In 2008, facility workers in the US closed an isolation valve between the heat exchanger shell and a relief valve to replace a burst rupture disk. Maintenance workers replaced the rupture disk on the day, however, they forgot to reopen the isolation valve. The next day, other facility workers closed a block valve to isolate the pressure control valve from the heat exchange so that they could connect a steam line to the process line to clean the piping. The steam flowed through the heat exchanger tubes, heated the liquid in the exchanger shell, and increased the pressure in the shell. The closed isolation and block valves prevented the increasing pressure from safely venting through either the pressure control valve or the rupture disk and relief valve. The pressure in the heat exchanger shell increased until it violently ruptured.
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