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torque from the drive shaft to the disk

PROBLEM fell out of its keyway, disconnecting the
drive shaft from the disk. System
pressure was high enough to eject the

ertain types of check and butterfly
valves can undergo shaft-disk unrestrained drive shaft from the valve,
s e p a r a t i o n , a n d f a i l cata­ carrying with it the external
strophically or “blow-out”, causing toxic counterweight assembly, weighing over
and/or flammable gas releases, fires, and 200 lbs., a distance of 43 feet away.
vapor cloud explosions. Such valve
failures can occur even when the valves The absence of the drive shaft left a hole
are operated within their design limits in the valve body the diameter of the
of pressure and temperature. shaft (3.75 inches) directly to
atmosphere, and initiated a high-
pressure light hydrocarbon leak. The
ACCIDENT HISTORY leak continued for approximately 2 to 3
minutes, forming a large cloud of
flammable light hydrocarbon vapor. The

n a 1997 accident, several workers
vapor cloud ignited, resulting in an
sustained minor injuries and millions
explosion felt and heard over 10 miles
of dollars of equipment damage
away. The explosion and ensuing fire
occurred when a pneumatically assisted
caused extensive damage to the facility,
Clow stub-shaft Model GMZ check (non­

completely or partially destroying many

return) valve in a 300 psig flammable gas
major components, piping systems,
line underwent shaft blow-out. The
instruments, and electrical systems, and
valve’s failure caused the rapid release
requiring the complete shut-down of the
of large amounts of light hydrocarbon
affected unit for cleanup and repair.
gases which subsequently ignited,
Minor damage occurred to nearby

resulting in a large vapor cloud

residences and automobiles (mostly
explosion and fire.
broken glass and minor structural
damage due to the blast wave). Nearby
The check valve was designed with a highways were closed for several hours.
drive shaft that connects the internal Damage cost to the facility alone is
valve disk to an external pneumatic estimated at approximately 90 million
cylinder (see diagram on next page). The dollars. Fortunately, no fatalities and
valve failed when a dowel pin designed only minor injuries to workers resulted
to fasten the drive shaft to the disk from the accident.
sheared and a key designed to transfer
2 Shaft Blow-Out Hazard of Check and Butterfly Valves September 1997

Previous malfunctions involving check valves In the 1991 incident, the malfunction was
of the same or similar design occurred at manifested by the erratic operation of the valve,
facilities in 1980, 1991, and 1994. In each case, which was observed to operate independently
the affected check valve was located in a large from its external drive mechanism. System
diameter (36-inch or greater) pipe in a pressure was low enough (70 psig) that the
hydrocarbon gas compression system. Also in failure was detected before the shaft was
each previous case, a dowel pin fastening the expelled out of the valve body. (At the time the
valve’s drive shaft to its disk sheared (in the 1980 malfunctioning valve was identified, the valve
case the pin was possibly never installed) and a shaft was protruding about 0.75 inches out of
rectangular key fell out of its keyway, the valve body.) In the 1980 and 1994 cases, the
disconnecting the drive shaft from the disk. malfunction was identified when workers noted
Although shaft-disk separation occurred in each that the external piston rod connecting the air-
previous case, it did not result in shaft blow-out assist cylinder to the drive shaft had broken due
or catastrophic failure. This may be because the to axial movement of the drive shaft.
valves in these instances were installed in lower-
pressure service, or because the malfunctioning
valves were identified before shaft blow-out

systems containing chemicals leading to

HAZARD AWARENESS hydrogen embrittlement.

heck and butterfly valves are used in Valves subject to this hazard may be designed
many industries, including refineries, with a two-piece valve stem (sometimes referred
petrochemical plants, chemical plants, to as a “stub-shaft” design). In each of the cases
power generation facilities, and others. Most described above, the malfunctioning component
modern valve designs incorporate features that was a Clow stub-shaft Model GMZ
reduce or eliminate the possibility of shaft blow­ pneumatically assisted swing check valve (see
out. However, older design check and butterfly diagram below). In these check valves, one stem
valves with external appendages such as piece functions as a drive shaft that connects the
pneumatic-cylinders, counterweights, manual internal valve disk to an external air-assist
operators, or dashpots may be subject to this cylinder and counterweight assembly. The drive
hazard. Shaft blow-out may be of particular shaft penetrates the pressure boundary through
concern wherever these valves are installed in a stuffing box. The exterior portion of the drive
3 Shaft Blow-Out Hazard of Check and Butterfly Valves September 1997

