Anatomy of a disaster

State condemns lack of inspections at Salem power plant where 3 died in blast

For 10 years, officials at the Salem Harbor Power Station failed to carry out a crucial annual inspection, an oversight that has been linked to a boiler explosion that killed three employees last year, state officials said yesterday.

A report released yesterday by the Department of Public Safety cited extensive corrosion of tubes near an area of the boiler known as the dead air space - space within the boiler where there is no combustion.

The law requires a thorough external and internal inspection of the boiler, including the dead air space, according to the report.

"This dead air space had not been entered for 10 years, at least," said Commissioner Thomas G. Gatzunis of the Department of Public Safety. "If that's not reflective of incompetence, I don't know what is. You're supposed to look at something once every year, and you don't do it in 10 years? There's no excuse for that."

Dominion Energy New England officials said they "strongly disagree" with the report's findings and are considering their response.

State officials said they would pursue disciplinary action against the engineer in charge of the boiler and the inspector responsible for annual inspections.

Yesterday, the Public Safety Department revoked former engineer-in-charge Steve Dulong's first-class engineer's license and advised insurance inspector Robert Maule that it deems him "incompetent and untrustworthy to hold a Certificate of Competency to inspect boilers." That may lead to revocation of his certificate.

Gatzunis said state inspections of 33 other facilities with similar coal-fired boilers and dead spaces were in compliance with the law.

Richard Robey, president of the union representing Salem Harbor workers, said employees may not have been aware dead air space had to be inspected annually.

"I don't see anybody in Salem that would intentionally violate the law or jeopardize somebody," Robey said. "If it's supposed to be done, then I'm going to find out why it wasn't and make sure that it is definitely done in the future."

The Nov. 6 explosion killed mechanic Mark Mansfield, 41, of Peabody, engineer Phillip Robinson, 56, of Beverly, and Mathew Indeglia, 20, of Lawrence, who was on his second day of work.

The men's families secured a temporary restraining order late last year to stop the cleanup of the plant while they collected evidence for a possible lawsuit against Dominion. The family members and their lawyers declined to comment yesterday.

The state's investigation found a defective weld combined with significant external corrosion of the boiler's tubes caused the fatal blast. An annual inspection of the dead air space would have "significantly abated the degree of corrosion," the 104-page report said.

The explosion occurred after a tube sprayed water and steam onto adjacent tubes, causing a catastrophic failure that sent steam, water, and ash at about 600 degrees into the area below the boiler, according to the report.

The report also found that despite repeated boiler failures, plant personnel had "an unacceptable tolerance" of boiler tube failures and lacked a policy to examine other areas of potential concern for similar failures. Additionally, the plant failed to educate employees about failure mechanisms or how to identify them.

The report found that the plant's routine practice of washing the boiler furnace during a plant outage allowed water to enter the lower dead air spaces, which were full of ash, causing corrosion.

"There was no effort taken to routinely remove this corrosive ash mixture from those spaces," according to the report.

The investigators also found that it was a common practice to accelerate cooling after a boiler failure by "fan cooling" the boiler, exceeding the manufacturer's recommended boiler cool-down parameters. "This exacerbated cyclic stresses on boiler components," the report indicated.

The report added that a review of boiler control system trends found that early indications of a tube leak were not identified by operating personnel and that there was a backlog of approximately 2,500 work orders.

The department said it revoked the certificates for all four boilers that failed and inspected them before putting them back in service.

As recently as May, federal officials found safety violations at the plant, but Dominion Energy New England officials said they would contest accusations that they failed to keep workers safe.

Referring to yesterday's report, spokesman Jim Norville said it doesn't reflect the evidence:

"While we will continue to review the report and consider our options to respond, we strongly disagree with any suggestion that Dominion or our dedicated employees at Salem Harbor did not maintain a safe work environment or failed to operate and maintain our power generating facilities properly."

David Abel can be reached at dabel@globe.com. Jonnelle Marte can be reached at jmarte@globe.com.