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Resid Hydrotreater Unit (RHU) Heat Exchanger Failure

Severity
Incident
Was Hydrogen Released?
Yes
Was There Ignition?
Yes
Incident Date
Incident Attributes
Setting
Damage and Injuries
Probable Cause
Characteristics
When Incident Was Discovered
Describe the incident, including corrective steps taken and their result.

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.

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 / CauseEquipment Design or SelectionComponent FailureOperational ErrorInstallation or MaintenanceInadequate Gas or Flame DetectionEmergency Shutdown ResponseOther or Unknown
Hydrogen Gas Metal Cylinder or Regulator 3/31/2012
4/30/1995
2/6/2013
4/26/201012/31/1969  3/17/1999
11/1/2001
12/23/2003
Piping/Valves4/4/2002
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
2/7/20091/24/1999
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
1/1/19829/30/2004
10/7/2005
 10/7/2005 
Compressor 10/5/2009
6/10/2007
8/21/2008
1/15/2019
  10/5/20098/21/2008 
Liquid Hydrogen Tank or Delivery Truck4/27/198912/19/2004
1/19/2009
8/6/200412/31/1969 1/1/197412/17/2004
Pressure Relief Device7/25/2013
5/4/2012
1/15/2002
1/08/2007
12/31/1969    
Instrument1/15/20193/17/1999
12/31/1969
2/6/2013
  11/13/73  
Hydrogen Generation Equipment7/27/1999  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
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