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Ensuring Safe Operation Of Vessels With Quick-Opening Closures http://www.nationalboard.org/index.aspx?pageID=164&ID=183

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Ensuring Safe Operation Of Vessels With Quick-Opening Closures http://www.nationalboard.org/index.aspx?pageID=164&ID=183

Ensuring Safe Operation Of Vessels With Quick-Opening Closures

D.C. Perreira
Assistant to the Chief Engineer The Boiler Inspection and Insurance Company of Canada

April 1980

Category: Incidents

Summary: The following article is a part of National Board Classic Series and it was published in
Board BULLETIN. (9 printed pages)

Pressure vessels with quick-opening doors command a great deal of respect from the Boiler Inspe
Insurance Company of Canada (B.I.& I.). We know by simple calculation that a pressure vessel ei
diameter with working pressure 150 psi, has an end force of just over one million pounds acting on
This does not worry us unduly in a conventional pressure vessel with welded heads. However, whe
serves as a door and it needs to be held in position by some form of locking mechanism, we have
concerned. Brick curing autoclaves, metal bonding autoclaves, autoclaves used in the textile indust
treating cylinders, tire vulcanizers, even sterilizers can all be likened to a loaded rifle with the hamm
when in operation. It doesn't take much to set it off. It's a lethal weapon and it needs to be handle
carefully.

Our respect for pressure vessels with quick-opening doors does not stem from theoretical calcula
but from bitter experience.

Some 12 years ago, an autoclave failure occurred at an insured concrete plant in Hamilton,
8'6" diameter by 108' long brick hardening cylinder, one of six installed in the plant, had the
off just as the steam pressure reached its normal maximum 145 psig at the start of a curing
After deflecting off the low wall of the loading bridge pit, the door of the autoclave pierced a
and continued piercing the plant research laboratory located over the steam kilns. The walls
large portion of the plant's roof collapsed from the pressure of the explosion.

The 45 ton autoclave moved 150 feet away from its foundation and destroyed a delivery tru
racks, and numerous cubes of inventory block. Fortunately and miraculously no one was se
injured.

The incident was fully investigated and the cause of the door failure was attributed to reduc
area of worn wedges and possible slippage of the locking ring.

In June 1969, another concrete block manufacturing plane in Hamilton was leveled by an au
door failure. The B.I. & I. was not involved in this accident but we had previously insured the
and were naturally shaken by the disaster.

The newspaper report on the incident gives the size of the autoclave as 12 feet in diameter
long and indications are that the door blew off during operation. The roof of the plane was l
into the air, one wall was knocked down, and steel plates and concrete blocks were hurled
into the air. The vessel tore free of its concrete supports and ripped across an empty lot int
children's club (thankfully the club was empty because the children were away swimming).
was flattened and the autoclave continued for another 200 feet squashing three pick-up truc
cars before slamming into a wall of an autobody shop. The wall fell on top of at least four p
and the autoclave finally butted a Volkswagen 80 feet into the middle of a nearby street.

Unfortunately, one operator died instantly and three others were reported to be critically inju

We do not have any details as to the cause of the accident but photographs 3 and 4 attest
devastation. Note in both cases the plants appear to have been bombed. They probably we
accept the fact that the energy stored in autoclaves of this size is approximately equivalent
pounds of TNT.

Following these disasters, a special Ad Hoc Committee on Autoclave Safety was set up by
Concrete Producer's Association. C. A. Williams, B. I. & I.'s vice president of engineering, r
the insurance industry on this committee that was responsible for the 1970 publication of th
entitled "Safety Precautions for Autoclaves." The foreword of this booklet is of special inter

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Ensuring Safe Operation Of Vessels With Quick-Opening Closures http://www.nationalboard.org/index.aspx?pageID=164&ID=183

"In the past 20 years (1950-1970) about 200 concrete block manufacturers in the United St
A Boiler: The Explosive Potential of a
Canada have installed autoclaves to high-pressure steam cure their products. Prior to 1950
Bomb
about 20 autoclave plants in operation. In these 220 plants employing this curing process th
Acoustic Emission Examination of probably well over 500 autoclaves in use today.
Metal Pressure Vessels
In the history of the concrete block industry, there have been eight autoclave failures; one e
Anatomy of a Catastrophic Boiler Mexico, Texas, North Carolina, Virginia, Illinois, Quebec and two in Ontario. Seven of the ei
Accident quick-opening door failures, and six of these seven were wedge-lock type doors.
Austenitic Stainless Steel
A recent tour of autoclave plants in Canada pointed out major deficiencies that effected the
Auto-Refrigeration operation in three of the twenty-one plants inspected. Most common deficiencies found wer
Basic Weld Inspection - Part 1 the autoclave door safety locking device.

