ordered a channel in the ash, within the west side dead air space, be dug to gain a better view the current conditions of the space. The ash in the space was a mixture of fine ash and hardened solid rocklike form. The solid ash was broken up with poke rods and shovels and vacuumed out of the space. Mooney observed the space to be nearly full of ash, with the west side division wall header (directly opposite the one that was involved with the failure) completely encased in ash. The header and tubes on the west side had similar corrosion to that found on the east side. (See photos 42 53). Compliance of other Boilers in the Commonwealth In response to the Salem boiler explosion, the DPS identified thirty-three (33) other boilers at 16 locations across the Commonwealth that burned solid fuel with the potential of having dead air spaces where ash could build up and create a problem if not periodically inspected. On Monday, March 24, 2008, the State District Engineering Inspectors were briefed on a compliance action, which occurred following the briefing. The purpose of this compliance action was to identify all coal or solid fuel fired boilers in the Commonwealth and to determine if they had a current certificate of inspection, as well as determining if all of the spaces within the boiler that are accessible to an inspector had been opened at the time of inspection. All of the facilities were visited by the end of the day. Only one facility could not immediately provide proper documentation, however it was able to produce the requested information the following day. In all of the facilities, all of the confined spaces, including all dead air spaces, in all 33 boilers were opened and accessed within the past year. Of these boilers, twenty (20) of the 33 had dead air spaces. Based on this assessment, it was determined that all of the boilers listed that had spaces known to fill with ash had those spaces inspected within the past year. January 2007 Leak In January 2007, following a repair of a waterwall leak in Boiler #3, an additional leak was identified below the waterwall slope in the dead air space, as it enters the east side furnace lower slope dead air space. Based on witness accounts of maintenance personnel and the plant Quality Control Person Ken Brusgalis (Brusgalis), the plant cut tubes out of the waterwall to access the leak from the furnace side, due to the excessive ash buildup inside the furnace lower slope dead air space, which hindered access. According to Brusgalis, the cause of this leak was determined to be corrosion fatigue at a weld between the division wall and a membrane between the division wall and the waterwall slope. Brusgalis indicated that the plant did not look further to determine if the
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problem was an isolated problem or if the same condition existed at other locations. Dulong stated that he relied on others including Brusgalis to determine if further examination was necessary. Decisions such as this are the sole responsibility of the Engineer-in-charge. Several witnesses including Dulong, stated that control room operators were trained by coworkers and did not go through a training program that would specifically educate them with the knowledge to be able to identify tube leaks, or which trends should be watched for possible indications of potential tube leaks. Dulong also stated that operators are not formally trained and that their training is passed down from one guy to the next. BOILER MANUFACTURER / EPRI BULLETINS Startup / Shutdown Procedures The Manufacturer (B & W) produced an operation and maintenance manual (Manual) for Boiler #3, which is common industry practice. This document provides directions on how to properly operate and maintain the boiler. Additionally, the Electric Power Research Institute (EPRI) conducts research and development on technology, operations and the environment for the global electric power sector, and provides helpful guides and bulletins to the power industry. The Manual provides direction regarding shutdown procedures to ensure that the boiler is not cooled too quickly, which can create unnecessary and excessive thermal stresses on boiler components. Page 15 of the B & W Boiler manual, (See appendix 27) states, [a]fter the firing equipment and fans are out of service, the dampers, including the superheater and superheater bypass dampers, when provided, should be closed in order to permit the unit to cool as slowly and uniformly as possible. It also goes on to state that hastening the cooling of the furnace by allowing large quantities of cool air to pass through the setting tends towards brickwork difficulties and unnecessary stresses in the pressure parts. Further, in quick shutdowns, the Manual cautions operators to not permit the drum temperature difference to exceed the cooling cycle curve. (See appendix 29). The cooling cycle curve is shown in appendix 30. The Manual directs operators, on page 9, (See appendix 30) under emergency shutdown to stop the primary air fan and close the primary air control damper and stop the force draft fan and close the force draft dampers as well as stop the induced draft fan and close the induced draft damper. Based on witness statements, during boiler failures and shutdowns, plant control room operators admitted to cooling down the boilers without following manufacturer procedures and did not take measures to ensure the boilers were not cooled too quickly. Control room operators operating the boiler stated that it was common for them to leave fans on to hasten cooling in order to begin repairs sooner. Rapid temperature changes in boiler components create unnecessary and excessive thermal stresses on boiler components. Inspections The Manual also provides instructions for operators for routine inspections. On Page 17 of the Manual, (See appendix 31) it states [i]n addition to routine operating inspections, a thorough inspection, from the viewpoint of safety, should be made yearly at the time of the visit of the Insurance Inspector or State Inspector. This should include a careful search for evidence of internal and external corrosion, leakage of seams, leakage of expanded, screwed or welded joints, evidence
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of overheating, and the condition of structural supports. It goes on to state [i]t may be necessary to remove small sections of brickwork or casing to make such inspection complete, but it should be borne in mind that the parts which are most slighted, due to soot accumulation or difficulty of access, may be the very parts in which trouble will develop. The lower dead air space in which the failure occurred had excessive soot accumulation as well as being a difficult place to access. Neither Maule or Dulong ever opened or inspected this area. The NBIC also requires that these areas be periodically cleaned and inspected. In accordance with the NBIC, part RB-9050, the maximum period between internal inspections or a complete inservice evaluation of pressure retaining items shall not exceed one-half of the estimated remaining service life of the vessel or ten years, wherever is less. The method for estimating inspection intervals for exposure to corrosion is given in Part RB-9110 of the NBIC and is determined by the following formula:

