A hydrogen reformer furnace at a refinery was shutdown for maintenance to remove and cap the inlet and outlet headers of some radiant tubes that had previously developed hot spots and been isolated by externally pinching them off at the inlet. A decision was made to leave steam in the steam-generating circuit during this maintenance operation to prevent freezing. After maintenance was complete, the startup procedure required the furnace to be first heated up to 350°C (662°F) prior to introducing 4136 kPa (600 psig) steam into the radiant tubes. Just after the 4136 kPa (600 psig) startup steam was introduced into the reformer furnace inlet, the control room alarm journal reported an extreme positive pressure spike at the same time a single loud bang was reported by the operations view more

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