Basic Weld Inspection - Part 2 Due to wear and tear and to a degree of over-confidence often associated with long term t
Black Liquor Recovery Boilers - An operation, most of the autoclave doors should be thoroughly inspected NOW! Subsequent i
Introduction by a representative of the door manufacturer or other qualified person should take place ev
years. Weekly, monthly, and yearly inspections are the responsibility of plant personnel and
Boiler Efficiency and Steam Quality: company inspectors."
The Challenge of Creating Quality
Steam Using Existing Boiler A copy of this pamphlet was issued to each inspector in the B. I. & I. with instruction to rea
Efficiencies the material and retain for reference. The need for adequate overlap on wedges was stres
Boiler Logs Can Reduce Accidents inspectors.
Boiler/Burner Combustion Air Supply We do not know of any major disasters in Canada since 1970 but we have, from time to tim
Requirements and Maintenance incidents involving autoclaves that serve as grim reminders of the hazards involved in opera
Carbon Monoxide Poisoning
vessels.
Preventable With Complete
On December 3, 1974, an operator was killed at an aircraft plant in Brampton, Ontario, wh
Inspection
of a metal bonding autoclave (an 8' by 30' vessel) was blown open by residual pressure as
Combustion Air Requirements:The operator was about to open it. The operator was slammed against a concrete wall and died
Forgotten Element In Boiler Rooms
Newspaper reports on the inquest into the death of the operator indicated that the vessel w
Creep and Creep Failures operated without a safety device that had been recommended by the insurance carrier.
Description of Construction and
In April 1976, a 17-year-old youth was killed in a cindercrete block manufacturing plant in R
Inspection Procedure for Steam
incident involved a 10-1/2' diameter by 124' long autoclave with a Ring-Lok Quick Opening
Locomotive and Fire Tube Boilers
autoclave was being vented at the end of a cycle and pressure was down to 5 psig on the g
Ensuring Safe Operation Of Vessels the young man, impatient at the delay in waiting for the pressure to dissipate, decided to op
With Quick-Opening Closures despite shouted warnings from a senior operator. The door flew open, striking the concrete
killing the youth.
Environmental Heat Exchangers

Factors Affecting Inservice Cracking


On February 2, 1977, the door of a tire curing autoclave 12' 8" diameter by 9' long blew op
of Weld Zone in Corrosive Service
plant in Montmagny, Quebec, shortly after it was placed in service. It completely demolishe
200' building in which it was located. Fortunately no one was injured.
Failure Avoidance in Welded
Fabrication In May 1977, a vessel used for curing retreaded tires blew open at a location in Toronto. Th
bears little resemblance to the vessels mentioned previously except for the fact that the cov
Finite Element Analysis of Pressure
place by a concealed locking device and is therefore analogous to the loaded rifle. No one
Vessels
and the vessel, which was badly damaged, was replaced by the manufacturer at their own
Fuel Ash Corrosion about the same time a similar failure occurred in Alberta, and again no one was injured but
damage was substantial.
Fuel Firing Apparatus - Natural Gas

Grain Boundaries
In August 1977, at a plant in Edmonton, the chief engineer and production superintendent e
8'6" diameter by 140' long brick hardening autoclave to examine the rails which carry the lo
Heat Treatment - What Is It? While they were inside, the operator, unaware of their presence, proceeded to push the tra
How to Destroy a Boiler -- Part 1
cars into the autoclave. The two men managed to climb on top of the stacked blocks and b
crawling desperately along the 14 inch space above the blocks toward the front, but were c
How to Destroy a Boiler -- Part 2 inside by the train so they were 80 feet from the door when the train stopped. They got to w
How to Destroy a Boiler -- Part 3
feet before the operator closed the door, and their shouts could not be heard above the din
forklift truck that was used to push the train into the vessel. As steam was being admitted,
Identifying Pressure Vessel Nozzle managed to remove some blocks and pull free a steel tray that they used to pound on the d
Problems
A welder working nearby heard faint thumping sounds and mentioned it to the operator. But
Inspection, Repair, and Alteration of
men listened near the door they could hear nothing unusual. However, they decided to shut
Yankee Dryers
unit and open the door anyway. Both men were unconscious but quickly revived. They had o
Inspection, What Better Place to numerous cuts and bruises in their desperate scramble over the blocks.
Begin

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Ensuring Safe Operation Of Vessels With Quick-Opening Closures http://www.nationalboard.org/index.aspx?pageID=164&ID=183

Laminations Led to Incident Why do these vessels fail? In almost all cases it is a combination of improper operation and
maintenance.
Lay-up of Heating Boilers
How can we ensure safe operation of these vessels? The answer is fairly obvious.
Liquid Penetrant Examination

Low Voltage Short Circuiting-GMAW The vessel must be designed, fabricated, and inspected in accordance with Section
ASME code.
Low Water Cut-Off Technology

Low-Water Cutoff: A Maintenance The vessel must be properly installed on adequate foundations with provisions for th
Must
expansion.

