API Publication 2376:1998 pdf download

API Publication 2376:1998 pdf download.Summary of U.S. Occupational Injuries, Illnesses, and Fatalities in the Petroleum Industry.
Four companies reported experiencing at least one fatality during 1997. Each of them submitted detailed information on the circumstances surrounding the five on-duty fatalities reported w API.
API has published information provided by member companies on fatal accidents in the petroleum industry since 1933. Each incident is described in a brief narrative and is intended to provide information that could be used to avoid the occurrence of similar accidents in the future.
REFINING
01/21/97 — Fire and Explosion
At approximately 7:41 p.m. on January 21, 1997, a pipe ruptured a a hydrocracker unit which caused an explosion and fire. This incident caused the fatality of a hydrocracker operator and forty-six minor injuries were reported by other employees and contractors in the days following the incident. No significant off-site impacts were reported.3
The pipe ruptured as a result of being subjected to excessively high temperature and not being properly depressured. per emergency procedures. Cause for the excessive temperature was a very high rapid temperature excursion4 which started in catalyst bed 4 of Reactor 3 in Stage 2 of the hydiocracker. Although, no single or conclusive cause for the temperawre excursion could be determined after the explosion, all possible causes for the temperature excursion were identified. Possible reasons identified for the temperature excursion include: spontaneous formation of a “hot spot” in bed 4; the flow characteristics of fluids in bed 4; or the possibiLity of uneven liquid distribution within the bed.
A contributing cause for the pipe rupture was that the operators did not depressure the unit as specified in emergency procedures for safely controlling temperature excursions. Reasons for the operators not depressunng the unit include: the incident occurred very rapidly and was outside previous experiences:
they did not believe the control room temperature indicators; and they were confused and distracted by process information which was inconsistent with past temperature excursion experiences.
Corrective actions were identified to respond to the possible causes for the reactor temperature excursion. These actions include installation of new controls which will automatically depressure the unit in the event of a future high temperature excursion, and retraining of operations personnel.
This report summarizes the results of a 3 month refinery investigation into the causes of this incident. The first section of the repon describes the investigation procedure. The next several sections describe the physical design and operation of the hydrocracker unit, as well as its control system, operational history, operator staffing and training, and the events leading up to the incident itself. The last section of the report presents conclusions and recommendations based on the investigation results.