Forensic & Steam Projects

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Wayne F. Kirsner, P.E
Principal / Kirsner Consulting Engineering

MS/Physics/1973/Georgia Institute of Technology
BS/Physics/1972/Georgia Institute of Technology
BSME/1980/Georgia Institute of Technology

Professional Engineer/Mechanical/1983

ASHRAE Distinguished Lecturer:
June 2001 thru 2008

Fairbanks Alaska- Feb. 1997 investigating valve explosion.

Investigations, Reports & Design Experience.

Consolidated Edison: assisting defense attorneys in the event analysis of the steam main rupture at 41st and Lexington Ave in New York City. On going.

For NASA Langley Research Center, March 2008, inspected layout of new 10" HPS line and reported to NASA engineers and safety personal on design flaws/construction errors and areas of concern with new line. Found that steam traps were under-rated for service, omitted traps stations were needed directly up- and downstream of a critical valve station to preclude a waterhammer incident at this location, and expansion joints (or their guides) which were designed to accept axial stress would be subjected to lateral stresses that did not appear to be accounted for in design. My 2002 report on a similar investigation for NASA LaRC is accessible below. Taught a two-day 8-hour seminar for NASA engineers, mechanics, and supervisors after completing my report on there system.

University of Massachusetts Expansion Joint Failure, Amherst, MA. February 2008, Investigated and reported on root cause of externally-pressurized expansion joint failure in one of two 20" steam mains from new Central Heating Plant. Found that condensation-induced waterhammer had occurred due to misunderstanding of inverted bucket trap operating characterizes by the start-up engineering company--a not uncommon mistake that has caused other accidents. As a consequence, a "parallel two-phase flow instability" between the two nearly-identical 20" lines allowed 7500 gallons of condensate to accumulate in one 20" line unbeknownst to operators. The condensate was able to accumulate without notice because the system was "looped" and under low-flow conditions so that all steam was readily delivered through one line while the other blocked with condensate. Advised University on identifying other expansion joints which may have sustained damage. Dr. Peter Griffith advised in this investigation. Clogged trap strainer pictured below is explained below.

Strainer removed from trap assembly draining the low point in the 2000' of 20" Mains. Clogging material is pipe scale loosed from pipe walls as a result of pipe cleaning by the start-up contractor who, afterward, neglected to clean the strainers. While not the cause of this Accident, the pictures speak to the residual pipe scale present in new pipe and the need for strainers to protect trap orifices. This strainer on the lowest elevation trap drained the most liquid and so caught the most crud.

For Counsel for Consolidated Edison Company of New York, assisting attorneys in understanding the cause of a steam explosion which occurred beneath the intersection of 41st and Lexington Ave. Litigation is Ongoing.

For Trigen-Boston Energy Corp., the district heating company serving the City of Boston, investigated steam release from expansion joint failure in underground steam conduit due to waterhammer event. In Nov. 2007, at direction of Company Legal Counsel, briefed VP/General Manager and engineering staff on root cause of event . Dr. Peter Griffith attended the briefing and advised in this investigation. Did 8-hour seminar for Trigen engineers and supervisors on understanding waterhammer in steam systems.

Expert Witness for Attorney defending Industrial Campus against OSHA Citation and Fine
in case where steam worker was killed during start-up/warmup of a branch steam main. OSHA cited management for violating OSHA's Lock-Out/ Tag-Out Standard CFR 1910.147. My report and affidavit argued that employees' procedures exceeded requirements of OSHA's Lock-Out/ Tag-Out Standard and that the accident was caused by circumstances not included in the Citation or anticipated by the Standard. The Federal Judge upheld this argument among others made by the attorney and dismissed this citation. At right is a photo of the 8" Class 250 cast iron valve which ruptured while being opened to 220 psig steam by the worker. (The valve bypass line has been removed.) My investigation found that the actual root cause of the accident was Shut-down/Start-up Procedures which did not require a drain be opened and LEFT OPEN at the low point in the isolated pipeline. A closed gate valve under full steam pressure leaked steam into the isolated section of line which, over five days, filled the line with condensate. Even though there was a trap in the isolated line section, there was insufficient pressure to discharge condensate from the trap. At start-up, full steam pressure was applied to the water-logged line without noticing the condensate accumulation. When the downstream isolation valve was opened, draining condensate allowed steam to intrude into the subcooled condensate and hammer.