Magnetic Particle Examination The vessel must be properly operated. This is the responsibility of the owners or ma
Their attitude is all important. They are the ones who should ensure that operators a
Maintaining Proper Boiler Inspections
trained and re-trained for the job.
Through Proper Relationships

Microstructural Degradation The vessel must be properly maintained;

Miracle Fluid? The vessel should have the required complement of safety devices.
Organizing A Vessel, Tank, and
The human element cannot be overlooked in the prevention of accidents. All too often after
Piping Inspection Program
association with an operation, even key operating personnel have a tendency to become ca
Paper Machine Failure Investigation: lax. Personnel without complete knowledge of the hazards involved in the operation are eve
Inspection Requirements Should Be likely to become careless and fail to follow safe operating procedures. Thorough training of
Changed For Dryer Can personnel is most important and special attention must be given to the following:
Pipe Support Performance as It A complete explanation of the entire process and hazards involved.
Applies to Power Plant Safety and A thorough understanding of routine duties and emergency procedures.
Reliability
Thorough instruction and explanation of the functions and operation of control device
Polymer Use for Boilers and An explanation of how safety devices function.
Pressure Vessels
Proper procedures for depressurizing the autoclave before opening the door.
Pressure Vessel Fatigue Proper procedures for operating the quick-opening door.
Pressure Vessels: Analyzing Change The dangers involved by forcing operating mechanisms.
Preventing Corrosion Under Instructions to report at once any malfunctioning of equipment or control devices.
Insulation Instructions should include where to look for wear and evidence of possible failure of
equipment.
Preventing Steam/Condensate
System Accidents
It is fairly certain that the autoclave disaster in Hamilton stemmed from the fitting of an over
Proper Boiler Care Makes Good gasket which prevented proper overlap of the wedges and engagement of the mechanical i
Business Sense:Safety Precautions overcome this problem the operator took a hammer to the interlock, bent it, and got it into p
for Drycleaning Businesses disastrous results.
Putting a Stop to Steam Kettle Failure Though seemingly unrelated to autoclaves, there is a film that deals in depth with the cause
Quick Actuating Closures disaster in Paris, some years ago, involving a DC-10 aircraft. The crash was caused by a c
blowing open shortly after takeoff. The point in common with autoclaves is that the door clo
Quick-Actuating Door Failures mechanism carried a small flap which sealed a hole in the fuselage when the door was lock
Real-Time Radioscopic Examination aircraft could not be pressurized unless the hole was sealed and the flap served the same f
an interlock on an autoclave. On that fateful day in Paris, the door locking mechanism did n
Recommendations For A Safe Boiler properly but the operator managed to get the flap into position by applying a little extra forc
Room bent the mechanism sufficiently and sealed the hole. Some 350 lives were lost.
Recovering Boiler Systems After A
A lack of adequate knowledge and understanding is dangerous, especially when working w
Flood
under high pressure. A very important lesson to be learned from past explosions is that pro
Rendering Plants Require Safety properly constructed equipment alone will not prevent accidents. Instructions must be under
employees must be adequately trained if potentially serious accidents are to be prevented.
Repair or Alteration of Pressure
Vessels Management should also establish definite operating procedures and have them prominentl
Residential Water Heater Safety and followed by all plant personnel. These procedures would ensure:
School Boiler Maintenance that special care be exercised in loading to prevent damage to the vessel, door gask
Programs: How Safe Are The gasket bearing surfaces;
Children?
closing of the door must be done only by authorized personnel thoroughly acquainted
Secondary Low-Water Fuel Cutoff locking mechanism and safety devices;
Probe: Is It as Safe as You Think?
that the gasket and contact surfaces must be clean and free of any debris. Should a
occur during closing, the trouble must be determined and corrected. Under no condit