Remaining life = t(actual) t(required) (years) corrosion rate

DENE did not provide any documentation regarding any corrosion rates for any of the pressure parts, and did not have any documentation of this form for any of the components within the dead air spaces. Because this evaluation was not performed, the maximum period between internal inspections or complete in-service evaluations and remaining life could not have been properly determined. EPRI Bulletins In the 1980s, the industry developed guidelines for extending the boiler life (boiler life extension programs), including monitoring areas susceptible to failure for a variety of reasons such as corrosion, erosion or boiler stresses. In May 2000, B & W issued the Standard Recommendations for Pressure Part Inspection During a Boiler Life Extension Program (BR-1701). It stated that lower temperature water and steam cooled headers are not susceptible to creep but may be damaged by corrosion, erosion, or severe thermal stresses. (See appendix 32) On page 5 of this document, it states that typical inspections of these headers consist of: Visual Inspection Wet Fluorescent Magnetic Particle a WFMT inspection should be performed on welded attachments, handhold plugs, header end plate welds and 10% of tube to header welds. Video Probe Inspection An internal visual inspection can be performed to locate internal problems. UTT Should visual inspection reveal areas of wall loss from either corrosion or erosion, then ultrasonic thickness data may be taken to assess header thickness. DENE did not provide any documentation on these lower headers that would demonstrate that any of these methods were used. During the interview process, Dulong indicated that he did not know about any life extension studies for Boiler #3.

