OVERVIEW

1/ The main purposes of safety are to prevent human injury, equipment damages and environmental impac

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
- Construction have to comply with the designs
Part I - 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 compani
The purpose here is to show what has gone wrong in the past and to suggest how similar incidents might be

LESSON LEAN FROM THE PAST INCIDENTS

Topic

Feyzin Incident
(France 1966)
Reverse flow into
service mains

Reverse flow from a

product reciever or
blowdown line
back into the plant
 Trip

Pump leakage
 Pump failure

Vessel not isolated

from sources of
danger

Part II

Reverse flow from

reactors
Dead-End

Furnaces
Relief Valves

Level gauge
 Dead-End

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
 WHAT WEN
IEW
ain purposes of safety are to prevent human injury, equipment damages and environmental impacts

ch above purposes, safety stragery should be applied for design, construction and operation
all equipment and process have to choose with detail information
ction have to comply with the designs
on have to comply with procedures and safety rules.

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

N LEAN FROM THE PAST INCIDENTS

What happened?
- An operator drain water from a 1,200-m3 spherical storage vessel
nearly full of propane
- Operator open valve A & B, traces of oil showed that the draining was
nearly complete.
- He closed valve A and then crack open to completely drain
- Nothing come out, he fully open valve A.
- the choke - hydrate, a compound of water and light hydrocarbon with a
melting point above 0 deg.C - cleared suddendly lead to operator and 2 mans
were splashed with liquid
- valve A handle was broken and valv B is freezed, the leakage can not be
stopped
- A cloud of vapor was ignited by a car near by
- The flame flash back to the sphere, but no explosion.
- The sphere was fitted with water spray but only a haft of design.
- The fireman used water to cool the neighboring sphares to prevent fire
spreading
- 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

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

A toxic gas in a blowdown header flowed into a tower and out of the
drain valve. The operator who was draining the tower was killed
-A high temperature trip in a reactor occurred and the trip valve failed to
close although it was tested regularly.

- Light leak oil from a pump caught fire. The flames were 10 m
- operator closed a remotely operated valve in the pump suction line
- flames soon died down
- if the emergency valve was not provided, the fire would have burned for
many hours.
Pump failure

- Reactor has been finished maintenance work. And the splip-plate has been
removed to prepare for start up
- This was realized that additional work have to be done and the man was
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

Some ammonia got back into the ethylene oxide storage tank, past
several check valves in series and a positive pump. It got past the pump
through the relief valve, which discharged into the pump suction line. The
ammonia reacted with 30 m3 of ethylene oxide in the storage tank. There
was a violent rupture of the tank, followed by an explosion of the vapor
cloud, which caused damage and destruction over a wide area
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.

Explosion while lighting furnace

- A foreman tested the atmosphere inside a furnace with a combustible gas
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.
A restriction developed after the furnace
The relief valve lifted" flow through the furnace tubes fell to low
The low-flow trip is inactivated because flow through it was normal, tubes
overheated and burst.
 - 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.

USION (What we lean?)

s could be happened anytime and could cause catastrophic consequences

ent safety design
s could be prevented if safety issues are prioritized
 WHAT WENT WRONG

nvironmental impacts

and operation

y different companies.
ar incidents might be prevented in the future

Root cause
- Poor design of drain valves and vessel
- Non-compliance with design of fire water system
- Lack of knowladge about Boiling Liquid Expanding Vapor Explosions or BLEVEs during
fire distinguishing
A hosed had been fixed up to prime a pump

Leaking valve

Leaking valve
-the flow control valve before the trip valve was failed to open position and full
upstream pressure applied to trip valve
-the pressure drop through the trip valve was so high that the valve could not close
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
- Wrong operation such as not venting completely, starting with discharge valve open
or suction valve close,..
- Pump manufacturing faults
- seal failure lead to leakage of flammable materials
- Dead-heading (like punp running with discharge valve close) --> rise temperature -->
damage seal

- Reactor was not isolated and gas test before entering

- Explosion cause by hydrogen leaking to the reactor
- Operator bypass procedure

Malfunction check valves

Wrong design causing water collected in dead-end

- Fuel gas inlet valve was leaked

- The furnace was not purged by inert gas and gas test before igniting
Relief valve was installed improperly position
-Poor isolation
-Inadequate permit and lockout/tagout system
-Poor handover between shift and critical information was not shared
 How to prevent it?

- Prevent fire from starting:

+ Second drain valve should be 3/4 in. and place at least 1m from first valve.
+ Fit remotely controlled emergency isolation valve on drain line
+ only one connection and full welding from veseel to EIV
+ Install combustable gas detector to provide early warning of a leak.
- Prevent a fire from escalating
+ Insulate vessels with a fire-resistant insulation to prevent heat input to vessel
+ Provide water spray or deluge (If insulation is provided, 2.4 L/m2.min. If insulation is
not provided, 8 L/m2 min.)
+ Slope the ground to collect the spillage
+ Fit an emergency depressuring valve so that pressure in the vessel
can be reduced to one fifth of design in ten minutes to reduce the strain
on the metal
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.

A slip-plate could have been inserted between product receiver or blowdown with plant
Emergency valves have to be tested against the maximum pressure or flow they
may experience

- Install Emergency Isolation Valve (EIVs) at the line which a large of material may spread
during leakage
- Install check valve for pump to prevent backflow
- EIV should automatically shutdown any pump in the line
- EIVs should close quickly but not too quick (<30s)
- EIVs should be tested regularly to prevent sticking
- Keep operating condition as stable as possible
- carry out alignment and leak test for seal before running
- Develop practical procedure for running pump
- Check and test pump carefully for new pump
- Install minimum line for pump to prevent dead-heading

- Before enter to any confined space, ensure that the vessel have been isolate from all
hazardous sources by blind
- purging and gas test should be carried out completely
- Use gas mark or SCBA during working inside the confined space

The reactant(s) should be added via a small break tank so that if reverse flow
occurs only a small quantity will react and not the main stock.
The pressure drop in the pipeline should be measured, and if it gets too low, a trip
valve should be closed automatically.
-Dead-ends should be avoided
- If could not avoided, connected dead-end to the top of the main pipeline (unless the
liquid in the pipeline is denser than water).

- 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.
- 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
The relief valve should have been placed after the furnace or the low-flow trip.
Mounted vertically and should not be mounted horizontally.

- Level glasses should not be used on vessels containing flashing flammable or toxic
liquids, use magnetic types is better
- Level glasses should be fitted with ball check valves, which prevent a
massive leak if the glass breaks.
- The valve with check ball should be fully opened for the ball operation
-Insert a spade for positive isolation
- Enhance procedure for maintainnace and shift handover
- Improve employees' saftey awareness
 Reference

What went wrong, page

166
What When Wrong,
page 330

What When Wrong,

page 328

What When Wrong,

page 329
What When Wrong,
page 273

What When Wrong,

page 155
What When Wrong,
page 206

What When Wrong,

page 233

What When Wrong,

page 332
What When Wrong,
page 181

Chapter 10 - page 223

What When Wrong,
page 181

What went wrong, page

148
What Went Wrong, page
5