Steam Release Accidents in Chicago, IL Chemical Plant, . Three separate failures in the steam system were investigated at the Plant; two were determined to be caused by water hammer, the third by unrestrained pipe expansion after an anchor was removed but not replaced. The sketch below was used to explain the waterhammer incidents.
My Report explained that the waterhammer incidents were brought on by allowing condensate to accumulate in the steam system due to the practice of isolating and de-energizing steam mains without opening drains or vents to prevent a vacuum from drawing condensate backward from condensate system. While this common denominator could be considered the ultimate cause of both accidents, other proximate causes were:
  1. Cold plant water was backfeeding through a check valve into the depressurized steam line when it was shut down. When on, steam pressure prevented the backfeeding.
  2. The new yet-to-be-insulated steam main (shown above) rapidly generated condensate when energized that filled the line because traps had been inadvertently disabled presumably while trying to find the source of the backfeeeding.
  3. Condensate indeed was being sucked backwards into the steam main when it was de-energized because of a missing check valve on one trap assembly (tracked down by the Chief Engineer using an infrared gun as was the cold water ingress).
  4. In other locations, such as the at the boilers, it was found that steam traps were being disabled as a routine response by operators to perceived trap malfunctions.
  5. Steam traps were absent in a low-elevation tunnel under a road. .
  6. Underrated low-pressure rated steam traps were found that had failed closed.

During the investigation found several condensate-filled dead ended steam lines were found with a potential for serious water hammer if someone opens the right (or wrong) valve.

For Suncor Energy in Alberta, Canada, investigated transients in bybass/blow-off line from OTSG boilers which caused large expansion loops to deform enough to damage adjacent electrical cable racks and be dislocated from their pipe supports. On a second trip investigated waterhammer explosion in steam discharge line from Steam Generator. Wrote report explaining three different waterhammer scenarios in 11.000 kPa steam line and recommended corrective action. For Oil Sands site, conducted nineteen 6-hour training classes for workers in Ft. McMurray, Alberta. Investigated and explained transients in the two-phase condensate return line being used to lift condensate to a flash tank at oil sands site. (If you think about it, you can't lift condensate in a two phase condensate-return line without transients).

Coronado North Island Naval Air Station, San Diego, Sep 2004. Comprehensive Report on 8 in.steam valve rupture in a manhole which blew apart releasing 125 psi steam during an attempt to open the valve. The civilian steam worker opening the valve, received second and third degree burns over 20 to 25 % of his body. Had he not been in the process of evacuating the manhole in response to a loud bang which preceded the rupture, it's doubtful he would have survived the incident. Found that the direct cause of the rupture was condensation induced waterhammer resulting from nucleate boiling of ground water in a manhole 300 feet from the accident site. A heat transfer calculation showed that completely submerged steam piping within the downstream manhole (as had been, on occasion, observed to be the case) would generate enough condensate within the pipe to overcome the capacity of the steam trap in the Manhole and fill the 300 feet of 8" pipe between the two manholes. This is a somewhat rare but recurring problem at the base because of the Environmental Protection's office objection to discharging ground and rain water to the street level by sump pumps and the resultant abandonment of sump pump maintenance and replacement.

Ruptured 8" Cast Iron Valve Above.

Boiling ground water in downstream Pit Below.

Concurrent with accident analysis, taught three half-day sessions for civilian steam fitters on condensation-induced water hammer and briefed supervisors and managers on the systemic causes of the accident.

In another phase, inspected 8 Piers at Naval Station San Diego for steam waterhammer potential and reported on hazards found.

For Motorola, now Freescale Semi-Conductor, in Austin, TX, June 2004, investigated cause of steam rupture which shattered a 10" cast iron strainer releasing steam and condensate into the mechanical room of the Plant. Found that one of two 16" steam mains that made up the "loop system" serving the Plant was completely blocked by condensate resulting in an unstable equilibrium in the system. Closing any of several isolation valves between the East and West 16" mains would again accelerate the slug and repeat the accident. Advised Freescale engineers to immediately locked-out valves. Helped them devise a first-of-its-kind method to defuse the situation without down shutting steam production . Taught two-day training class to workers, supervisors, and engineers on condensation- induced water hammer and what caused their accident.

