PROCEDURES MUST BE FOLLOWED STEP BY STEP

At around 6.00 am, a flash was produced during operations in a chemical plant. The accident took place between two production campaigns. On the 7 and 9 February, the hydrogenation reactor was cleaned, deodorised and dried to eliminate residual waste from the previous production cycle and prepare the reactor for the following one. On 12/02 at 5.00 am, the production supervisor issued specific instruction on a new production cycle to a technician. The technician did not follow them in the right sequence as indicated in the instructions before staring production: to save time when pressurising the device at 9 bar of nitrogen, he simultaneously made several adjustments and carried out several checks The reactor was pressurised using nitrogen. The operator observed N2 leaking from a manhole. He decompressed the reactor and removed the fastening bolts from the lid to change the gasket. During this operation, he heard a leaking noise at the joint. The two technicians were projected backwards in an explosion that ensued. Both the technicians sustained burns on their faces and hands and were initially hospitalised in Nice and subsequently transferred to a specialised unit in Toulon. 

The investigation report explained that the explosion occurred as a small quantity of H2 ignited upon contact with the catalyst in presence of oxygen coming from the manhole. It also noted that the tightness of the reactor was checked and the pipe pressurised at the same time without following the guidelines

The drying conditions may have contributed to have increased the pyrophoric nature of the catalyst. Changes have been planned in the hydrogenation equipment (installing pressure sensors, flame guards on regulator vents, etc.) and procedures (risk analysis, verification of H2 pipes, de-commissioning the H2 pipe before opening the manhole.

Source: Aria database

ARE YOUR FLANGE TIGHTENING TORQUES PROPERLY SET?

While re-starting an ammonia production unit in a chemical plant following a technical breakdown that lasted one hour and 30 minutes, a synthesis gas leak (50% hydrogen, methane, nitrogen and 17% ammonia) ignited on a flange (O-ring joint) located just after the synthesis reactor. The operator triggered the emergency shutdown after the unit’s alarms were triggered, isolating and depressurising the synthesis cycle. Steam was sprayed on to the leak using mobile fire nozzles to extinguish the fire that was brought under control 55 minutes following its start. Material damage was estimated at 60 K euro The blaze did not damage the reactor that was protected by a deflector. Operating losses stood at 300 k euro. 

The tightening torques of the bolt on flange where the leak occurred is responsible for the accident: they were not adapted to the exceptional conditions prevailing during the accident (significant temperature difference between the bolt and the flange resulting from the abrupt temperature variation due to the short technical breakdown.) The implemented corrective actions involved redefining the tightening torques, improving the tightness of the drip collar on the flanges (defective at the time of the accident), designing a nitrogen injection system in drips collars and installing a steam injection crown to protect the bottom of the synthesis reactor.

Source:Aria database

ARE DOLLARS TAKING PRECEDENCE OVER OVER PROCESS SAFETY?

Shortly after midnight, a highly flammable gas leaked in an ammonia manufacturing unit of a chemical plant producing nitrogenous fertilizers. The gas, mainly comprising hydrogen, leaked from a valve at a pressure of 220 bar and a temperature of 120°C. It spontaneously ignited forming a fiery stream directed towards the pipeline carrying the gas. Due to the heat, the pressure in the pipeline increased; the top portion of the pipe ruptured releasing the gas that exploded. The alert was sounded and the police implemented an emergency plan: traffic was stopped in the roads in the vicinity of the plant and resident were asked to stay indoors. The rest of the gas burnt at the rupture point for 2 hours. The leak was plugged and the fire brought under control at 2.45 am. Human casualties included 2 employees who suffered mild concussions and sustained cuts. They were treated onsite. The plant operations were stopped during the enquiry. 

The accident occurred due to a gas leak at the joint of a valve (in open position and at maximum flow). There was no leakproof joint between the two metal parts in contact. The internal metal surface of the valve was not compliant with the specifications in terms of quality. The valve, replaced in 2002, was not considered to be an element critical to the safety even though the process was classified in the high-risk category. Only price was taken into consideration while selecting the maintenance supplier. There was no exchange of information between the operator and the subcontractor during the operation and no acceptance of work was done (especially inspection of the valve bolting). The operator revised procedures, optimised management of maintenance and subcontractors (qualification, information, follow-up, etc.). The emergency operation conditions were also reviewed (appropriate number of trained staff even during low activity periods).

Source:Aria database

COMPETENCE AND CULTURE - GO HAND IN HAND

During a maintenance operation in a refinery, two operators opened the wrong purge. Four hundred litres of naphtha spilled out and caught fire. The operators were not qualified to perform this task and, like 10% of their colleagues, did not follow the operating procedure. The authorities noted persistent shortcomings in the facility operator's safety culture.

Source:Aria database  

THE IMPORTANCE OF OPERATIONAL READINESS REVIEWS - ARE YOU WALKING THE LINE?

 Leak of boron trifluoride (ARIA 51230) Five employees were hospitalised following the release of 15 kg of BF3 during the restart of a petrochemical site. A valve had remained open during a leak test performed the previous day. The operating procedure did not specify the position of the valve (not identified in the DCS) upon completion of the test.

Ammonia leak incident:

When a service provider was filling a tank, 2.1 m³ of NH3 was released via a drain. The day before, the technician preparing the operation was interrupted to take an urgent sample. The service provider's procedures did not provide for an inspection of the installation.

Source: Aria database