Process safety time for fired heaters

The fired heater is a common unit operation in the refining and petrochemical industries that is used to increase the temperature of a process fluid. Fired heaters are required when a process-to-process heat exchanger or a utility exchanger (steam condenser, hot oil heater) cannot provide sufficient driving force to raise the temperature of a process fluid for downstream processing. There are numerous applications for fired heaters, from preheating feed to process units to reboiling distillation towers.

During the course of normal operation a fired heater will be exposed to disturbances in the supply of fuel, combustion air, or process fluid that may lead to a potentially hazardous condition developing. To manage these disturbances and take appropriate action to safely operate and control the fired heater, several layers of protective systems are normally provided.¹ These protective systems are designed to take independent action that will prevent the fired heater from reaching a hazardous condition.

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REFINERY FIRE INCIDENT

Incident at Visakh Refinery Date of incident : 23.08.2013 Time: 16:46 hrs Entity: HPCL Location: VRCFP Cooling Tower, Visakh Refinery, Vishakhapatnam

Description:On August 23, 2013, one of the cells of the Salt Water Cooling Tower of Visakh refinery was being commissioned. During the opening of the water line at about 16:46 hours, there was a minor explosion and fire. The cooling tower burned down and collapsed. Due to the fire, workers working near other cells and surrounding area sustained burn injuries. There was one fatality (company employee) and 39 persons sustained injuries and were shifted to INS Kalyani and other hospitals in the city. On the next day, another 6 dead bodies were found in debris. 

Observation:

•One new cell was added to the existing cooling tower, and the existing cells were under maintenance.

•Hot jobs were going on in the nearby area.

•The ingress of hydrocarbon in the cooling water was due to leakage of cooler / condenser in process units connected with this return line.

•There was imbalance in load of two distribution headers on the top of cooling tower cells. To reduce the load on the cooling towers, a process modification scheme was issued whereby the cooling water return headers were proposed to be re-routed to the ground level and construction of riser pipes from the bottom header to the top of each cell, for uniform supply of hot cooling water to the Cooling Tower. With this, the load of return header, which earlier was on top of the cell, would be shifted from Cooling Tower structure to the separate supports outside the Cooling Tower.

•There is distinct possibility of entrapped / accumulated light hydrocarbon in the portion of the new line since it is located at an elevation and that there was no escape route for this entrapped hydrocarbon as the other end of the header was closed by valve.

•The entrapped hydrocarbon gushed into the Cooling Tower as soon as the cooling water return line valve to the new cell was opened. The hydrocarbon got ignited by the spark of welding jobs being carried out nearby causing explosion and major fire. The wooden structure of the Cooling Tower got ignited in the process which continued for about 45 minutes till the fire was extinguished by F&S personnel.

•The accident resulted in serious burn injuries and fatality to a number of persons working in the cooling tower area.

Cause:

•Gushing out of entrapped hydrocarbon from the cooling water return header to newcell, which got ignited since hot jobs were being carried out in close vicinity. The ingress of hydrocarbon was due to leakage of hydrocarbon in cooler/condenser in connected process units.

•Not adhering to the practice of stopping all work (especially hot work) and prohibiting all unrelated contractor and company personnel at site, before commissioning a new system/ facility. Also, carrying out hazard analysis/ risk assessment would have probably indicated that there could be trapped HC gas, and prompted commissioning/ operation team to vent out entrapped gases.

•Undertaking commissioning activities, even though several jobs were unfinished: HC and H2S detectors were not installed. Instrument cabling, cooling fan jobs were still unfinished.Decision to go ahead with commissioning was taken at fag end of the day.Improper coordination amongst Operation, Maintenance and Project departments.Non – liquidation of the gaps identified in internal safety audit & operation check-list before commissioning.

Recommendations:

•Do not allow simultaneous hot work and commissioning activity at site as this increasemanifolds the chances of accidents.

•While commissioning activity is planned/ undertaken, it must be ensured that other than the required personnel, nobody should be allowed to be present at the work site.

•Hazard analysis must be done prior to commissioning of any new facility.

•Hazard Identification and Risk Assessment must be carried out before commissioning of any new/ temporary facility / system; this analysis by a multi-disciplinary group can easily identify the risks involved and suggest measures to overcome the same.

•Facility(s) must not be commissioned unless pre-com audit is carried out.•No facility should be commissioned unless it is ensured that internal audit points / precom check-list points are liquidated; further a multi-disciplinary group must carry out the internal audit.

•There must be a proper coordination amongst the various departments; in the instant case there was clear communication gap and lack of coordination amongst Operation, Project and Maintenance Departments.

•No facility must be commissioned unless safety devices like Hydrocarbon or Hydrogen Sulphide detectors are installed.

•Standard Operating Procedure must be prepared; shared with operating personnel and ensured its display at site prior to commissioning.

•Proper house-keeping must be done at the commissioning site; the site should be clear of unwanted materials and debris.

