Hydrogen Leak at Chlorate Plant Due to Process Automation Error
In a plant manufacturing chlorate products, a hydrogen leak occurred via the water drainage outlet onto the factory floor. Pressure in the hydrogen line increased because the hydrogen pipes were filled with water. The situation was rectified by shutting down the process, draining the pipes and by redirecting the hydrogen flow.CAUSE: The root cause may be deemed to be insufficient level of automation because a selection permitting human error had been left in the process. Water entered into the hydrogen pipes because the selection switch on the hydrogen compressor had been turned to the 'fresh water' position, and as consequence more water was incorrectly fed into the process. As the intention was to run the compressor in the standard mode, water did not, within the time available, exit the system along the open route; instead, it rose to the hydrogen pipes.
Event Date
January 10, 2000
Record Quality Indicator
Region / Country
Event Initiating System
Classification of the Physical Effects
Nature of the Consequences
Causes
Cause Comments
Shortcomings in planning of equipment
Facility Information
Application Type
Application
Specific Application Supply Chain Stage
Components Involved
hydrogen supply line
Storage/Process Medium
Location Type
Location description
Industrial Area
Operational Condition
Pre-event Summary
Material flow failures
Lessons Learned
Lessons Learned
The ultimate accident cause was an insufficient level of automation, which allowed human error. As a corrective measure, the switch, which had been manually turned into an incorrect position was removed and another upper limit was set that locks the valve controlling the separator level and ensuring that the compressor is stopped.
Event Nature
Emergency Action
Unknown
Release Type
Release Substance
Detonation
No
Deflagration
No
High Pressure Explosion
No
High Voltage Explosion
No
Source Category
References
References
Source lost