Event
- Event ID
- 654
- Quality
- Description
- A short circuit developed in the wiring of a fire eye system on one of two 600 psig boilers serving a refinery. This triggered a rapid sequence of events that resulted in a one week shutdown of much of the refinery. Fortunately no one was injured and equipment damage was negligible.
When the hydrocracker make-up compressor started slowing down, the control system at the reformer released the excess hydrogen to the flare. However, no increase flame was observed at the flare and the crude unit pressure went over 50 psig. The trouble was quickly diagnosed as a blockage in the flare system. The hydrocracker units were shutdown. Quick action by operating personnel prevented potentially catastrophic failures to the flare system and other operating equipment.
No major leak occurred and within two hours, it was concluded that the molecular seal was plugged. Witnesses at the time of the upset observed debris flying out of the flare. A search revealed five or six ice boulders, each weighing 50 to 60 pounds at the base of the flare. Also the 3 inch centre steam pipe and nozzle was found in the area. - Event Initiating system
- Classification of the physical effects
- No Hydrogen Release
- Nature of the consequences
- Macro-region
- Europe
- Country
- United Kingdom
- Date
- Main component involved?
- Venting System
- How was it involved?
- Malfunctioning
- Initiating cause
- Ice Formation
- Root causes
- Root CAUSE analysis
- The INITATING CAUSE was a series of events starting with an electrical short cicuit, causing failure of venting the excess hydrogen because the vent duct was blocked (probably by ice).
The source reports big ice blocks as the reason for blocking vent stack flow. It seems to suggest a ROOT CAUSE related to harsh enviornmental condtion and shortcoming in design of the vent.
Facility
- Application
- Petrochemical Industry
- Sub-application
- Hydrocracking process
- Hydrogen supply chain stage
- All components affected
- flare, hydrocracker, compressor and boiler
- Location type
- Unknown
- Location description
- Industrial Area
- Operational condition
Emergency & Consequences
- Number of injured persons
- 0
- Number of fatalities
- 0
- Post-event summary
- Witnesses at the time of the upset observed debris flying out of the flare. A search revealed five or six ice boulders, each weighing 50 to 60 pounds at the base of the flare. Also the 3 inch centre steam pipe and nozzle was found in the area.
Event Nature
- Release type
- no release
- Released amount
- 0
- Presumed ignition source
- No release
References
- Reference & weblink
Event description extracted from the UK database ICHEME in PDF<br />
<br />
https://www.icheme.org/knowledge/safety-centre/resources/accident-data/… />
(accessed October 2020)<br />
JRC assessment
- Sources categories
- ICHEME