Event
- Event ID
- 91
- Quality
- Description
The event occurred while re-starting the ammonia production unit after a technical stop, a synthesis gas (50% hydrogen, 17% ammonia, methane and nitrogen) leak ignited on a flange located just after the synthesis reactor.
Emergency shutdown of the unit was executed and the fire was extinguished in a bit less than 1 hour.The leaking at the flange was caused by a tightening torques of the bolt which were not adapted to the exceptional conditions prevailing during the accident. The short technical breakdown had induced a very quick temperature evolution with significant temperature gradients between the bolts and the flange.
- 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 (bolts)
- Failure mode
- leak & ignition
- Initiating cause
- loss of tightness (thermal stress/cycling)
- Root CAUSE analysis
The INITIATING CAUSE was loss of tightness of the flange due to the temperature gradient occurred during the technical shutdown. flange were not adapted to the situation.
The ROOT CAUSE (or at least an intermediate cause) is related to the fact that these temperature excursions had not been taken into account in the design of the reactor. Assuming that the operation of tightening had been executed by a contractor during the last inspection and maintenance works, another factor of the ROOT CAUSE could be the management of the contractor's operation by the site operator.
- Root causes
- Date entry in HIAD
- 28/02/2009
Facility
- Application
- Chemical industry
- Sub-application
- Ammonia production
- Hydrogen supply chain stage
- All components affected
flange
- Process temperature range [C]
- High temperature (100°C to 500°C)
- Location type
- Unknown
- Location
- industrial area
- Operational condition
- Pre-event occurrences
The ammonia producing unit had to be shut down rapidly due to a technical issue. At the moment of the re-start, the reactor had been shut down for 1h30.
Emergency & Consequences
- Number of fatalities
- 0
- Number of injured persons
- 0
- Currency
- Euro
- Property loss (onsite)
- 360.000
- Post-event summary
The material damage was estimated at 60 K Euros and concerned the thermal insulation of pipes, louvers protecting the reactor against atmospheric action, fire-proof concrete of the reactor frame and the instrumentation cables within a radius of 3 m. The blaze did not damage the reactor that was protected by a deflector. Operating losses stood at 300 k Euros.
- Emergency action
The unit’s automatic alarms were triggered and the operator started the emergency shutdown, which isolated and depressurised 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.
Lesson Learnt
- Corrective Measures
The following was implemented as corrective measures from the lesson learnt :
i) modification of tightening torque.
ii) improvement of leak collector on flange.
iii) nitrogen injection system in leak collector
iv) installation of vapour injectors to protect the reactor.
In-depth data
- Release type
- gas mixture
- Involved substances (% vol)
- H2 50%,
NH3 17%,
CH4,
N2 - Probable IGNITION SOURCE
- Flame type
References
- Sources categories
- ARIA
- Reference & weblink
Event description in French database ARIA
https://www.aria.developpement-durable.gouv.fr/accident/32174/
(accessed September 2020)Also uptaken from ARIA by US database H2TOOLS
https://h2tools.org/lessons/ignition-syngas-leak-ammonia-production-pla…
(accessed Sept 2025)