Event
- Event ID
- 81
- Quality
- Description
While de-plugging a cooling circuit, a blockage suddenly released, causing a heavy movement of a flexible hose connected to the system. The flexible hose hit several small pipes and one employee standing nearby. Due to the broken pipework there was a release of hydrogen and butane for about five minutes. Sprinkler systems were activated, no ignition occurred.
- Event Initiating system
- Classification of the physical effects
- Unignited Hydrogen Release
- Nature of the consequences
- leak no ignition
- Macro-region
- Europe
- Country
- European Union
- Date
- Component involved
- pipe (generic)
- Failure mode
- rupture, no ignition
- Initiating cause
- impact, rollover, crash
- Root CAUSE analysis
The INITIATING cause was a mechanical failure, the root cause is not reported. However, an abnormal situation had occurred previously during the day, hinting probably at some human and/or organisation error.
- Root causes
- Date entry in HIAD
- 28/02/2009
Facility
- Application
- Chemical industry
- Sub-application
- Polymerisation plant
- Hydrogen supply chain stage
- All components affected
cooling circuit, hose, pipes, Plastics and rubber manufacture
- Location type
- Unknown
- Location
- industrial area
- Operational condition
- Pre-event occurrences
De-blocking of a cooler was done by using water at high pressure, but with great difficulties. During the day, a nitrogen feed had been temporarily opened out of fear for an explosive atmosphere in the receiving tank-truck. When the water pressure was put on the system again, a nitrogen plug was probably compressed. When the blockage released, the plug was ejected with great velocity, causing the connected flexible hose to move violently.
Emergency & Consequences
- Number of fatalities
- 0
- Number of injured persons
- 1
- Post-event summary
One employee standing nearby was hit by the flexible hose. Loss of hydrogen and butene for several minutes. Limited loss of polyethylene powder and hexane. Estimated production loss: 7 days.
- Emergency action
Sprinkler systems were activated to contain hydrocarbon cloud and to prevent ignition. Leaking pipes were blocked after five minutes. The injured employee was hospitalised.
- Emergency evaluation
An explosion could have destroyed the entire polymerisation unit.
Lesson Learnt
- Lesson Learnt
This is a classic case of injuries and damages caused by a whiplash of high-pressure hoses. Best practice and work procedures require the use of hose whip restraints (whip checks) to secure the hose and prevent it from whipping during a failure. It is recommended to regularly check if the hoses are securely anchored and to wear appropriate PPE. A lose, unrestrained hose shall never be operated.
In-depth data
- Release type
- gas mixture
- Involved substances (% vol)
- C4H8
H2 - Probable IGNITION SOURCE
References
- Sources categories
- eMARS
- Reference & weblink
Event description in the European database eMARS (accessed December 2020)