Event
- Event ID
- 987
- Quality
- Description
- During a work tour on a refinery, an employee noticed a fire at the level of a flange at the inlet of the grille of an exchanger, located at the outlet of a reactor of the catalytic reforming unit.
The plant operator detected a lack of uniformity of torque on the bolts. Two years before, during a shutdown period, some parts of the exchanger had been removed for inspection. The flange on the heat exchanger side was not easily accessible. During reassembly, the presence of a pipe tee near the flange made it difficult to tighten with a bolting machine. The faulty tightening (1.5 mm opening) could have led to the leakage of high-octane gasoline, mixed with hydrocarbon gases and hydrogen. Without a hot spot nearby, this 500°C fluid could have spontaneously ignited on contact with air.
The plant operator tightened the flange and modified procedures to specify the use of a suitable wrench for the configuration. The operator also planned to carry out independent checks on the quality of the connections made.
(ARIA database) - Event Initiating system
- Classification of the physical effects
- Hydrogen Release and Ignition
- Nature of the consequences
- Fire (No additional details provided)
- Macro-region
- Europe
- Country
- France
- Date
- Main component involved?
- Flange
- How was it involved?
- Leak & Formation Of A Flammable H2-Hc-Air Mixture
- Initiating cause
- Loss Of Tightness (Wrong Operation)
- Root causes
- Root CAUSE analysis
- The INITIATING cause was the ignition of leaked mixture of hydrocarbons, including hydrogen. The INTERMEDIATE or ROOT CAUSE could have been the lack of tightness of a flange caused by a not-properly tightening of the bolts. Finally, A CONTRIBUTING or ROOT CAUSE was the difficulty of re-assembling of the system due to design.
Facility
- Application
- Petrochemical Industry
- Sub-application
- catalytic reforming process
- Hydrogen supply chain stage
- All components affected
- reformer, heat exchanger, flanges, bolts
- Location type
- Unknown
- Location description
- Industrial Area
- Operational condition
Emergency & Consequences
- Number of injured persons
- 0
- Number of fatalities
- 0
Lesson Learnt
- Lesson Learnt
The quality of the event description does not allow for a detailed lesson learnt. nevertheless, better operative/maintenance procedures and a (better) reporting system shall be part of it.- Corrective Measures
- The plant operator modified procedures to specify the use of a suitable wrench for the configuration.
The operator also planned to carry out independent checks on the quality of the connections made.
Event Nature
- Release type
- gas mixture
- Involved substances (% vol)
- gasoline,
hydrocarbons,
H2 - Presumed ignition source
- Auto-ignition
References
- Reference & weblink
Event description no 55225 in the French database ARIA <br />
https://www.aria.developpement-durable.gouv.fr/accident/55225_en/?lang=… />
(accessed October 2021)
JRC assessment
- Sources categories
- ARIA