Severity
Incident
Leak
Yes
Ignition
Yes

A facility experienced a major fire in its Resid Hydrotreater Unit (RHU) that caused millions of dollars in property damage. One employee sustained a minor injury during the emergency unit shutdown and there were no fatalities.

The RHU incident investigation determined that an 8-inch diameter carbon steel elbow inadvertently installed in a high-pressure, high-temperature hydrogen line ruptured after operating for only 3 months. The escaping hydrogen gas from the ruptured elbow quickly ignited.

This incident occurred after a maintenance contractor accidentally replaced an alloy steel elbow with a carbon steel elbow during a scheduled heat exchanger overhaul. The alloy steel elbow was resistant to high-temperature hydrogen attack (HTHA), but the carbon steel elbow was not. Metallurgical analyses of the failed elbow concluded that the HTHA severely weakened the carbon steel elbow.

Incident Date
Jul 28, 2005
Setting
Equipment
  • Piping/Fittings/Valves
  • Piping
  • Heating Equipment
  • Heat Exchanger
Damage and Injuries
Probable Cause
Characteristics
When Incident Discovered
Lessons Learned

In the future, refining, petrochemical, and chemical industries need to review material verification programs to ensure that the maintenance procedures include sufficient controls and positive material identification (PMI) testing to prevent improper material substitutions in hazardous process systems.

Human Factors Based Design
Designers should consider the entire process system life cycle, including planned maintenance, to avoid piping configurations that allow critical alloy piping components to be interchanged with non-compatible piping components.

Positive Material Verification Programs
In-situ alloy steel material verification using x-ray fluorescence or non-destructive material testing is an accurate, inexpensive, and fast PMI test method. Facility owners, operators, and maintenance contractors should ensure that the verification program requires PMI testing, such as specified in API Recommended Practice 578, or other suitable verification process, for all critical-service alloy steel piping components that are removed and reinstalled during maintenance.

At a minimum, piping components and their respective locations should be tagged or marked before removal, and the correct installed location should be verified after reinstallation.

Key:

  • = No Ignition
  • = Explosion
  • = Fire
Hydrogen Incident Summaries by Equipment and Primary Cause/Issue
Equipment / Cause Equipment Design or Selection Component Failure Operational Error Installation or Maintenance Inadequate Gas or Flame Detection Emergency Shutdown Response Other or Unknown
Hydrogen Gas Metal Cylinder or Regulator   3/31/2012
4/30/1995
2/6/2013
4/26/2010 12/31/1969     3/17/1999
11/1/2001
12/23/2003
Piping/Valves 4/4/2002
2/2/2008
5/11/1999
4/20/1987
11/4/1997
12/31/1969
8/19/1986
7/27/1991
12/19/2004
2/6/2008
10/3/2008
4/5/2006
5/1/2007
9/19/2007
10/31/1980
2/7/2009 1/24/1999
2/24/2006
6/8/1998
12/31/1969
2/7/2009

9/1/1992
10/31/1980

10/3/2008  
Tubing/Fittings/Hose   9/23/1999
8/2/2004
8/6/2008
9/19/2007
1/1/1982 9/30/2004
10/7/2005
  10/7/2005  
Compressor   10/5/2009
6/10/2007
8/21/2008
1/15/2019
    10/5/2009 8/21/2008  
Liquid Hydrogen Tank or Delivery Truck 4/27/1989 12/19/2004
1/19/2009
8/6/2004 12/31/1969   1/1/1974 12/17/2004
Pressure Relief Device 7/25/2013
5/4/2012
1/15/2002
1/08/2007
12/31/1969        
Instrument 1/15/2019 3/17/1999
12/31/1969
2/6/2013
    11/13/73    
Hydrogen Generation Equipment 7/27/1999     10/23/2001      
Vehicle or Lift Truck   7/21/2011         2/8/2011
12/9/2010
Fuel Dispenser   8/2/2004
5/1/2007
6/11/2007
9/19/2007
  2/24/2006
1/22/2009
     
Fuel Cell Stack            

5/3/2004
12/9/2010
2/8/2011

Hydrogen Cooled Generator       12/31/1969
2/7/2009
     
Other (floor drain, lab
anaerobic chamber,
heated glassware,
test chamber,
gaseous hydrogen
composite cylinder,
delivery truck)
  11/14/1994
7/21/2011
7/27/1999
6/28/2010
8/21/2008
12/31/1969
3/22/2018
    6/10/2019
  • = No Ignition
  • = Explosion
  • = Fire