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(MCRRF) Root Cause Analysis

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(MCRRF) Root Cause Analysis Montgomery County Resource Recovery Facility (MCRRF) Root Cause Analysis Prepared for: Northeast Maryland Waste Disposal Authority And Montgomery County Prepared by: HDR Engineering, Inc. and Fire & Risk Alliance, LLC 7361 Calhoun Place Suite 690 Rockville, MD 20855 Final May 12, 2017 Table of Contents TABLE OF CONTENTS 1.0 INTRODUCTION .................................................................................................. 1 2.0 EXECUTIVE SUMMARY ...................................................................................... 4 3.0 CODES AND STANDARDS ................................................................................. 7 4.0 PROJECT SCOPE ............................................................................................... 8 4.1 Background ................................................................................................ 8 4.2 Preparation of a Root Cause Analysis (RCA) ............................................ 8 5.0 SUMMARY OF PRIOR EVENTS ......................................................................... 9 5.1 July 17th, 2016 ........................................................................................... 9 5.2 August 19th, 2016 ....................................................................................... 9 5.3 October 19th, 2016 ..................................................................................... 9 5.4 November 5th, 2016 ................................................................................... 9 5.5 Similarities Among Previous Incidents ..................................................... 10 5.6 Comparison to Other Similar Facilities. .................................................... 11 6.0 DECEMBER 8TH EVENT RECONSTRUCTION ................................................. 12 6.1 Timeline Prior to Fire Discovery ............................................................... 13 6.1.1 Water Supply................................................................................. 16 6.2 Incident Reports ....................................................................................... 16 6.3 Fire Discovery .......................................................................................... 17 6.4 Emergency Response.............................................................................. 17 6.4.1 Emergency Action Plans ............................................................... 22 6.4.2 Fire Protection Equipment ............................................................. 24 6.4.3 Incident Command ........................................................................ 28 7.0 ROOT CAUSE ANALYSIS................................................................................. 30 7.1 Fire Cause and Origin .............................................................................. 30 7.1.1 Unquenched Fires from Previous Fire Events ............................... 32 7.1.2 Spontaneous Combustion ............................................................. 32 7.1.3 Waste Composition ....................................................................... 33 7.2 Incident Duration- Severity of Fire ........................................................... 34 7.2.1 Waste Inventory ............................................................................ 34 7.2.2 Additional Inventory Resulting From NRG Shutdown. ................... 38 7.2.3 Fire Protection Systems ................................................................ 38 Page ii Table of Contents 7.2.4 Crane out of Service ..................................................................... 38 7.2.5 Reduced Boiler Availability and Capacity ...................................... 38 7.2.6 Other Factors ................................................................................ 39 7.2.7 Coordination between MCFRS and Covanta ................................ 40 8.0 RECOMMENDATIONS ...................................................................................... 41 8.1 Pit Level and Waste Management ........................................................... 41 8.2 Advanced Detection and Early Response Systems ................................. 41 8.3 Improved Facility Maintenance Practices ................................................. 41 8.4 Improved Coordination with MCFRS ....................................................... 42 8.5 Comprehensive Facility Analysis ............................................................. 43 9.0 SUMMARY ......................................................................................................... 46 APPENDIX A – INCIDENT SUMMARY LOGS ........................................................... A-1 APPENDIX B SUMMARY OF INTERVIEWS .............................................................. B-1 APPENDIX C – EMERGENCY ACTION PLAN .......................................................... C-1 APPENDIX D – FIRE AND GENERAL EMERGENCY PLAN .................................... D-1 APPENDIX E – PLANT OPERATING PROCEDURE .................................................. E-1 APPENDIX F – ADDITIONAL REFERENCED DOCUMENTS .................................... F-1 Page iii Table of Contents LIST OF FIGURES Figure 1 Montgomery County Resource Recovery Facility Model................................................ 1 Figure 2 Montgomery County Resource Recovery Facility site plan............................................. 2 Figure 3 Montgomery County Resource Recovery Facility Tipping Floor and Pit ....................... 2 Figure 4 Refuse Pit and Tipping Floor (01/18/2017) .................................................................... 14 Figure 5 Refuse Pit and Tipping Floor (12/05/17)........................................................................ 14 Figure 6 Trash on tipping floor back to entrance bay door (12/10/2016) ..................................... 15 Figure 7 Trash level up to 85 foot mark in Bay A (12/10/16) ..................................................... 15 Figure 8 Tipping room floor visibility, PE714 seen north side rollup door (12/09/2016)............ 19 Figure 9 South wall horizontal ventilation openings (12-10-2016) .............................................. 20 Figure 10 Ventilation hatches open and roof opening by Centimark (December 12, 2017) ........ 20 Figure 11 Tankers on scene to supply additional water (12/09/2016) .......................................... 21 Figure 12 Blistering paint on the tipping floor south wall (12/08/2016) ...................................... 31 Figure 13 Layout drawing with star indication of fire origin ....................................................... 32 Figure 14 Graph of Estimated Waste Inventory for 2016 ............................................................. 35 Figure 15 Graph of Estimated Pit Height for 2016 ....................................................................... 36 Figure 16 Impact of Boiler #1 Feed Table Damage on Waste Inventory ..................................... 39 Figure 17 Pit Air ........................................................................................................................... 40 LIST OF TABLES Table 1 Fire Protection System Description ................................................................................. 25 Table 2 Covanta Logbook July 17th, 2016 ................................................................................. A-1 Table 3 Covanta Logbook July 18th, 2016 .................................................................................. A-1 Table 4 MCFRS Incident Log on July 17th, 2016 at Montgomery Covanta ............................... A-2 Table 5 MCFRS Incident Log on July 18th, 2016 at Montgomery Covanta ............................... A-3 Table 6 Covanta Logbook August 19th, 2016 ............................................................................. A-3 Table 7 MCFRS Incident Log on August 19th, 2016 Montgomery Covanta .............................. A-4 Table 8 Covanta Logbook October 19th, 2016 ............................................................................ A-4 Table 9 MCFRS Incident Log on October 19th, 2016 Montgomery Covanta ............................ A-5 Table 10 Covanta Logbook November 5th, 2016 ........................................................................ A-5 Table 11 Covanta Logbook November 6th, 2016 ........................................................................ A-5 Table 12 MCFRS Incident Log on November 6th, 2016 Montgomery Covanta ........................ A-6 Table 13 Covanta Logbook December 8th, 2016 Through December 18th, 2016 ....................... A-6 Table 14 MCFRS Incident Log December 8th, 2016 Through December 18th, 2016 Montgomery Covanta ....................................................................................................................................... A-8 Page iv Introduction 1.0 INTRODUCTION On December 8th 2016 a fire was reported by Covanta Montgomery, Inc. (Covanta) on the tipping floor at the Montgomery County Resource Recovery Facility (MCRRF or facility herein). Through the course of a ten-day operation, the Montgomery County Fire and Rescue Service (MCFRS) was on scene to lead fire suppression efforts, as well as direct Covanta personnel in support of these efforts. There were several changes in personnel and leadership between both Covanta and MCFRS due to the long duration of this incident. The facility has also had several recent fire incidents in the trash pit and on the tipping floor locations. Figure 1
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