BOILER TREND DOCUMENTATION

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Based on my training and experience, when a boiler has a tube leak, it is common for certain operational trends to react in a particular manner. As more water is added to a boiler to compensate for the water lost through a leak, the amount of chemical concentration in a boiler will decrease unless action is taken to increase the chemical feed. The boiler makeup water volume increases, which can be seen in makeup trends. As a leak becomes more apparent, the rapid flashing of hot water to steam within the fireside area or section occupies a greater volume, therefore boiler induced draft fan dampers will open up in order to maintain the set furnace pressure. These automatic changes result in increased minor fluctuations in furnace pressure. As a leak progressively worsens, typically the boiler furnace pressure will become less stable. Based on boiler trend information reviewed by the DPS, it was determined that the boiler failure began to cause some changes in trends approximately 3 weeks before the failure and became more apparent and progressively worsened to an irreversible condition approximately 45 minutes before the failure (See appendices 22, 23, 24, 25). Although the leak was in a dead air space, there were sufficient gaps between the boiler waterwall and the dead air space for the leak to begin to show these typical fluctuations. As seen in appendix 23, the trends showed a slight decrease in boiler sodium and boiler pH, as well as a progressive increase in boiler water (hotwell) makeup and a change in the furnace pressure amplitude and frequency. This is a typical pattern leading to a failure. As previously explained, when a leak worsens, an automatic control valve (boiler hotwell makeup control valve) begins to open to allow new water into the boiler to compensate for water lost in the system. Boiler water can be lost though the normal operation of a boiler (such as through boiler blowdowns), but these normal conditions require operator knowledge and intervention. In viewing the boiler hotwell makeup control valve trend for the month prior to the failure, the trend showed an obvious change in frequency and volume beginning around October 20, 2007 and worsened in time. (See appendix 23) Five days before the failure, the medium feedwater flow trend demonstrated a clear change in amplitude and frequency. (See appendix 25) As steam is introduced into the furnace space, it creates volumetric changes that have an effect on plant emissions. As a steam leak worsens, it can have an effect on boiler carbon monoxide (CO) and boiler opacity (visible smoke) emissions. A review of the Boiler #3 opacity also showed an increase in opacity in the six (6) hours prior to the failure. There were seven (7) low level spikes in opacity within the 8 hours prior to the failure. (See appendix 25) The boiler carbon monoxide emissions trends did not demonstrate anything that could have been singled out as a clear indicator, however the unexplained loss in boiler water should have been investigated. None of these trends were noticed by the plant personnel including Dulong. METALLURGICAL FAILURE ANALYSIS On December 7, 2007, Manager Edward Kawa escorted the failed components to the metallurgical test lab (Structural Integrity Associates) in Austin, Texas. The metallurgical testing occurred through the months of January and February 2008. In Structural Integrity Associates failure analysis of the boiler components from the lower dead air space, it was noted in the executive summary, that there was no evidence uncovered during the examination of the header and tubing to indicate that either excessive wall thinning due to external corrosion, or waterside corrosion fatigue cracking, or base metal defects had played any role in the failure (See appendix 6). However, in the technical summary, it explained that a hypothesis of the suspected cause of failure was one that the division
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wall nipple tubes had ruptured after losing a substantial amount of its original wall thickness due to external corrosion, and that the defect grew in size, due to the interaction of corrosion and stress with intermittent discontinuities in the remaining intact ligament of weld metal, until it finally penetrated through the thickness of the weld and a small steam leak initiated. (See appendix 7). In the Visual Inspection I portion of the report, under external surfaces corrosion, it states it was apparent that both the header and tubes had suffered some measurable amount of wastage due to the external corrosion, with signs of widespread pitting attach visible on all surfaces. (See appendix 8). In the Visual Inspection II portion of the report, under results of EDS and XRD Analysis, it states in all cases the deposit/scale accumulations were a mixture of elements associated with combustion by-products, such as sulfur, silicon, sodium, potassium, calcium, and iron oxides. The large amounts of sulfur and iron oxide are consistent with the observations regarding the surface corrosion, which was believed to have been caused by acid attack related to the wetting of reactive elements in the deposit, and particularly sulfur, during periods when the unit was not operating. (See appendix 9). Also in the Visual Inspection II of this report, it describes white-colored compound observed on Tube 5 identified as Urea. Witness accounts from the plant following the failure indicated that the injection of the urea had continued for some time after the unit had tripped off line, so that the presence of the urea in the deposit material appeared to be a secondary effect of the failure and was not considered in any way unusual. This is consistent with the DPSs findings. Based on the full context of the metallurgical report, external corrosion accelerated the failure. Based on boiler trend data and the physical damage of the components around the area of failure, it was evident that the boiler began to leak and progressively worsened over time until a catastrophic event occurred. Boiler leaks at this pressure create a significant and discernable sound. Since no witnesses heard any such sound, it is believed that the volume of packed ash within the space significantly muffled the sound of the leak making it indiscernible even when people were immediately adjacent to the leak. The high decibels of the coal pulverizers also aided in masking the muffled sound of the leak. As confirmed in the metallurgical failure analysis, the failure began as a result of a weld defect at Tube 9, which grew in size due to corrosion and stress. The tube was also subjected to external corrosion, which decreased the thickness of the tubes. As a result of these mechanisms, a small leak initiated. The leak progressively worsened over time cutting adjacent tubes, which caused secondary leaks. The progressive thinning resulted in tube 10 and tube 11 catastrophically rupturing. The rapid release of 600 degree hot water at 1900 PSI into atmospheric pressure within the dead air space caused the water to flash to steam resulting in the rapid pressurization of the dead air space. The rapid pressurization of the dead air space caused the lower boiler casing within the dead air space to fail, releasing the full force of the failure to the area immediately below the boiler, where the victims were working.

