The catalyst in a dehydrogenation reactor, which was usually operated under a hydrogen atmosphere, was changed while the reactor was isolated from the peripheral equipment by closing a 20-inch remotely controlled valve. The hydrogen pressure in the peripheral equipment was set at 20 KPaG, and the reactor was opened to the atmosphere. Anticipating some hydrogen leakage, suction from the piping was accomplished with a vacuum device and, nitrogen sealing was performed. When the piping connections were restored after changing the catalyst, flames spouted from the flange clearance and two workers were burned. One cause of the fire was poor management of the catalyst replacement process.

Incident Synopsis

A catalyst exchange was carried out in a dehydrogenation view more

A person working in a hydrogen lab unknowingly closed the wrong hydrogen valve and proceeded to loosen a fitting in one of the hydrogen gas lines. The pressure in the 1/4"-diameter hydrogen line was approximately 110 psig. Hydrogen escaped from the loosened fitting and the pressure release resulted in the tubing completely detaching and falling to the floor. The person noted seeing a white stream around the hydrogen jet leak. The person noted a color change and noise change as the leak ignited (this happened in a matter seconds and he did not have a chance to react). The person left the lab and pushed the emergency stop button. Someone else pulled the fire alarm. Both of these actions were designed to close the main hydrogen solenoid (shutoff) valve. The local emergency response view more

A process area alarm activated. The alarm was caused by an instrument channel located above a reaction vessel off-gas system final HEPA filter canister, which indicated 25% of the lower explosive limit (LEL) for hydrogen. Since the only source of hydrogen is from the reaction vessel during the reaction of sodium with concentrated sodium hydroxide, the immediate actions were to shutdown the reaction process and place the facility in a safe condition.

The root cause was inadequate or defective design. Had the pre-filter drains been vented to outside the building, no hydrogen could accumulate in the process area. The corrective action for this is to complete an Engineering Task Authorization (ETA) to install a sample/drain collection system with loop seals to prevent any release of view more