Source: https://www.pngrb.gov.in/pdf/ERDMP/Analysis of incidents reported to PNGRB from July 2013 to Dec 2014

Incident due to ineffective PSM system

 OSHA's inspection identified several serious deficiencies in a company's process safety management program, a detailed set of requirements and procedures employers must follow to proactively address hazards associated with processes and equipment that involve large amounts of hazardous chemicals. In this case, the chemical was acetone, used in a PSM-covered process known as direct solvation. On the day of the explosion, a valve on a transfer line inadvertently was left open, resulting in the release of flammable acetone vapors. The vapors exploded after being ignited by an undetermined source.

"In this case, the company knew from prior third party and internal compliance audits conducted at the plant that aspects of its PSM program were incomplete or inadequate, and misclassified electrical equipment was in use. The company did not take adequate steps to address those conditions,"

"Luckily, the explosion happened when there were few workers in the plant. Otherwise, this incident could have resulted in a catastrophic loss of life."

Specifically, OSHA found that the process safety information for the solvation process was incomplete. The employer's analysis of hazards related to the process did not address previous incidents with a potential for catastrophic results, such as forklifts that struck process equipment, and did not address human factors such as operator error, communication between shift changes and employee fatigue from excessive overtime. In addition, the company did not ensure that a forklift and electrical equipment, such as a light fixture, switches and a motor, were approved for use in Class 1 hazardous locations where flammable gases or vapors are present. 

Source:OSHA.gov

Hydrogen leak incident

A hydrogen leak at the flange of a 6-inch synthesis turbocharger valve in an ammonia production plant ignited and exploded. Hydrogen detectors and the fire alarm alerted the control room, which immediately shut down the plant, and the fire was then extinguished rapidly. There were no injuries caused by the accident, since the operator heard a wheezing sound and was able to run away just before the explosion occurred. The leaking gas was composed of 70% hydrogen at a flow rate of 15,000 cubic meters per hour. Property damages in the turbocharger included electrical cabling, melted siding, and heavily damaged pipes. The ammonia plant was shut down for more than a month.Five days before the incident, a problem with the CO2 absorber column led operators to open the vent downstream of the column. In retrospect, this excessive venting was an operational error. It caused a reduction in the suction pressure of the ammonia synthesis turbocharger and the activation of the plant emergency stop. The relief valve on the line between the turbocharger and the methanation reactor was then exposed to high pressure, causing it to open without the operator noticing. Production resumed the next day, but abnormal consumption of syngas led the operator to conduct further investigations. He discovered that the valve was no longer leak-proof and was allowing the gas to escape through a 47-meter chimney. The plant was shut down again to replace the relief valve.When the plant was restarted, the methanation reaction was initiated at 10:00 PM, the synthesis turbocharger started operating at 1:30 AM, and the incident occurred at 3:14 AM on the flange of the newly installed 6-inch-diameter valve. The incident was caused by vibrations in the relief valve, resulting in the quick release of the flange screws, which were probably not tightened sufficiently. In addition, when the relief valve was replaced, it was probably under-calibrated.

Source:https://h2tools.org/lessons/hydrogen-leak-ignites-and-explodes-ammonia-production-plant

Cryogenic incident

 What Happened?

A researcher inserted metal racks into a liquid nitrogen tank when her right hand came into contact with the chemical; she sustained cold burns to her index, middle and ring fingers. The researcher reported the incident immediately to her PI, and went to the emergency room for medical attention. At the time of the incident the researcher was wearing appropriate PPE including a pair of latex gloves underneath the cryogenic gloves; however, the chemical had penetrated the gloves upon submersion.
What Was The Cause?

The cryogenic gloves worn by the researcher appeared to be intact. Cryogenic gloves are meant to handle cold items and protect to temperatures as low as -162°C (-260°F). However, they are not meant to be submerged into liquid nitrogen which has a temperature of −196 °C ( −321 °F). In addition, if the gloves were used for other purposes where they get wet, the problem can be compounded. Not all cryogenic gloves are water-resistant.
 

What Corrective Actions Were Taken?
• Review the correct use of cryogenic gloves and modify SOP for handling cryogenic chemicals
• Review modified SOP with lab members
 

How Can Incidents Like This Be Prevented?
• Make sure to use all equipment according to their specifications

 

Source: https://cls.ucla.edu/

High pressure water can kill

 At 5:45 p.m. on April 29, 2018, an employee was inspecting a leak beneath a valve. The employee was struck by high pressure water at 2,200 psi when the valve failed and came off, penetrating his upper torso. The employee was killed. 

Source:osha.gov

Hydraulic hose incident

 At 6:15 p.m. on November 20, 2017, an employee was working on a hydraulic leak on Filter Press #1 at the Pollution Control Plant. The employee was struck on the left side of his head by a high pressure hydraulic hose which was released from a tee fitting. The employee sustained trauma to the head when struck by the high pressure hydraulic hose fitting and was killed. 

Source:osha.gov

Hydrogen explosion

 At 9:23 a.m. on November 17, 2018, an employee was stabilizing magnesium metal. Magnesium is reacted with water to make magnesium oxide, which is a more stable compound. During this process hydrogen and oxygen are released. The hydrogen ignited and in the presence of oxygen and created a large explosion. The employee was killed. 