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APPARENT PATTERN OF FAILURE The following sketches present a graphic representation of the apparent series of events that explain the damage to the tubes involved in and leading up to the catastrophic failure. It is the opinion of the DPS that the initial leak began at a significant welding flaw and was exacerbated by stress and external corrosion. That leak caused a series of collateral damage to adjacent tubes, until the final catastrophic failure. 1. Tube 9 begins to leak as a result of a significant welding flaw at the time of manufacture, and external corrosion a. Leak strikes Tube 10 and 11 causing collateral damage
Tube

11

Leak 1

Tube

2. Initial leak in Tube 9 continues to damage Tube 10 and 11 a. Tube 11 begins to leak and starts to damage Tube 9

Leak also damaging tube 10 (not shown between tube 9 & 11)
Tube

11

Leak 2

Tube

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3. All leaks continue to progress. a. Leak from Tube 11 results in a new leak in Tube 9, continues to damage Tube 10
Tube

11 Leak 3

Tube

4. All leaks continue to progress and worsen a. New leaks from collateral impingement damage develop

Tube

11

Leak also damaging tube 10

Tube

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5. All leaks continue to progressively worsen over time a. Tube 10 is thinned along one plane far below minimum wall thickness b. Tube 11 is also thinned considerably below minimum wall thickness c. Tube 10 fails catastrophically forcing steam/hot water in the direction of Tube 11 d. The lateral force applied by the failure of Tube 10 toward the weakened Tube 11 causes Tube 11 to separate from the header.

Tube

11

Tube 10 spraying tube 11

Tube

Tube 9 lower leak caused by tube 11

6.

View of tube arrangement on header looking down. a. As stated in (5) above, the lateral force applied by the failure of Tube 10 toward Tube 11 caused the already weakened Tube 11 to separate from the header.

Areas of thinning 2. Tube 11 stub separates from header as a result of thinning and force of tube 10 rupture.

