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

The incident occurred in the catalytic hydrotreatment plant of an oil refinery. The plant, which began operations in September 1997, has a capacity of 1650 tons/day of light fuel oil and 1450 tons/day of heavy fuel oil. The plant was designed to desulfurize the light and heavy fuel oil fractions produced in the refinery by treating them with high-pressure hydrogen over a catalyst to remove sulfur (producing hydrogen sulfide as a byproduct). The plant has two heating/reaction/fractionating sections to treat the two fuel oil fractions, but a single gas purification and compression section for the recycled hydrogen gas.

The heavy fuel oil reactor feedstock from the vacuum distillation plant is sent to the heavy fuel oil treatment section through three pipelines equipped with flow view more

A refinery hydrocracker effluent pipe section ruptured and released a mixture of gases, including hydrogen, which instantly ignited on contact with the air, causing an explosion and a fire. Excessive high temperature, likely in excess of 1400°F (760°C), initiated in one of the reactor beds spread to adjacent beds and raised the temperature and pressure of the effluent piping to the point where it failed. An operator who was checking a field temperature panel at the base of the reactor and trying to diagnose the high-temperature problem was killed. A total of 46 other plant personnel were injured and 13 of these were taken to local hospitals, treated, and released. There were no reported injuries to the public.

Property damage included an 18-inch (46-centimeter) long tear in the view more

Summary
A faulty modification to a multiple-gas piping manifold allowed mixing of hydrogen and oxygen that resulted in a storage tube explosion. Several employees suffered severe burn injuries from the incident.

Incident Synopsis
An employee, without authorization, fabricated and installed an adapter to connect a hydrogen tube trailer manifold to an oxygen tube trailer manifold at a facility for filling compressed-gas cylinders for a variety of gases, including hydrogen, oxygen, nitrogen, and helium. A subsequent improper purging procedure allowed oxygen gas to flow into a partially filled hydrogen tube on a hydrogen tube trailer. An ignition occurred in the manifold piping system and a combustion front traveled into the hydrogen tube where, after traveling about a view more