Ruptured 10" Cast Iron Strainer
For Houston, TX law firm representing industrial concern, investigated cause of steam accident resulting in operator death when a hydraulic shock stripped the nuts from the studs of a valve flange allowing it to separate releasing a spray of scalding water.
The release burned the operator to death. I concluded that the accident was due to condensate which accumulated atop the valve and subsequent water hammer which was initiated by the operator when he attempted to open the valve. The root cause of the water hammer was not operator error, but the improper original design configuration by the engineer of the trap assembly with respect to the valve.
For NASA Langley Research Center, 2002, investigated anchor failures and seized joints in 4900 ft. long Steam Tunnel No.4 carrying 350 psig steam. Found joint misalignment due to deficient 1964 engineering drawing detail resulting in widespread improper anchor installation by the original contractor. Problems were not due to water hammer as others had postulated. Analyzed system vulnerability to waterhammer as a result of several incidents. Documented root causes of tunnel problems in Report to NASA Engineers August 2002. Click to view Report.
For BP Refinery and Chemical Plant in Grangemouth, Scotland, investigated two water hammer incidents one of which fractured an 18 in. steam main (at right) carrying 200 psig steam. Identified cause related to flooding of a culvert thru which a steam main passed. Briefed British Health and Safety Executive occupational safety engineers after delivering reports to BP Engineers. Conducted training session for sixteen BP engineers on water hammer. The article, "The Danger of Flooded Manholes and Submerged Steam Lines" describes one of the two accidents.

Link to the Scottish Environmental Protection Agency to view their report on the accident based on my Report. http://www.hse.gov.uk/comah/bpgrange/incident/page8.htm

"A Wee Bit ah Wa'er Ham-mor"

For Tennessee State Board of Regents, surveyed and analyzed problems in the 6000 ft. underground steam and chilled water utility distribution tunnel at Tennessee State University to determine whether the design engineer or maintenance unit was responsible for chronic problems. The Report identified the root causes of failed anchors, seized expansion joints, blowing valve gaskets, and inoperative traps finding the prime culprits were poor anchor welds and faulty guide installations. Published a “virtual tour” of the tunnel problems with analysis on the Internet for use by all parties involved. Wrote new preventive maintenance schedule, confined space entry program, and detailed start-up procedure for tunnel steam distribution system.
Click to view cover as pdf. Send me an email if you would like to see the final report.
CLICK to take a Virtual Tour of Steam Tunnel Problems!

Prepared Permit-Required Confined Space Program for Motlow State Community College to meet OSHA's 29CFR1910.146 regulation. Performed testing of manholes for hazardous levels of H2S, CO, CH4 and O2 and trained operators and administrative staff on use of testing and rescue equipment.

Expert engineering consultant to attorney defending Chubb Insurance Co. against a law suit brought by the victim of a chemical accident at a large paper mill in Houston, Texas. Found that accident was due to improper installation rather than material defect in the rubber expansion joint that failed releasing a spray of caustic 220oF white liquor.

1999, 2000, 2001 Faculty member at University of Wisconsin's annual "Boiler Plant Design Course" speaking on steam accidents. Speaker at Kansas City IDEA Steam Distribution Forum on "Understanding Water Hammer."

Investigated cause of steam accident at Metcalf Lumber in Metcalf, Georgia in which a Class 250 cast iron valve exploded killing a worker as he passed by the valve. Accident report found that the water hammer event was due to lack of rudimentary engineering design for the "in-house installed" addition of an additional drying kiln.
Steaming Valve on the night of the Accident (left) and the next day (above)

Authored "Reconstruction of the 1988 Steam Accident in Manhole C-4 at Fort Wainwright, Alaska" for the US Department of Justice, Sept. 1997. Expert Witness defending the Army Corps of Engineers in lawsuit involving accident in which a 10" cast iron valve was fractured by steam water hammer severely scalding two asbestos abatement workers.

Authored "Investigation of Dec. 1996 Steam Accident at the Sacramento Regional Waste Water Treatment Plant" in which a cast iron trap fractured during steam start-up. Developed and trained operators on new safe start-up procedures for the site to prevent future accidents.

Author of investigative report on cause of valve gasket leaks in steam pits at Wright Patterson AFB, Dayton Ohio. Stress analysis showed leaks were caused by inadequate provision for expansion in design, not bad gaskets as was being charged by the owner.

Author and chief investigator retained by the manufacturer for the report on The Expansion Joint Failures at Le Moyne College in Syracuse, NY in which three flexible-hose type joints catastrophically failed during start-up of the steam system. Report found water hammer was not responsible for failure.

