CSFD Report: Drake Power Plant Fire Caused By Mechanic Error

Drake Power Plant on the day of the fire

Colorado Springs Utilities confirms that a massive fire at a downtown power plant was caused by human error.

According to a duty report released by the Colorado Springs Fire Department Friday, a mechanic committed the error while making repairs to an oil filter. He told an investigator that he believes he turned the wrong filter. Pages four and five of the 85-page document contains a summary of an interview with the mechanic. Below is an excerpt:

The mechanic stated that he had a "PM" to change the filters on the latching system for the turbine.

The mechanic stated he "walked the clearance down" and signed on the clearance...he returned to the area to make the repair and he "cracked it," it being the oil filter, with a strap wrench. The mechanic stated as soon as he turned the oil filter it shot turbine in the direction of the "hot pipes." The mechanic stated that he didn't have time to turn it back because of the fire occurred so quickly. "It flashed so fast."

...He [the mechanic] stated it was a big ball of fire.

According to report, the turbines are fed by super-heated steam from the boiler. The filter that the mechanic was scheduled to repair is on the latching system for the turbine. There are two different filters, and they are set up to where when one is being worked on, the other is operational. The mechanic was told that there would not be pressure in one of the two lines.

The mechanic told the investigator that he believes he turned the filter that still had pressure.

According to the report, the mechanic said that he double-checked the work order before getting started, but that when he started making the repairs "he wasn't thinking" and turned the top filter instead of the bottom one. The top filter had not been turned off, and shot the turbine oil in the direction of the hot pipes. The mechanic said that the fire happened so fast that he didn't have time to turn it back.

The mechanic believes the bottom filter was the one that had been shut off. The work order, listed in the report, states that the lower filter was the one to be replaced.

The reason for the repair was that a previous inspection showed there was an abnormal reading in the oil pressure gauges.

"Unfortunately in tragic industrial events and accidents, similar things happen" CSFD Fire Marshal Brett Lacey said Friday in response to the report. "Sometimes human error is involved and it's unfortunate, but occasionally that's just what happens.

"Colorado Springs Utilities does a really good job with their loss control and their safety management, take this fire out of it and I think this is a very well-run plant," Lacey continued. He reiterated that the fire was an accident.

"This is not a fault finding issue; I think what this does is makes us take a step back and evaluate the safety processes and the different procedures that we have in place...make modifications to that so this doesn't happen again."

The Drake Power Plant fire started on the morning of May 5. Roughly two-thirds of the city's firefighters responded to the fire. The fire knocked out power for more 20,000, injured one person and necessitated a voluntary evacuation zone for five blocks around the plant.

The duty report details the moments after the flash fire started. A second mechanic described hearing a coworker yelling about a fire; when he looked himself, the second mechanic said he saw flames racing from the basement to the third floor.

Mechanic B stated the employee was alerting everyone to the fire and he started to contact the control room. ...He peered through the vision panel in the door into the plant and it was "pure flame."

...He "started running" and then he heard the alarm sounding. Mechanic B stated he then started to alert others.

The mechanic was scared that the fire would reach the "highly explosive" Powder Room Basin coal.

Mechanic B stated if the fire would have reached the bunkers it would have been horrible.

After the fire, CSFD Fire Chief Christopher Riley praised the firefighters' bravery in rushing into the building despite the high risk of an explosion.

"We really had the ultimate test...firefighters made the ultimate decision to go inside and put the fire out with the possibility that there could have been an explosion while they were fighting the fire. Had they not gone in, it could have caused an explosion in the surrounding neighborhood that would have been catastrophic," Riley said.

A city official says the investigation is still ongoing, and the duty report is not the full final report. To read the duty report, click the link on the right side of this page.