The Need for Effective Communication and Coordination During a Plant Shutdown

The Need for Effective Communication and Coordination During a ...

The Need for Effective

Communication and Coordination

During a Plant Shutdown

Man’s Greatest Gift

Machiney Installation &

Maintenance, Inc.

Man’s Greatest Gift

The art of communication.

There is much discussion in the academic world of

communication as to what actually constitutes

communication. Currently, many definitions of

communication are used in order to conceptualize

the processes by which people navigate and assign

meaning. Communication is also understood as

the exchanging of understanding.

Machiney Installation &

Maintenance, Inc.

A Near Miss

• Previous Employer

• Hydro Plant on the Sultan River.

• Mechanical Constructor

• Responsibility during plant shutdown

• Summer hire programs

• Will not allow photos.

• Caused me some concern because;

• What good is a near miss if you cannot share.

• By not sharing, we loose the reasons for our gift.

Machiney Installation &

Maintenance, Inc.

Brad’s Lecture

The ability to talk and apply direction.

• We would not be here in this present environment if not

for the ability to transfer knowledge.

The ability to listen.

The second part of this gift we all need improvement.

The ability to comprehend the information.

Machiney Installation &

Maintenance, Inc.

Plant Spec’s

• 8 mile penstock

• 500 psi at turbine with full reservoir.

• 4 Units

• Two 50 MW Peltons

• Two Francis 8 MW Francis

Machiney Installation &

Maintenance, Inc.

The Outage

• Shut down due to ball valve repair.

• Required an empty penstock or pipeline

• A long day shift to prepare and drain tunnel is required.

Machiney Installation &

Maintenance, Inc.

Getting Ready

• Assemble the tools and equipment on Friday.

• Ropes, lights, impact wrench, sockets.

• Confine space and hole watch.

• Harness.

• Dreaded paperwork.

• Pressure washer, rain gear.

• Clean spiral case and penstock to the valves.

• Inside must be cleaned to perform the work.

Machiney Installation &

Maintenance, Inc.


• Shut down starting Sunday afternoon by

closing the gate at Spada Lake

• Draining Blue Mountain

• Several hours due to water pressure behind rocks.

• Monitor pressures during the ramping.

• Forebay = 1450’

• Spiral Case = 273’

Machiney Installation &

Maintenance, Inc.

The “Scene”

• Two Summer hire “Overachiever” types.

• I gave a list and would came back one hour later.

• Most equipment was then in place.

They were instructed to continue with gathering tools.

• I left the area to unload a truck on top deck.

Machiney Installation &

Maintenance, Inc.

The “conversation”

• Me….”when you get done come up and find

me on the top deck”

Them…”OK, do the lights go inside?”

• Me….”Yes”

Machiney Installation &

Maintenance, Inc.

The Horn

• Usual call was four short beeps on the horn.

• Several short beeps with short durations

• Run to the control room to find two temporary

employees soaking wet.

• Operator….they started to open the mandoor.

• Me….””””WHAT””””

• I run down the stairs to the mandoor

Machiney Installation &

Maintenance, Inc.

The Mandoor

• Found turbine floor flooded

• Water at 450psi shooting out of the bottom of

hatch & bolt holes. (broken door O-ring)

• Entire TSV pit flooded and standing 6” water on

the floor

• Quickly run upstairs and instructed operator to

shut the unit down and transfer load to Unit One.

• Back down to watch the TSV closing.

• Several minutes of closing time, to long.

Machiney Installation &

Maintenance, Inc.

Machiney Installation &

Maintenance, Inc.

Control Room

• TSV closed and water continued to flow.

• I was told to clear the building.

• Me….”you guys hit the top deck, I am not losing

this *.%^^$$ing Powerhouse.”

• Back down to start installing bolts.

• Four bolts left out of twenty with two of them loose.

• Pressure was extreme.

• Install bolts against no air.

• Used air wrench to tighten each as I installed them.

Machiney Installation &

Maintenance, Inc.


• Found Electrical Engineer handing me bolts.

• He did not want to loose it either.

• Completed installing the bolts as water continued

to flow. (Door would not now open)

• Water suddenly stopped

• Electrician had jumper’d a terminal block to allow the

needles to open, relieving pressure on mandoor.

• TSV was shut and seals were not engaged

• Power unit under water.

Machiney Installation &

Maintenance, Inc.

Plant Saved

• Had the mandoor opened

• Water would fill the powerhouse in 2 ½ minutes

• Building = 75’ x 180’ x 2ea 14’ levels.

• Equipment and components take up some space.

• Two temporary employees and one outside

contractor drowned.

• One plant destroyed internally.

• 160 million dollars.

• Two years to rebuild.

• Civil damage to tunnel and lost generation.

Machiney Installation &

Maintenance, Inc.

After Action

Communication failure.

• We all talked and completely understood the task.

• Brad assumed they understood.

• “Do the lights go inside”

• “Yes”

Machiney Installation &

Maintenance, Inc.


Talk to me after the


Machiney Installation &

Maintenance, Inc.

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