Event
- Event ID
- 987
- Quality
- Description
During a work tour on a refinery, an employee noticed a fire at the level of a flange at the inlet of the grille of an exchanger, located at the outlet of a reactor of the catalytic reforming unit.
The plant operator detected a lack of uniformity of torque on the bolts. Two years before, during a shutdown period, some parts of the exchanger had been removed for inspection. The flange on the heat exchanger side was not easily accessible. During reassembly, the presence of a pipe tee near the flange made it difficult to tighten with a bolting machine. The faulty tightening (1.5 mm opening) could have led to the leakage of high-octane gasoline, mixed with hydrocarbon gases and hydrogen. Without a hot spot nearby, this 500°C fluid could have spontaneously ignited on contact with air.
The plant operator tightened the flange and modified procedures to specify the use of a suitable wrench for the configuration. The operator also planned to carry out independent checks on the quality of the connections made.- Event Initiating system
- Classification of the physical effects
- Hydrogen Release and Ignition
- Nature of the consequences
- fire
- Macro-region
- Europe
- Country
- France
- Date
- Component involved
- flange (generic)
- Failure mode
- rupture & ignition
- Initiating cause
- loss of tightness (wrong operation)
- Root CAUSE analysis
The INITIATING cause was the ignition of leaked mixture of hydrocarbons, including hydrogen. The INTERMEDIATE or ROOT CAUSE could have been the lack of tightness of a flange caused by a not-properly tightening of the bolts. Finally, A CONTRIBUTING or ROOT CAUSE was the difficulty of re-assembling of the system due to design.
- Root causes
- Date entry in HIAD
- 01/01/2024
Facility
- Application
- Petrochemical industry
- Sub-application
- Catalytic reforming processes
- Hydrogen supply chain stage
- All components affected
reformer, heat exchanger, flanges, bolts
- Process temperature range [C]
- Very high temperature (500°C to 1000°C)
- Location type
- Unknown
- Location
- industrial area
- Operational condition
Emergency & Consequences
- Number of fatalities
- 0
- Number of injured persons
- 0
Lesson Learnt
- Lesson Learnt
The quality of the event description does not allow for a detailed lesson learnt. nevertheless, better operative/maintenance procedures and a (better) reporting system shall be part of it.
- Corrective Measures
The plant operator modified procedures to specify the use of a suitable wrench for the configuration.
The operator also planned to carry out independent checks on the quality of the connections made.
In-depth data
- Release type
- gas mixture
- Involved substances (% vol)
- gasoline,
hydrocarbons,
H2 - Release temperature [°C]
- 500
- Probable IGNITION SOURCE
References
- Sources categories
- ARIA
- Reference & weblink
Event description no 55225 in the French database ARIA
https://www.aria.developpement-durable.gouv.fr/accident/55225_en/?lang=…
(accessed October 2021)