Tube

Tube

11

Header

Tube

10

1. Tube 10 fails catastrophically. Tube stub separates from header. Force of failure directed at tube 11

NATIONAL BOARD INSPECTION CODE

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Part RB-2020 of the NBIC describes what owners or users should do to prepare a boiler for an internal inspection. Paragraph 3 of this section (See appendix 12) states [m]anhole and handhole plates, wash out plugs, as well as inspection plugs in water column connections shall be removed as required by the inspector. The boiler shall be cooled and thoroughly cleaned. Part RB-3120 (b) (See appendix 13) lists parts that should be removed as required to permit inspection. This section repeats that manhole and handhole plates are components that should be opened. It also repeats in (c) that the boiler shall be cooled and thoroughly cleaned. The manhole plate to access the dead air space was not opened and therefore the space was not cleaned. Part RB-2030 of the NBIC (See appendix 14) states that [i]f a vessel has not been properly prepared for an internal inspection, the inspector shall decline to make the inspection. Despite of the lower dead air space not being opened or cleaned out, Maule failed to decline to make the inspection and issued a certificate of inspection. Part RB-3133 of the NBIC (See appendix 13) describes types of defects. It states [d]efects may include bulged or blistered plates, cracks or other defects in welds or heat-affected zones, pinhole leaks, improper or adequate safety devices, wasted or eroded material. (Emphasis added) An inspection of the lower dead air space, in accordance with the code, would have revealed wasted material as a result of corrosive effect of the ash. Part RB-3158 of the NBIC (See appendix 15) is part of the in-service inspection section of the code. This particular section is dedicated to corrosion. Paragraph J states [t]he surfaces of tubes should be carefully examined to detect corrosion, erosion, bulges, cracks, or evidence of defective welds A leak from a tube frequently causes serious corrosion or erosion on adjacent tubes. Paragraph K of this section (See appendix 16) also states [i]n restricted fireside spaces such as where short tubes or nipples are used to join drums or headers, there is a tendency for fuel and ash to lodge at junction points. Such deposits are likely to cause corrosion if moisture is present and the area should be thoroughly cleaned and examined. Maules and Dulongs failure to inspect or have the tubes inspected violated these sections of the code. Finally, Part RB-3280 of the NBIC (See appendix 17) states the following: [a]ny defect or deficiency in the condition, operating and maintenance practices of the pressure vessel should be discussed with the owner or user at the time of inspection and, if necessary, recommendations made for the correction of such defect or deficiency. Based on the above, it is apparent that the active corrosion in the lower dead air space was something that should not have been overlooked and at a minimum should have required periodic monitoring. Massachusetts commissioned boiler inspectors, such as Maule, must also hold a National Board Commission. The National Board requires commissioned inspectors to receive continuing education courses each year to ensure they are familiar with the current NBIC. The NBIC code has the following applicable changes since the 1999 version: Part RB-1010 [u]nderstanding the potential damage/deterioration mechanisms that can affect the mechanical integrity of a pressure retaining item and knowledge of the inspection methods that can be used to find these damage mechanisms are essential to an effective inspection. (See appendix 19)

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Part RB-2000: Visual examination is the basic method used when conducting an in-service inspection of pressure retaining items. Additional examination and test methods may be required at the discretion of the inspector to provide additional information to assess the condition of the pressure retaining item. (See appendix 19) Part RB-5525: The refractory supports and settings should be carefully examined, especially at points where the boiler structure comes near the setting walls or floor, to ensure that deposits of ash or soot will not bind the boiler and produce excessive strains on the structure due to the restriction of movement of the parts under operating conditions. (See appendix 20) Part RB 5525: Drums and headers should be inspected internally and externally for signs of leakage, corrosion, overheating, and erosion. Part RB 5601: There are many locations both internal and external where moisture and oxygen combine causing primary concern for corrosion Unique parts associated with this type of construction such as casing, expansion supports, superheater, economizer, soot blowers, drums, headers, and tubes should be inspected carefully and thoroughly. (See appendix 21)

Despite these specific references in the NBIC, Maule failed to enter the dead air space and inspect the components contained within it. Further, RC-2030 of the NBIC states that Repairs to pressure retaining items shall not be initiated without the authorization of the Inspector, who shall determine that the repair methods are acceptable. Based on statements by both Dulong and Brusgalis it was determined that the plant did not always receive proper authorization in accordance with this section.