Forensic Analyst retained by the Georgia Department of Human Resources to investigate the cause of a steam accident which resulted in an operator's death at Northwest Georgia Regional Hospital. Authored the report: "Analysis of Conditions and Events which led to the Valve Failure in Steam Pit 3A ...". Retained as the expert witness defending the engineering design firm from the law suit which arose from the accident. Report found that the accident was due to a combination of operator error and the inadvertent disabling of a trap during a building demolition which had taken place years earlier. The magazine article "What Caused the Steam Accident that killed Jack Smith" which appeared in the July 1995 issue of Heating/Piping/Air Conditioning magazine and the Feb. '96 issue of National Engineer was based on this accident.

Engineer for design of new $1.5 million dollar Central Steam Plant for the campus of Northwest Georgia Regional Hospital.

Technical reviewer adjudging validity of energy conservation measures submitted in Technical Analysis Reports (TA's) to the State of Florida's Energy Office to compete for grants through the Department of Energy’s Schools & Hospitals Grant Program. Authored State's Life Cycle Costing methodology to be required in all reports submitted in 1995. Conducted training session for approximately 120 professional engineers seeking certification to write TA Reports in Florida in 1995. Conducted subsequent training session on Life Cycle Costing at DOE Region IV Conference for State Energy Directors from Southeastern States.

Authored 1992 Technical Analysis Report of energy conservation measures for Patterson Hospital in Randolph County, Georgia. Wrote engineering study --Deficiencies in Design and Operation of Chilled Water Plant which analyzed and offered solutions to inadequate CHW distribution in the hospital. In 1993, designed, bid, and oversaw construction of redesigned central chilled water plant for the hospital. Similarly, completed comprehensive lighting retrofit project for the hospital and nursing home. Completed projects reduced Hospital's electric utility bill by 35%. Projects were awarded a $114,000 matching grant through the D.O.E.

Re-designed and supervised replacement of steam traps and attendant condensate piping including removal of asbestos in steam pits on the campus of the 15 building Fulton-Dekalb Hospital Complex, 1985. 

Project Engineer and Project Manager for 1985 design of $500,000 Waste-to-Energy Incineration Plant and waste heat boiler at 915 bed Grady Memorial Hospital. Authored $385,000 grant request for this project received from D.O.E..

Investigated underground leaks from hot water piping systems serving six of eight buildings which received new HVAC systems at Brook Run Mental Health Facility. Identified manufacturing defect in pipe joints.

In association with JND Sterling, co-authored feasibility study of energy conservation measures in prototypical existing NASA Office Building at the Johnson Space Center in Houston, Texas. This study added a fourth volume to the three volume set previously accomplished for NASA. Project Director and primary author for the $144,000 Energy Conservation Analysis of Existing Buildings and the two volume set: New Building Energy Design Guidelines for the NASA Johnson Space Center in Houston, Texas. 

Project Manager for evaluation of all Mechanical, Electrical, Plumbing, and Fire Protection Systems in the 42 story First Atlanta Bank Tower and 8 story Bank Annex.

Project Manager and co-author for $200,000 energy study conducted in five largest mental hospitals and institutions operated by the State of Georgia. Five million dollars worth of energy saving measures were identified of which about $1 million worth were selected for implementation. Head mechanical engineer on design of two largest projects:

For the Georgia Forestry Commission, co-authored "Wood Energy Feasibility Study for Northwest Georgia Regional Hospital" to replace fossil fuel steam boilers with wood fired boiler. This report was submitted to the Department of Energy through the State Office of Energy Resources and received a 50% matching grant to fund the $1/4 million project.

Retained by the International Engineering Support Group of Coca Cola to advise on the feasibility of a programmed $5 million cogeneration plant for their Heightstown, New Jersey plant. Based largely a re-evaluation and correction of a computer study performed by the recommending consulting engineer on the project, the project was canceled after Mr. Kirsner demonstrated that the project had a negative net cash flow.

At NASA Johnson Space Center, analyzed impending purchase of two 2,000 ton steam turbine driven chillers designed by NASA's consulting engineers. Recommended alternative chiller selection based on predicted first cost savings of $300,000 and annual savings of $230,000 per year. NASA accepted recommendation, canceled procurement action, and re-designed the Chiller Plant addition based on Mr. Kirsner's recommendation.

Publications, Seminars

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