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Short-Term High Temperature the door or locking mechanism be forced into position;
Failures
that safety devices, controls, and interlocks must be checked for proper operation;
Specification of Rupture Disk Burst
Pressure at the end of the opening cycle, no attempt must be made to open the door until the
CERTAIN that all pressure has been dissipated.
Steam Traps Affect Boiler Plant
Efficiency Since most of the accidents on vessels with quick-opening closures are caused by imprope
and poor maintenance, we must make certain that neither is neglected.
Steps to Safety: Guide for Restarting
Boilers after Summer Lay-Up
Safety devices are dealt within the ASME code and we do not dispute the merits of the cod
Stress Corrosion Cracking of Steel in
Liquefied Ammonia Service - A However, it should be noted that the code itself recognizes that it is impractical to write det
Recapitulation requirements to cover the multiplicity of devices used for quick access, or to prevent neglig
operation or the circumventing of safety devices. We, as an insurance company, have a def
Suggested Daily Boiler Log Program
preference for the inclusion among safety devices of a positive mechanical locking device th
Suggested Maintenance Log place ensures that the door is properly positioned and cannot be opened and when release
Program visual and audible warning of any residual pressure in the vessel.
System Design, Specifications,
Thus far, we have dealt with the subject of ensuring safe operation of vessels with quick op
Operation, and Inspection of
closures in terms of action required by owners and operators. What part does the B. I. & I.
Deaerators
this? What do we do when we are requested to provide insurance coverage on such vesse
Tack Welding
Our inspection procedures call for a critical inspection of the vessel when coverage is first p
Temperature And Pressure Relief
The company sees the object through the eyes of our field inspector who must verify that th
Valves Often Overlooked
constructed to code, is free of defects, is properly installed, etc. Special attention is given t
Temperature Considerations for it is of the quick-opening type.
Pressure Relief Valve Application
The inspector describes and provides a sketch of the door and reports on the condition of w
The Authorized Inspector's
wedge overlap, (if a wedge type door), condition of hinges, alignment, etc. He describes or
Responsibility for Dimensional
sketch showing all mechanical safety locking devices that serve to prevent accidental openi
Inspection
door under pressure and any audible or visual alarms which are fitted. He determines if the
The Effects of Erosion-Corrosion on are competent, and if they are aware of the hazards involved. He looks at the attitude of th
Power Plant Piping management and of the plant. Are they aware of the hazards? Have they issued safety inst
Have they properly delegated responsibility for the safe operation of the vessel?
The Forgotten Boiler That Suddenly
Isn't
In most cases, approval of coverage hinges on the presence of a mechanical safety locking
The Trend of Boiler/Pressure Vessel Our philosophy is that if an operator can see, feel or hear steam or air blowing from a vent
Incidents: On the Decline? immediately after disengaging a mechanical interlock, his own common sense should tell him
wait until the pressure has dissipated. The device buys time. It gives them a chance to think
The Use of Pressure Vessels for
Human Occupancy in Clinical
Pressure activated devices and electrical devices do fail despite the many guarantees issue
Hyberbaric Medicine
designers. Operators all too often regard such devices as being infallible and look to them o
Thermally Induced Stress Cycling if they, the operators, make a mistake.
(Thermal Shock) in Firetube Boilers
We feel that safety must not be compromised and cannot be overdone.
Top Ten Boiler and Combustion
Safety Issues to Avoid
The engineering department of the B. I. & I. will not approve insurance coverage of autocla
Typical Improper Repairs of Safety similar vessels unless they are fitted with an approved mechanical locking device.
Valves
A well-known manufacturer had this to say about safety devices:
Wasted Superheat Converted to Hot,
Sanitary Water
"There is a need for quick-opening doors with safety devices which remain effective even w
Water Maintenance Essential to personnel operating the door will not concern themselves about safety. We believe that, to
Prevent Boiler Scaling a safety device must:
Water Still Flashes to Steam at 212 be easily operated so that the operator has no reason to object to its use;
Welding Consideration for Pressure
be difficult to circumvent or make ineffective;
Relief Valves

Welding Symbols: A Useful System be impossible to circumvent in such a manner that it can quickly and easily be return
or Undecipherable Hieroglyphics? original condition, say, at the end of a shift;

What Should You Do Before Starting be mounted so that supervisory personnel walking by the door can see at a glance t
Boilers After Summer Lay-Up? device is ensuring safe operation;
Why? A Question for All Inspectors
be simple so that the principle of operation is obvious and rugged so that confidence

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effectiveness is maintained."

