Explosion and Fire in a Refinery
The incident occurred in a hydrocracker unit of the refinery. A control valve on the liquid line between the high- and the low-pressure separators was opened in error and the liquid allowed to drain. High pressure hydrogen passed uncontrolled into the closed LP Separator which had limited pressure relief capacity. It over-pressurized rupturing at an estimated pressure of 50 bar. The explosion disintegrated the separator and also damaged other vessels and pipes. Released flammable substances were ignited resulting in jet-fires. The explosion occurred in the hydrocracker unit in which waxy oils reacted with hydrogen at high temperature and pressure in presence of a catalyst to form light petroleum spirits and gases (approximately 23 m3/h). The following substances were released from the LP separator after the explosion: hydrogen (1 tone)). Petroleum Gases: (3 tones)), Hydrocarbon Liquids in released aerosol (10 tones)). The following substances were released from the nearby pipework and vessels damaged by the explosion: Light Petroleum Spirits ((190 tones). -Heavy Hydrocarbons Liquids (220 tones). 8 people were directly involved in the explosion and the subsequent fire (1 person was killed by explosion). The smoke from the fire did not affected the locality. The effects of the LP separator burst were equivalent to those of an explosion of 90 kg of TNT. The accident occurred because of an operator error (due to both the insufficient training of the operator and to the inappropriate procedures) in opening the control valve on the liquid line from the HP to the LP separator without noticing that the liquid contents in the HP vessel was draining away. Alarms did not operate because they had been previously disconnected without taking into account the decrease in safety. The main reason for the disconnection of the alarms was due to avoid operational difficulties because of the insufficient design capacity of the plant.
Event Date
March 22, 1987
Record Quality Indicator
Region / Country
Event Initiating System
Classification of the Physical Effects
Nature of the Consequences
Causes
Cause Comments
The immediate cause was an operator in opening the control valve. The error was due to both insufficient training and the inappropriate procedures. Contributing cause was the fact that the alarms had been previously disconnected without taking into account the decrease in safety. Since the main reason for the disconnection of the alarms was to avoid operational difficulties related to the insufficient design capacity of the plant, it can be concluded that the root cause is related to the plant organization .
Facility Information
Application Type
Application
Specific Application Supply Chain Stage
Components Involved
hydrocracker, valve, LP separator, adjacent factory
Storage/Process Medium
Location Type
Location description
Industrial Area
Operational Condition
Pre-event Summary
The accident occurred in an oil refinery specialized in cracking heavy oils to spirits and gases (about 7 millions tones per year). About 1,200 people were employed and up to 1,000 contractor staff used at major maintenance works. The refinery is in an industrial area with a hydrocracker unit some distance from factory's boundaries. According to the ARIA report, the accident occurred during a restart procedure subsequent to a routine shutdown of the hydrocracker. This abnormal condition is not mentioned by the eMARS report (see references). The hydrocracker unit was commissioned in the early 1970's. According to the eMARS report (see references) the potential for high pressure gas breakthrough into the low pressure (LP) separator had already been recognized in the design phase and an automatic prevention system had been provided. Later, due to operational difficulties (too frequent spurious trips), the control valve alarm and trip was removed and not replaced. One of the reasons was that the system was unreliable and therefore distrusted. After the removal of the alarm system It was left to the operators to detect dangerous low levels and close the valves when they judged it appropriate. The removal of the safety system was authorized at operations supervisor level. Maintenance and instrument engineering managers were aware of the situations and turned a blind eye to it.
Lessons Learned
Lessons Learned
According to the references), the following measures were established after the accident: 1)Properly designed pressure relief valves on the low-pressure separator; 2)improved instrumentation and fail-safe shut-off valves in series with level-control valves to be included when rebuilding of the hydrocracker; 3)Strict procedures adopted in order to drain the high pressure separator of liquid as shut-down; 4)The systems for reporting plant defects, for testing interlocks and trips, for authorizing equipment changes and for training operators had to be tightened up; 5)Routine audits to be carried out rigorously. Senior management had to take a much closer interest in the safety performance of refinery departments.
Event Nature
Emergency Action
EMERGENCY MEASURES INSIDE THE PLANT:The operator initiated the emergency shut-down and venting system of the hydrocracker unit, and evacuating the control room. The on-site emergency procedure was activated, implying the shut-down of the entire refinery, the evacuation of non-essential personnel, the mobilization of the refinery fire brigade and the call on-site of engineering management staff. The refinery fire fighting installation was quickly brought into use. EMERGENCY MEASURES OUTSIDE THE PLANT:Road blocks were set up. Workers in neighbouring factories were asked to inspect their sites for damages. It was not necessary to evacuate houses.
Release Type
Release Substance
Release Amount (kg)
1000.00
Ignition Source
Detonation
No
Deflagration
No
High Pressure Explosion
No
High Voltage Explosion
No
Flame Type
Source Category
References
References
Event description in the European database eMARS,
https://emars.jrc.ec.europa.eu/en/eMARS/accident/view/d4011671-a395-740…,
(accessed October 2020)
Event description in the French database ARIA,
https://www.aria.developpement-durable.gouv.fr/accident/6189_en/?lang=en,
(accessed October 2020)