CONCLUSIONS Based on the investigation, the DPS has concluded that the following are the primary causes of the
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failure: 1. Division wall tube #9 was identified with a significant through wall weld defect at the tube to stub weld. Internal corrosion or corrosion fatigue propagated the defect to a leak. Although tube stub #11 has yet to be found, it is evident that tube #11, as well as tube #10 sustained substantial collateral damage from steam/water impingement. The collateral damage to tube #10 resulted in a catastrophic failure of tube #10. The force of the failure of tube #10 and the thinned condition of tube #11 (from steam/water impingement) caused the stub of tube #11 to separate from the tube and header. The failure allowed high pressure steam and water to pressurize the dead air space until the boiler casing in that area failed. This sent steam, water and ash, at approximately 600F, into the immediate area below the boiler. 2. Although the point of initial leak washed the metal away at the leak, as stated in the metallurgical report, the entire header and tubes suffered from external corrosion. It was determined that the external corrosion decreased the tube thickness. This reduction, combined with the weld defect, caused the tube to be in a condition that resulted in the failure. Annual inspection of this space would have significantly abated the degree of corrosion in the space and observation of the current level of corrosion should have prompted further examination. Based on this investigation, the DPS has identified the following contributing factors: 1. A Failure to inspect and maintain the Dead Air Spaces. Massachusetts regulation 522 CMR 2.02 places the responsibility of the operation and maintenance of steam boilers under the Engineer-in-charge. Not a single witness, including the Engineer-in-charge Dulong, could indicate when the dead air space had been opened for inspection or maintenance since at least 1998 or 1999. The National Board Inspection Code specifically highlights areas of concern that must be inspected, including tubes and headers that may be exposed to, or covered with ash. Proper maintenance and inspection of this area would have minimized the potential for external corrosion. 2. Failure of the Insurance Inspector to Inspect the Dead Air Space Annually. Massachusetts General Law Chapter 146 section 25 requires steam boilers to be inspected in accordance with the rules of the Board of Boiler Rules. Massachusetts regulations 522 CMR 15.00 adopts the National Board Inspection Code. The boiler was not inspected in accordance with the National Board Inspection Code which requires Drums and headers should be inspected internally and externally for signs of leakage, corrosion, overheating, and erosion. (Part RB 5525). 3. Improper Delegation of Responsibilities to Unlicensed Personnel. During the interview process it was clear that the Engineer-in-charge improperly delegated his responsibilities to unlicensed individuals. This overall delegation of Dulongs responsibilities as the Engineer-in-charge to others resulted in a systematic breakdown in which no one assumed responsibility for ensuring compliance with statutory and regulatory requirements. Such improper delegation included: a. Reliance on unlicensed individuals to oversee boiler repairs and allowing these unlicensed persons to make decisions regarding the extent of the repairs and the
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non-destructive testing. Dulong relied on the Quality Control person (Brusgalis) and others to evaluate other areas in the boiler to determine if the potential for additional problems existed. Brusgalis, however, stated that these decisions were in fact made by the mechanical maintenance group. Further, Dulong stated that he relies on others to ensure repairs are performed in accordance with the Code. These responsibilities rest with the Engineer-in-charge who is presumed to have the requisite knowledge and experience to make such determinations. Following the January 2007 tube repair, Dulong failed to properly investigate whether any further action was necessary or was appropriate. Had the space been opened and properly maintained, the extensive corrosion would have been noticed and a properly licensed person should have determined that further testing was appropriate. b. Reliance on others to ensure that Authorized Inspectors were contacted before boiler repairs were initiated in accordance with the NBIC. During the interview process, Brusgalis admitted that repairs to the boilers were initiated and/or completed prior to contacting the Authorized Inspector and Dulong did not appear to understand that the Code required an Authorized Inspector to be contacted prior to making repairs. Further both Dulong and Brusgalis stated that the plant, and not the Authorized Inspector, determined whether a hydrostatic test should be performed following a repair, in violation of the NBIC. c. Reliance on others to ensure that the boiler was pressure tested per the direction of the Authorized Inspector following a repair. The procedures followed by the plant in performing boiler repairs failed to comply with the National Board Inspection Code and the plant failed to properly pressure test Boiler #3 following the last boiler repair in September 2007. 4. Failure to Implement The Boiler Condition Assessment and Life Extension Program. It is the responsibility of the Engineer-in-charge to have knowledge of, or perform boiler condition assessment and life extension studies, when recommended by the boiler manufacturer or industry standards. Although plant personnel believed a life extension program had been done on the plant in the 1980s, it was evident from interviews that the plant personnel did not know exactly what that plan required, and Dulong was not even aware if one existed. As stated earlier, Babcock & Wilcox issued a document Standard Recommendations for Pressure Part Inspection During a Boiler Life Extension Program in May 2000. Since the space had not been opened since the issuance of this document from the manufacturer, it is clear that the facility failed to follow these recommendations. 5. Improper Recognition of Existing Plant Hazards. Despite repeated common boiler failures, the plant personnel had an unacceptable tolerance of boiler tube failures and did not have a policy in place to examine other areas of potential concern for similar failures at the time of a failure. Additionally, the plant did not have a policy or procedure in place to educate or warn employees of failure mechanisms or how to identify them. 6. Improper Boiler Maintenance Practices. It has been the plants routine practices for personnel to water wash the boiler furnace during a plant outage. This water was allowed to enter the lower dead air spaces, which was full of ash, causing corrosion. There was no effort taken to routinely remove this corrosive ash mixture from those spaces.
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7. Improper Plant Personnel Operating Practice It was a common plant practice to accelerate boiler cooling following a boiler failure by fan cooling the boiler, resulting in exceeding the manufacturers recommended boiler cool down parameters. This exacerbated cyclic stresses on boiler components. 8. Failure of boiler operators to identify the leak prior to catastrophic failure. A review of the boiler control system (DCS) trends demonstrated that the early indications of a tube leak were becoming apparent, but were not identified by operating personnel.

