Lessons Learned

Several workers sustained minor injuries and millions of dollars worth of equipment was damaged by an explosion after a shaft blew out of a check valve. The valve failure rapidly released a large vapor cloud of hydrogen and hydrocarbon gases which subsequently ignited.Certain types of check and butterfly valves can undergo shaft-disk separation and fail catastrophically or "blow-out," causing toxic and/or flammable gas releases, fires, and vapor cloud explosions. Such failures can occur even when the valves are operated within their design limits of pressure and temperature. Most modern valve designs incorporate features that reduce or eliminate the possibility of shaft blow-out. However, older design check and butterfly valves, especially those with external appendages such view more

An operator went to purge a process tank per standard operating procedure. The operator reviewed the previous shift's purge time and determined the next required purge time. The operator found that the tank had been purged earlier than expected on the previous shift. Because the earlier purge time was not recognized, the 12-hour purge frequency was exceeded.

Background: On the previous day, during the night shift, an operator performed 12-hour hydrogen purges per the requirements of the standard operating procedure. Each of the hydrogen purges was completed within the required time limits. The operator correctly recorded the time and date that the next hydrogen purges would be required. The following morning, shift turnover was conducted. The direct and root cause of this view more

The valve stem for a funnel valve to a solution neutralization tank was found to be separated from the body of the valve. This valve is used for purging hydrogen gas from the vessel. The functional classification of this valve is safety-significant. The "as-found" condition of the affected valve prevented the valve from performing its intended design function.

The affected valve is a one-half inch polyvinyl chloride (PVC) ball valve. The valve has an extension shaft coupled to the valve body, and the valve handle is coupled to the extension shaft, allowing the valve to be operated outside the process panel cover. The valve stem is cross-drilled and the extension shaft is pinned through the stem.

With this occurrence, engineering evaluated the one-half inch PVC view more

A demolition technician noted an elevated combustible gas lower explosive limit (LEL) on a pipe that was being tested prior to cutting (No. 2 pipe). The No. 2 pipe was one of four pipes being tested. The other three pipes tested less than detectable for combustible hydrogen gas. Testing involves tapping the pipe and connecting the pipe to an Explosive Gas Detector via a tube. When an elevated LEL is identified, the pipe is allowed to vent and then retested prior to cutting. After tapping the No. 2 pipe, the work crew left the pipe open to vent and departed the area for the end of shift.

At approximately 7"45 PM on the same day, a crew was on overtime to support roofing activities. Since additional workers were available, the craft supervisor decided to re-enter the viewing view more

During inspection of a hydrogen make-up compressor, it was discovered that a 1/4” stainless steel screw and nut that mounted a temperature gauge to a stainless steel pipe was resting against the side of a schedule 160 high-pressure hydrogen pipe. Constant vibration of the process equipment had caused the bolt to rub a hole in the high-pressure suction piping, resulting in the release of make-up hydrogen. The pipe was out of sight, and the problem was identified by an employee who heard the whistling sound of escaping hydrogen. The compressor was taken offline and depressurized.

An explosion occurred in a Microbiological Anaerobic Chamber of approximately 2 m3 capacity that contained an explosive mixture of hydrogen and air. A fire followed the explosion, but was rapidly extinguished by staff using fire extinguishers prior to the arrival of fire service personnel. The pressure wave from the explosion blew windows out of the laboratory, with glass hitting a passerby on a path outside and glass shards landing up to 30 m away. Ceiling panels were dislodged in the laboratory and adjacent rooms, and a worker using the apparatus at the time was taken to the hospital by ambulance for burn treatment. The worker subsequently fully recovered. Another worker in the lab at the time required medical observation, but was otherwise unharmed.

Mixtures of inert gases view more

An incident involved an explosion of an oven that was heating decaborane for vaporization. In this incident, the heater controller was defective so the heating element was disconnected from the controller and plugged directly into a wall outlet. This situation allowed the oven to reach temperatures in excess of 400 °C within 20 minutes. While the temperature increased, the decaborane continued to expand, causing a significant pressure build-up within the oven. The pressure increase eventually caused the oven's viewing window to burst. A burst of burning hydrogen was emitted from the window and burned the face of a researcher who was hospitalized for approximately three weeks.

A subcontractor employee was using a band saw to cut a 1" metal pipe when a flash fire occurred on the third floor hydrogen fluoride area. Subcontractor employees were removing all piping associated with the Anhydrous Hydrofluoric Acid (AHF) system. These lines were being removed during plant decontamination and demolition (D&D). The subcontractor employee was attempting to cut a 90-degree elbow located at the highest elevation on the 1" line, but the lowest elevation of the overall piping run. Since hydrogen is lighter than air, it is speculated that a minute amount of hydrogen gas had accumulated in the elbow.

Even though Safe Shutdown personnel had previously opened the system and placed it in a safe configuration, residual hydrogen fluoride could have still view more

The hydrogen feed system for the furnaces inside a pit furnace developed a leak. The leak was on the hydrogen dryer inside a shack attached to a building. The leak vented 200 psig hydrogen into the shack. The hydrogen low-pressure alarm sounded. No furnace operators were present at the time. An estimated 10,000 standard cubic feet of hydrogen vented. T

he hydrogen release was caused by a failure of an elastomeric pressure seal on the body of a particulate filter located in the hydrogen supply circuit of the Pit Furnace. After a similar event a month earlier, the cause was identified as a simple seal failure; however an independent engineering review after the present incident showed the cause to be system overpressure, caused by regulator failure.

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