A petroleum refinery experienced a catastrophic rupture at one bank of three heat exchangers in a catalytic reformer/naphtha hydrotreater unit because of high temperature hydrogen attack (HTHA). Hydrogen and naphtha at more than 500F were released from the ruptured heat exchanger and ignited, causing an explosion and an intense fire burned for more than three hours.

The rupture fatally injured seven employees working in the immediate vicinity of heat exchanger at the time of the incident. The workers were in the final stages of a start-up activity to put a parallel bank of three heat exchangers back in service following cleaning. Such start-up activities had resulted in frequent leaks and occasional fires in the past and should have been considered as hazardous and nonroutine. view more