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PHOTO LOG
Location: Salem Harbor Generating Station Date: 11/06/2007

Investigating Inspector(s): Photo Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Mark F. Mooney / Edward Kawa

Description Salem Harbor Generating Station Boiler 3 division wall header (facing north) Boiler 3 division wall header (facing south) Dead air space showing casing failure Dead air space showing ruptured boiler casing Work space immediately below point of failure Area adjacent to point of area below failure Area immediately below casing failure Division wall header Division wall header Close up of tube 9 and header Close up of tube 9 and header Close up of header at tube 10 & 11 Close up of header at tube 9 & 11 Steam impingement indications between tube 9 & 11 Overview of header after being removed Overview of header at failure area Close up of header at tube 10 & 11 Overview of header at point of failures Close up of tube 9 Close up of tube 9 top leak Close up of tube 9 top leaks Corrosion photos of tubes and header Corrosion photos of tubes and header Corrosion photos of tubes and header Corrosion photos of tubes and header Corrosion photos of tubes and header Overview of header at point of failure Close up of header damage from steam / water impingement Close up of tube 10 showing poor weld

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PHOTO LOG
Location: Salem Harbor Generating Station Date: 11/06/2007

Investigating Inspector(s): Photo Number 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

Mark F. Mooney / Edward Kawa

Description Close up of tube 10 showing poor weld Tube 10 Tube 10 showing damage from steam water impingement Close up of tube 11 Close up of tube 10 Internal view of tube 9 View of header after cleaning Cut away of tube 10 stub Boiler #3 data plate Boiler #3 data plate Close up of tube 9 middle leak West side dead air space before ash is completely removed West side dead air space West side dead air space West side dead air space West side dead air space ash West side dead air space ash West side dead air space tubes impacted with ash West side dead air space after ash is removed West side dead air space after ash is removed West side dead air space after ash is removed tube closeup West side dead air space after ash is removed header view

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1. Salem Harbor Generating Station Dominion Energy New England

Tube #10

Point of failure

2. Boiler #3 Division Wall Header (facing north)

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Waterwall forced into furnace ~12 18

Point of failure

Note: Entire area was encased in ash prior to failure. 3. Boiler #3 Division Wall Header (facing south) Point of failure

