Event
- Event ID
- 1090
- Quality
- Description
- The event occurred at the hydrogenation unit of a pharmaceutical company.
145 kg of hydrogen were released at the atmosphere at the gas circulation pump, due to a maintenance error. A specialist company (third-party company), had replaced the cylinder head of pump, but during assembly they did not re-installed the prescribed temperature sleeve for the thermometer (the temperature sleeve is the pressure-bearing element).
The safety flare of the affected plant was triggered, the plant operations management and plant fire brigade were called on duty, the hydrogen supply to the neighbouring hydrogenation unit was stopped and the system was switched to circular operation. - Event Initiating system
- Classification of the physical effects
- Unignited Hydrogen Release
- Nature of the consequences
- Leak No Ignition (No additional details provided)
- Macro-region
- Europe
- Country
- Germany
- Date
- Main component involved?
- Compressor / Booster / Pump
- How was it involved?
- Leak
- Initiating cause
- Wrong Installation
- Root causes
- Root CAUSE analysis
- The INITIATING CAUSE was an error during re-assembling of the system after maintenance.
A possible contributing CAUSE could be a lack of maintenance instructions, or their shortcoming.
Facility
- Application
- Chemical Industry
- Sub-application
- Farmaceutical manufacturing
- Hydrogen supply chain stage
- All components affected
- hydrogen recirculation pump
- Location type
- Unknown
- Operational condition
- Pre-event occurrences
- Maintenance works had been completed by a third party.
Emergency & Consequences
- Number of injured persons
- 0
- Number of fatalities
- 0
- Environmental damage
- 0
- Property loss (onsite)
- 0
- Property loss (offsite)
- 0
- Post-event summary
- Only operative costs due to loss of hydrogen and production stop.
Lesson Learnt
- Corrective Measures
To develop an assembly checklist together with the external (third party) company.
Event Nature
- Release type
- gas
- Involved substances (% vol)
- H2 100%
- Released amount
- 145 kg (H2)
- Actual pressure (MPa)
- 20
- Presumed ignition source
- No ignition
References
- Reference & weblink
Event from German database ZEMA<br />
https://www.infosis.uba.de/index.php/en/binaries/asset/zema_ereignis/16… />
(accessed December 2023)
JRC assessment
- Sources categories
- ZEMA