Source:osha.gov

Ammonia incident

 On January 10, 2020, Employees #1 and #2 were working from a scissor lift and dismantling an ammonia blast freezer in preparation for installing a new freezer. As they worked, ammonia was released. Employee #1 was killed by the chemical exposure. Employee #2 self-rescued, but was seriously injured. He was transported to the hospital and treated for severe burns and inhalation injuries. 

Source:osha.gov

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Hydrogen Sulphide accident

 At 11:00 a.m. on July 7, 2017, Employee #1was attempting to dislodge a 24 inch rubber plug from a 2foot diameter sewer pipe located inside a 24foot deep wet well. The workers were outside the well pulling on a 1/4-inch nylon rope that was attached to the 24-inch diameter plug. The plug was lodged inside a T-shaped PVC fitting from the force of the waste water emptying into the well. Without conducting any atmospheric testing of the work space, Employee #1 climbed down the ladder with a crowbar to dislodge the deflated 24inch diameter rubber plug, which was about 8 feet below the top of the well. He had difficulty releasing the plug with the crowbar and started to make his way up the ladder. He lost consciousness when he was about 2 feet from the top of the well and fell into the 24 foot deep well. Employee #2 descended down the ladder to provide emergency rescue, but lost consciousness and went underwater. The waste water level was about 3 feet deep at this point. Employee #3 climbed down the ladder to provide emergency rescue, but consciousness as well. All three workers were asphyxiated by hydrogen sulfide (H2S) gas. 

Source: osha.gov

Confined space incident

 At 12:30 p.m. on February 20, 2020, Employee #1, employed by a structural steel fabricator and erector company, was entering a tank to clean it. The tank had a combination of Ecocure II and methyl ethyl ketone (MEK) residues and had been purged with nitrogen. Employee #1 entered the permit required confined space that contained the residual chemicals and nitrogen to perform the cleaning operations. She was overcome by the oxygen deficient atmosphere. Employee #2, employed by a chemical distribution company, entered the tank to make a rescue attempt for Employee #1. He was also overcome from the oxygen deficient atmosphere. Both employees were killed by asphyxiation. 

Source:osha.gov

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Hazards of hydraulic accumulators

 https://www.machinerylubrication.com/Read/30331/hydraulic-accumulators-dangers

Fluid power incidents

 Fluid power incidents

Vacuum pump explosion in a lab

 Vacuum pump explosion in a lab

Learn from this incident

Employee #1 and several coworkers were working at a chemical plant that deals with nitric oxide. On the day of the accident, a major leak occurred in a stainless steel distillation column. The nitric oxide leaked into the facilities surrounding vacuum jacket and into the atmosphere through a pump, which controls a high quality vacuum inside the jacket to minimize transmission of heat toward the cryogenic distillation columns. A brown cloud quickly formed and the temperature and the pressure inside the distillation column and its surrounding vacuum jacket began to rise. The leak was detected and the vacuum pump was turned off to halt the leakage of nitric oxide into the atmosphere, allowing the pressure inside the column and vacuum jacket to stabilize around 130 psi. Although stabilized, the pressure was far above the normal pressure of less than or equal to atmospheric pressure (14.7 psi). Approximately 3 hours later, an explosion occurred. The operation and process were destroyed, and debris flew through the plant. Employee #1 suffered lacerations due to flying glass and was treated at a local hospital, where he received stitches and then released. A detailed investigation determined that the cause of the explosion was most likely due to something inside the vacuum jacket initiated the dissociation of nitric oxide, a reaction that is very rapid, exothermic, and self-propagating once started. 

Source:OSHA.gov

Accident due to a change implemented during an emergency

Reactor #1, part of the ABS polymerization process began to overheat as the viscosity increased and threatened to stop agitation. This would cause a runaway reaction and ultimately result in an explosion. A small leak had developed in the lower bushing of the agitator and the employer instructed an employee to tighten it with a wrench. The employer replaced the normal feed (a mixture of styrene monomer, ground rubber, and acrylonitrile) with pure styrene monomer, which has a much lower viscosity, to "flush" the process in the hope that this would stop the leak. The mixture began to spill through the lower agitator packing and at approximately 2:30 p.m., there occurred a major spill of styrene monomer (flammable) and acrylonitrile (flammable and carcinogenic). They evacuated the plant and called for outside assistance to stop the spill and initiate clean-up. 

Source: OSHA.gov

How fragile is your plant?

 How fragile is your plant?

Employee Killed By Inadvertently Drinking Acid Cleaning Fluid

At approximately 9:30 a.m. on October 3, 2002, an employee who worked for a company that provided vehicle maintenance such as car washes, detailing, fueling, and lube and oil servicing, inadvertently drank acid from a plastic spray bottle while he was on a rest break. The employee, feeling very ill after ingesting the contents of the quart bottle, asked his coworkers to transport him to the hospital. He was taken to San Antonio Community Hospital where he was pronounced dead at 11:49 a.m. from internal injuries. Laboratory analysis indicated that the acid solution in the plastic bottle contained hydrofluoric acid and phosphoric acid with a pH of less than one. 

Source:osha.gov