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

Incident Synopsis
A technician was welding a cable suspended over a stainless steel H2 instrument line. During the welding process, two holes were accidentally burned through the hydrogen tubing. The operator heard a hissing sound and closed the valve, but the hydrogen had already ignited and it burned his hand while he was feeling for a leak.

A short during welding caused the pinholes in the tubing containing the gaseous H2.

Incident Synopsis
One man was killed and another severely injured while working with a portable battery power supply.

At a test facility, a water-submersible portable battery power supply was used to power lighting. The battery power supply contained two 12-volt lead-acid automotive batteries, a wiring harness, and switching relays mounted in an air-tight case suitable for submersion in water. The case possessed ½-inch aluminum walls and a 13.8-pound lid. The box had been used periodically over two years.

After charging all night, the battery power supply was moved into place and connected to the lighting. Two technicians started to test the unit. One technician rested his hand on the case lid while the second leaned over the lid and threw the switch to activate view more

A brazing retort in a shop malfunctioned and resulted in an explosion that propelled the retort shell to the roof of the brazing area and then back to the floor. There were no injuries but damage was sustained by the furnace housing and the retort shell.

Administrative personnel were soon on the scene to make a preliminary assessment of the situation. An expert safety team was retained to assist in the investigation of the explosion. The safety team conducted their initial field investigation on the afternoon of the explosion and again on the following day.

Once it was determined that the explosion was the result of an ignition of a flammable mixture of hydrogen and air, the next step was to determine how air ended up in the retort, given that the retort is nominally view more