Approximate location of victims below failure

4. Dead air space showing ruptured boiler casing (facing south)

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Division wall header

5. Dead air space showing ruptured boiler casing (looking down, facing south)

Approximate location of victims

Point of casing rupture

Seal air fan (being tagged out) 6. Work space immediately below point of failure (facing north)
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Seal air fan

Point of casing rupture 7. Area adjacent to point area below failure (facing south)

Point of casing rupture 8. Area immediately below casing failure (facing south)

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Tube

Tube

9
Tube

12 11

Tube

10

9. Division Wall Header

Tube

Tube

11

Tube

10

10. Division Wall Header.

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Tube

Tube

11

11. Close up of tube 9 and header

Tube Tube

11

12. Close-up of tube 9 and header

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Tube

Tube

11

Tube

10

13. Close-up of header at tube 10 and 11

14. Close-up of header at tube 9 and 11

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15. Steam impingement indications between tube 9 and 11

16. Overview of header after being removed

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17. Overview of header at failure area

18. Close-up of header at tube 10 and 11

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19. Overview of header at point of failures

20. Close-up of tube 9

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21. Close-up of tube 9 top leak

22. Close-up of tube 9 top leaks

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Tube and Header Corrosion Photos (23 27)

23

24

25

26

27
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28. Overview of header at point of failure

29. Close-up of header damage from steam/water impingement

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30. Close-up of Tube 10 showing poor weld

31. Close-up of Tube 10 showing poor weld

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32. Tube 10

33. Tube 10 showing damage from steam / water impingement

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34. Close-up of Tube 11

35. Close-up of Tube 10

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36. Internal view of Tube 9

37. View of header after cleaning

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38. Cut away of Tube 10 stub (with bad weld)

39. Boiler Dataplate

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40. Boiler Dataplate

41. Close-up of Tube 9 middle leak

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42. West side dead air space before ash is completely removed

43. West side dead air space before ash is completely removed Tubes encased in ash going to lower header

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44. West side dead air space. Ash on top of header

45. West side dead air space before ash is completely removed Note level of ash behind tubes.

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46. West side dead air space before ash is completely removed

47. West side dead air space before ash is completely removed

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48. West side dead air space before ash is completely removed Note impacted ash between tubes above header (buried)

49. West side dead air space after ash is removed. Prior level of ash is evident on division wall header

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50. West side dead air space after ash is removed. Prior level of ash is evident on division wall header

51. West side dead air space header after ash is initially vacuumed out

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52. West side dead air space after ash is initially vacuumed out. Difference in corrosion in tubes closest to header

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Boiler #3 Drawing / Layout

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Appendix 1 AIG Inspection Report Page 1

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Appendix 1 AIG Inspection Report Page 2

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Appendix 1 AIG Inspection Report Page 3

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Appendix 1 AIG Inspection Report Page 4

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Appendix 1 AIG Inspection Report Page 5

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Appendix 1 AIG Inspection Report Page 6

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Appendix 1 AIG Inspection Report Page 7

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Appendix 2

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Appendix 2

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Appendix 2

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Appendix 2

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Appendix 2

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Appendix 2

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Appendix 2

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Appendix 3

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Appendix 3

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Appendix 4

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Appendix 5

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Appendix 6

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Appendix 6

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Appendix 7

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Appendix 7

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Appendix 7

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Appendix 7

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Appendix 8

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Appendix 8

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Appendix 9 Page 26 of SIA Report

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Appendix 9 Page 27 of SIA Report

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Appendix 10

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Appendix 11

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Appendix 12

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Appendix 13

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Appendix 14

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Appendix 15

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Appendix 16

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Appendix 17

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Appendix 18

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Appendix 19

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Appendix 20

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Appendix 21

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Appendix 22

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Appendix 23 Hot Well Makeup for Month of October 2007

Feedwater makeup began a slow and steady increase in fluctuation

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Appendix 24

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Appendix 25

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Appendix 26

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Appendix 27

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Appendix 28

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Appendix 29

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Appendix 30

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Appendix 31

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Appendix 32

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Appendix 32

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Appendix 32

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