Oil Refinery Integrity Related Incidents

David Willetts – HSE Manager Duqm Refinery Co.

Oil Refinery Integrity Related Incidents
• 3 separate maintenance related incidents occurred at a UK Oil
Refinery and Terminal during a 3-month period in 1987:
1. Flammable liquids released unexpectedly during maintenance
of a refinery flare system, resulted in a fire which killed 2 men
and seriously injured 2 more
2. One man was killed and extensive damage was caused by an
explosion with fire while the refinery Hydrocracker Unit was
being recommissioned after repairs
3. A fire within a storage tank at the refinery’s crude oil terminal
killed one of a contractor’s team removing sludge. Smoking
caused ignition
• Were these 3 tragic accidents coincidence or the result of
systemic safety management failures?
Hydrocracker Unit Explosion - Summary
Hydrocracker Unit involves an exothermic process involving the break down of low grade waxy
and viscous feedstock oils by mixing them with hydrogen gas at high temperature and pressure
in the presence of a catalyst to convert them to high grade light oils, petroleum and LPG

• Hydrocracker unit was being recommissioned

following a routine shutdown
• During recommissioning, a plant trip occurred
• This was thought to be a spurious trip and the
operators started to bring up the unit to
normal operating conditions
• The plant was held in standby condition
overnight with no fresh feed
• At 07:00 hrs the following morning there was
a violent explosion and subsequent fire
• One man was killed on site
• The explosion caused extensive damage and
could be heard 30 km away
• Debris weighing several tonnes was propelled
up to 1 km, in some instances off-site
What Happened (1)?
Part of the HC process involves passing hydrogenated liquid/gas mixture into a vertical high pressure (HP)
separator (V305) where hydrogen and light gases are separated from the liquid. From V305, liquid at 155
bar passed via control valves to a horizontal low pressure (LP) separator (V306) where more hydrogen and
light gases were separated from the liquid at 9 bar

• During recommissioning the HC

Unit was put on standby following
a plant trip
• Air operated CV LIC 3-22 between 155 bar
the HP and LP separators was
opened and closed on manually at
least 3 times while on standby
• Fluid level in the HP separator fell
resulting in HP gas breakthrough
into the LP separator
• LIC 3-22 did not close automatically
because its trip solenoid had been
9 bar
disconnected a year earlier
What Happened (2)?
• The pressure relief on the LP
separator had been designed for
a fire relief case not for gas
breakthrough 155 bar
• LP vessel subsequently exploded
• Control valve LIC 3-22 did not
close automatically because the
low low level trip on the HP
separator had been disconnected
• The operators did not trust the
main level control reading and
assumed that the level in the HP 9 bar

separator was normal

Preventive Measures (1)
1. There should have been a
high integrity automatic
safety system to protect
against gas breakthrough:
a. Pressure relief for maximum
anticipated gas flow rates
b. Safety shut off system should
have included a secondary shut
off valve in the line from V305,
in addition to the control
valves
c. Independent extra-low level
detection / trip should have
been fitted on V305
This was a classic HP-LP Interface.
Do you have similar on your facilities? Do you have adequate overpressure protection?
 Preventive Measures (2)
2. Control room practices should
have been monitored to detect
possibilities for malpractice or
error:
3. A full analysis of the dangers
and potential consequences
inherent in the operation of the
HC Unit should have been
carried out and documented:
a.Adequate safeguards provided
b.Communication of potential
dangers and precautions to all
concerned parties
Preventive Measures (3)
4. The trip systems and alarms as
installed should have been
connected and in full
operational order:
a. Comprehensive testing
schedules
b. Defects should have been
reported, recorded and
actioned
Key Messages (1)
• There have been many improvements and advances in process
and technical safety since 1987 e.g. Technology / Automation /
Distributed Control Systems (DCS)
• Regulations / standards for Process Safety Management (PSM)
e.g. COMAH / OSHA
• Identification and Assessment of Major Accident Hazards
(MAHs) is now more systematic e.g.
 Hazard Operability (HAZOP) / Process Hazard Analysis (PHA)
(Retrospective / Revalidation)
 Layers of Protection Analysis (LOPA)
 Safety Integrity Level (SIL) assessment
 QRA
 HP-LP Interface reviews / register
 Interlock and LO / LC Valve Register
 Register of Safety Critical Equipment (SCE) etc.
Key Messages (2)
• Management of Change (MoC) process with Risk Assessment
• Effective Maintenance Management System (MMS)
• Competence Assurance for operations and maintenance
Safety Critical Positions
• Consideration to be given to the effective management of
Human Factors in safety and integrity
• Process / Integrity Leading and Lagging Indicators

At least 64 people died at US refineries in 10 years before 2005

At least 58 people have died between 2005 - 2015