The manufacturer goes on to say:

"The patented safety devices on our doors fulfill these conditions. The relative locations of t
fixed in our shop before shipment to ensure a safe overlap of wedges and no means of adju
provided. All parts are welded permanently in place. The bolt operates between lugs on the
breech ring so that any maladjustment of the hinge would not affect the overlap ensured. Th
proportions of the safety device parts are adequate to resist even the full force of the hydra
tending to unlock the breech ring. As offered, the safety device should provide complete pro
that a two inch gate valve can only be closed when the door is safely locked, and the door
unlocked when the valve has been fully opened, and a hand wheel located in the path of the
from the valve has been operated.

"Various other means of providing safe operation can be envisaged but we believe that any
electrical switches and circuits can be circumvented without difficulty and, therefore, cannot
considered prime protection. However, if required, we can supply at extra cost, in addition t
standard safety device, any equipment which may be considered to offer useful secondary
For example, a limit switch may be mounted on our safety device and arranged to operate
the bolt is fully engaged; this switch could be used to control admission of steam or hot oil t
autoclave or to control the blow down valve. Also, a pressure actuated switch could be mou
autoclave and used to control operation of the hydraulic power unit, but the value of such an
arrangement is limited by the degree of sensitivity of the pressure switches."

Finally, a few quotes from an article copied from the Autumn 1974 issue of Vigilance - The
National Vulcan Engineering Insurance Group Ltd. of the United Kingdom. It is quite amazi
experience closely parallels ours.

"Pressure vessels with quick-opening doors such as autoclaves, sterilizers, and vulca
have long been subject to the danger of explosion and from time to time doors have
off for various reasons such as incorrect closure, worn parts of locking devices, and
operation."

"When the door is open at the end of the cycle, there may be residual pressure in th
which is not detectable by the pressure gauge. For example, a pressure of one poun
produces a thrust of two tons on a door two meters in diameter. In these circumstan
person opening the door may be struck and seriously injured or killed."

Let us digress for a moment and refer to the instruction manual for the Bandag type autocla
for curing retreaded tires. The operator is advised as follows:

Open the manually controlled chamber exhaust valve (i.e. the mechanical interlock) after the
cycle has been completed. Never try to open the door until the chamber pressure gauge re
a double check, place your hands around the silencer of the exhaust valve to make sure all
had been exhausted. Even one or two psi of air over the entire surface area of the door wil
enough thrust to cause damage to equipment or personnel.

SAFETY
The safe operation of autoclaves depends upon the following measures. Failure to im
any of them may give rise to an explosion.

The provision of appropriate interlocking safety devices for the door.


Periodical thorough examination of the vessel and its fittings.
Arrangements for regular systematic inspection and maintenance.
Conformity with proper operating procedures.
Adequate training and supervision of operators.

INTERLOCKING DEVICES FOR DOORS


A test cock or other equivalent device should give an audible and visual indication of interna
the vessel. This cock should also be interlocked with the door locking mechanism, in such a
the testcock has to be completely open before the door can start to unlock.

Quick-Opening Closures
B. L. Whitley, Director

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Ensuring Safe Operation Of Vessels With Quick-Opening Closures http://www.nationalboard.org/index.aspx?pageID=164&ID=183

Boiler and Pressure Vessel Division


North Carolina Department of Labor

Apparently, many owners/operators and inspectors are not aware that after many months o
after a few years of cyclic operation, the locking mechanism on quick actuated closures and
similar devices can fail with catastrophic results without proper maintenance and care.

A close inspection of the items making up these closures include pins, bushings, bearings, b
and wear rings. In many circumstances, these items reveal excessive wear that under certa
conditions can cause the vessel to be blown open while it is under pressure. This results in
personnel and an untold thousands of dollars in property damage.

This problem is not unique nor is it confined to any one specific design. It is common in all ty
closures having moving parts that are subject to wear and that have not been properly main

Each inspector should be cautioned to examine every quick actuating device for excess we
of small critical parts, such as pins, bushings, bearings, etc., should be scrutinized closely f
existing abnormal conditions such as looseness, excess wear, or improper fit.

Should any of these conditions be observed, they should immediately be brought to the atte
management and the proper authorities. The inspector should also be reminded that the pre
sensing device designed to prevent the vessel from being inadvertently opened should unde
circumstances be bypassed. If an inspector discovers the pressure sensing device has bee
bypassed, the inspector should immediately report the condition to the proper authorities.

Editor's note: Some ASME Boiler and Pressure Vessel Code requirements may have cha
because of advances in material technology and/or actual experience. The reader is caution
to the latest edition and addenda of the ASME Boiler and Pressure Vessel Code for curren
requirements.

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