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

Overview: A hydrogen leak and explosion occurred due to the installation of an incorrectly sized gasket at the suction line of a hydrogen compressor in a refinery hydrodesulfurization plant. The incorrectly sized gasket was mounted during the startup of the plant in 2001 and had never being inspected nor replaced.

Incident synopsis: The operating conditions were stable when the operator received an alarm indicating pressure loss in the circuit. He immediately instructed his field personnel to inspect the area. The hydrogen leak was confined inside the compressor room because the walls and roof were not provided with ventilation devices. An explosion occurred, causing two fatalities and the destruction of the compressor room and some of the surrounding area.