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

Facility management confirmed that a hydrogen gas cylinder did not comply with the limiting condition for operation (LCO) for flammable gas control systems in the lab's safety requirements. Earlier erroneous calculations had shown that a release of the entire contents of the cylinder into the hood could not reach the lower flammability limit (LFL).

The facility manager determined that the LCO was applicable and immediately entered the action statement in the safety system, which required immediate termination of normal operations in the affected wing of the building. Because normal operations had already been terminated in the wing for HVAC maintenance, further efforts to terminate normal operations were not necessary. The hydrogen cylinder was removed from the hood, thus view more