Human error and systematic flaws triggered the power outages nationwide on Aug. 15, according to a government analysis published yesterday.
The Executive Yuan released the analysis after wrapping up its investigation into the incident.
The blackouts occurred after the natural gas supply to a major power plant in Taoyuan’s Datan Township (大潭) was abruptly cut off, causing all six generators at the plant to shut down, the analysis said.
The ensuing power outages affected 5.92 million households, while 423 manufacturers reported losses and about 900 elevator shutdowns were reported.
Technicians employed by a contractor for state-run oil refiner CPC Corp, Taiwan (台灣中油), which manages a natural gas metering system connected to the power plant, committed several mistakes during routine maintenance.
The technicians did not switch the control of the metering system to manual and they cut off the power to the control system for 21 seconds, causing it to automatically shut down the gas supply valve, the investigation found.
CPC Corp should be held accountable for the errors, as there was only one CPC official supervising the replacement procedure conducted by the employees of the contractor, but the official left no record, it said.
CPC Corp also did not draw up a standard replacement procedure and failed to assess the risks involved in the contractor’s replacement procedure.
It also failed to timely inform Taiwan Power Co (Taipower, 台電), which runs the Datan plant.
The design of the metering system is also flawed, as it puts too many important functions on one single control system, which, when not working properly, automatically shuts off the supply valve, the investigation found.
The gas supply is also run by a single pipeline with no backup system, the report said.
Taipower, although it handled the emergency generator shutdown and contingency power rationing efforts well, does not have a warning system in place to notify users of its rationing measures, causing inconvenience to the public, the investigation found.
Taipower then compounded the problem by shifting control of a generator at the Taichung Power Plant from manual to automatic without first confirming that the system was completely restored, causing the generator to trip.
To make improvements, both CPC Corp and Taipower should launch a comprehensive examination of their systems and management, to try to remove the possibility of human error and mismanagement, the report said.
The two companies should also establish an effective cooperation mechanism and multiple backup power generation systems, while improving their professional management and training, the report said.
The Ministry of Economic Affairs would take disciplinary measures against all those involved, including CPC Corp and Taipower technicians and supervisors, the report said.
CPC Corp and Taipower staff deemed responsible for the incident are to be punished for negligence, and former officials whose duties involved the operations of the gas supply system in question would also undergo scrutiny, the ministry said.
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