WHAT WENT WRONG

OVERVIEW
1/ The main purposes of safety are to prevent human injury, equipment damages and environmental impacts
2/ To reach above purposes, safety stragery should be applied for design, construction and operation
- Design: all equipment and process have to choose with detail information
Part I - Construction have to comply with the designs
- Operation have to comply with procedures and safety rules.

3/ The "What Went Wrong" book contains a selection of the incident reports from many different companies.
The purpose here is to show what has gone wrong in the past and to suggest how similar incidents might be prevented in the future

LESSON LEAN FROM THE PAST INCIDENTS

Topic What happened? Root cause How to prevent it? Reference

- An operator drain water from a 1,200-m3 spherical storage vessel - Poor design of drain valves and vessel
nearly full of propane - Non-compliance with design of fire water system
- Operator open valve A & B, traces of oil showed that the draining was nearly - Lack of knowladge about Boiling Liquid Expanding Vapor Explosions or BLEVEs during
complete. fire distinguishing - Prevent fire from starting:
- He closed valve A and then crack open to completely drain + Second drain valve should be 3/4 in. and place at least 1m from first valve.
- Nothing come out, he fully open valve A. + Fit remotely controlled emergency isolation valve on drain line
- the choke - hydrate, a compound of water and light hydrocarbon with a + only one connection and full welding from veseel to EIV
melting point above 0 deg.C - cleared suddendly lead to operator and 2 mans + Install combustable gas detector to provide early warning of a leak.
were splashed with liquid - Prevent a fire from escalating
Feyzin Incident - valve A handle was broken and valv B is freezed, the leakage can not be + Insulate vessels with a fire-resistant insulation to prevent heat input to vessel What went wrong, page
(France 1966) stopped + Provide water spray or deluge (If insulation is provided, 2.4 L/m2.min. If insulation is not 166
- A cloud of vapor was ignited by a car near by provided, 8 L/m2 min.)
- The flame flash back to the sphere, but no explosion. + Slope the ground to collect the spillage
- The sphere was fitted with water spray but only a haft of design. + Fit an emergency depressuring valve so that pressure in the vessel
- The fireman used water to cool the neighboring sphares to prevent fire can be reduced to one fifth of design in ten minutes to reduce the strain
spreading on the metal
- the propane, which accummulitaed under sphere, was burn after 90 mins
later. the sphere was damaged causing 15-18 mans were killed, 80 injury
persons
- five spheres and two other pressure vessels burst, and three were damaged.
The chemical in the pump got into the water line used for coffee maker Check valves should be fitted on service lines
Disconnected a hose when not in use
Double blocks and bleed valves
Low pressure alarm on service line; High pressure alram on process line.
Reverse flow into What When Wrong,
A hosed had been fixed up to prime a pump
service mains page 330

Ammonia flowed backward from a storage vessel which was open for
maintenance

What When Wrong,

Leaking valve
page 328

Reverse flow from

a product reciever A toxic gas in a blowdown header flowed into a tower and out of the drain
A slip-plate could have been inserted between product receiver or blowdown with plant
or blowdown line valve. The operator who was draining the tower was killed
back into the plant

What When Wrong,

Leaking valve
page 329

-A high temperature trip in a reactor occurred and the trip valve failed to close
although it was tested regularly.

-the flow control valve before the trip valve was failed to open position and full
Emergency valves have to be tested against the maximum pressure or flow they may What When Wrong,
Trip upstream pressure applied to trip valve
experience page 273
-the pressure drop through the trip valve was so high that the valve could not close

- Install Emergency Isolation Valve (EIVs) at the line which a large of material may spread
- Light leak oil from a pump caught fire. The flames were 10 m
during leakage
- operator closed a remotely operated valve in the pump suction line
- Install check valve for pump to prevent backflow What When Wrong,
Pump leakage - flames soon died down
- EIV should automatically shutdown any pump in the line page 155
- if the emergency valve was not provided, the fire would have burned for
- EIVs should close quickly but not too quick (<30s)
many hours.
- EIVs should be tested regularly to prevent sticking

Main cause of pump failure:

- changing of operating condition or composition of liquid ---> corrosion increasing
- Incorrect installation or repair (fitting the bearing or seal, piping work,…) ---> pump
running with abnormal condition - Keep operating condition as stable as possible
- Wrong operation such as not venting completely, starting with discharge valve open or - carry out alignment and leak test for seal before running
What When Wrong,
Pump failure Pump failure suction valve close,.. - Develop practical procedure for running pump
page 206
- Pump manufacturing faults - Check and test pump carefully for new pump
- seal failure lead to leakage of flammable materials - Install minimum line for pump to prevent dead-heading
- Dead-heading (like punp running with discharge valve close) --> rise temperature -->
damage seal

- Reactor has been finished maintenance work. And the splip-plate has been - Reactor was not isolated and gas test before entering
removed to prepare for start up - Explosion cause by hydrogen leaking to the reactor
- This was realized that additional work have to be done and the man was - Operator bypass procedure
allowed to enter the reactor without splip-plate and gas test
- An explosion occurred, killing two and injuring two others.
- Explosion cause by hydrogen leaking to the reactor through tube leak

- Before enter to any confined space, ensure that the vessel have been isolate from all
Vessel not isolated
hazardous sources by blind What When Wrong,
from sources of
- purging and gas test should be carried out completely page 233
danger
- Use gas mark or SCBA during working inside the confined space
Part II
Part II

Some ammonia got back into the ethylene oxide storage tank, past The reactant(s) should be added via a small break tank so that if reverse flow occurs
several check valves in series and a positive pump. It got past the pump only a small quantity will react and not the main stock.
through the relief valve, which discharged into the pump suction line. The The pressure drop in the pipeline should be measured, and if it gets too low, a trip
ammonia reacted with 30 m3 of ethylene oxide in the storage tank. There valve should be closed automatically.
was a violent rupture of the tank, followed by an explosion of the vapor
cloud, which caused damage and destruction over a wide area

Reverse flow from What When Wrong,

Malfunction check valves
reactors page 332

The feed line to a furnace was provided with a permanent steam

connection for use during de-coking.
The connection was on the bottom of the feed line, and the steam valve
was not close to the feed line. Water collected above the steam valve,
froze during cold weather, and ruptured the line, allowing oil at a gauge
pressure of 30 bar to escape.

-Dead-ends should be avoided

What When Wrong,
Dead-End Wrong design causing water collected in dead-end - If could not avoided, connected dead-end to the top of the main pipeline (unless the
page 181
liquid in the pipeline is denser than water).

Explosion while lighting furnace - Fuel gas inlet valve was leaked
- A foreman tested the atmosphere inside a furnace with a combustible gas - The furnace was not purged by inert gas and gas test before igniting
detector.
- No gas was detected, so the slipplate was removed
- Two minutes later, a lighted poker was inserted. An explosion occurred
- The foreman and another man were hit by flying bricks, and the brickwork
was badly damaged.

- Before lighting burner, positive isolation of fuel gas line such as double block and bleed
should be install
- Test the atmosphere inside the furnace. If flammable gas was detected, purging with inert
gas.
Furnaces Chapter 10 - page 223
- If no gas is detected, light and then insert the poker (or switch on
the electric igniter).
- Line up fuel gas line by changing over the double block and bleed valves
- Open the fuel-gas isolation valve

A restriction developed after the furnace The relief valve should have been placed after the furnace or the low-flow trip.
The relief valve lifted" flow through the furnace tubes fell to low Mounted vertically and should not be mounted horizontally.
The low-flow trip is inactivated because flow through it was normal, tubes
overheated and burst.

What When Wrong,

Relief Valves Relief valve was installed improperly position
page 181

- Level glasses should not be used on vessels containing flashing flammable or toxic liquids,
use magnetic types is better
What went wrong, page
Level gauge - Level glasses should be fitted with ball check valves, which prevent a
148
massive leak if the glass breaks.
- The valve with check ball should be fully opened for the ball operation

- A pump relief valve was removed for overhaul and the open end
blanked by a blind flange.
- Another shift, not knowing that the relief valve was missing, started up
the pump. The blank was probably not tight, and light oil leaked past it
and exploded in the confined processing area.
-The exploision killed 163 people on oil platform in the sea.

-Poor isolation -Insert a spade for positive isolation

What Went Wrong, page
Dead-End -Inadequate permit and lockout/tagout system - Enhance procedure for maintainnace and shift handover
5
-Poor handover between shift and critical information was not shared - Improve employees' saftey awareness

CONCLUSION (What we lean?)

Part III - Incidents could be happened anytime and could cause catastrophic consequences
- Implement safety design
- Incidents could be prevented if safety issues are prioritized