shaft is connected to a pneumatic piston and Operational Factors

counterweight, and the interior portion of the
shaft is coupled directly to the valve disk using ◆ The valve is subject to high cyclic loads. In
a cylindrical hardened steel dowel pin and a all of the above incidents, the valve repeat­
rectangular bar key. This arrangement provides edly slammed shut with great force during
a power-assist to close the valve during compressor trips and shutdowns. Such re­
compressor shut down, preventing reverse flow peated high stresses may cause propagation
of compressed gases. These particular valves of intergranular cracks in critical internal com­
have probably not been produced since 1985, but ponents, such as dowel pins.
still exist in some process facilities constructed
before that date. Similar valves currently or ◆ The valve is subject to low or unsteady flow
previously produced and sold by other valve conditions, such that disk flutter or chatter
manufacturers may also be subject to this occur, resulting in increased wear of keys,
hazard. dowel pins, or other critical internal

Factors in Valve Failure ◆ Valves in high-pressure service lines may be

more likely to undergo shaft blow-out (in the
A number of design and operational factors may 1997 accident, system pressure at the failure
contribute to this hazard. These include the point was approximately 300 psig).
◆ Valves used in hydrogen-rich or hydrogen
Design Factors sulfide-containing environments may be
more susceptible to blow-out due to hydrogen
◆ The valve has a shaft or stem piece which embrittlement of critical internal components,
penetrates the pressure boundary and ends particularly if these are made from hardened
inside the pressurized portion of the valve. steel (as was the dowel pin in the 1997
This feature results in an unbalanced axial accident).
thrust on the shaft which tends to force it (if
unconstrained) out of the valve.
◆ The valve contains potential internal failure
points, such as shaft dowel-pins, keys, or bolts

acilities should review their process
such that shaft-disk separation can occur systems to determine if they have valves
inside the valve. installed that may be subject to this
hazard. If so, facilities should conduct a
◆ The dimensions and manufacturing detailed hazard analysis to determine the risk
tolerances of critical internal parts (e.g., keys, of valve failure. Check valves or butterfly
keyways, pins, and pin holes) as designed or valves which are subject to several or all of the
as fabricated cause these parts to carry above design and operational factors are at
abnormally high loads (e.g., in the 1997 high risk for shaft blow-out. Detailed internal
accident, the dowel pin rather than the key inspections may be necessary in order to
transmitted torque from the shaft to the disk). identify high-risk valves. Facilities should
consider r eplacing high-risk valves at the
◆ The valve stem or shaft is not blow-out earliest opportunity with a blow-out resistant
resistant. Non blow-out resistant design design. Several blow-out resistant designs of
features may include two-piece valve stems check and butterfly valves are available. If
that penetrate the pressure boundary immediate valve replacement is impossible or
(resulting in a differential pressure and i m p ract i cal , faci l i t i es s h o u l d co n s i d e r
unbalanced axial thrust as described above), immediately modifying the valves to prevent
single-diameter valve shafts (i.e., a shaft not shaft blow-out. Valve manufacturers should
having an internal diameter larger than the b e co n s u l t ed i n o rd er t o en s u r e t h at a ny
diameter of its packing gland) or shafts modifications made are safe.
without thrust retaining devices, such as split-
ring annular thrust retainers.
4 Shaft Blow-Out Hazard of Check and Butterfly Valves September 1997

American Petroleum Institute

Washington, DC 20005
ON VALVE SAFETY Phone: (202) 682-8000
Web site:
Some sources of information on valve safety
are listed below. Relevant API standards include:
API 598-1996 — Valve Inspection and Testing
General References API 570-1993 — Piping Inspection Code:
Information on cases of valve failure can be found Inspection, Repair, Alteration, and Rerating of
in T. Kletz, What Went Wrong?, 3rd Edition, Gulf In-Service Piping Systems
Publishing Co., Houston (1994). This reference
API 941-1991 — Steels for Hydrogen Service at
contains general information related to check valve
Elevated Temperatures and Pressure in
failure (pp 127, 129, and 175) and cites one specific
Petroleum Refineries and Petrochemical Plants
case of check valve failure (page 124) similar to
those described in this Alert.
Relevant API Recommended Practices include:
Information on hydrogen embrittlement can be RP 574-1992 — Inspection of Piping, Tubing,
found in F.P. Lees, Loss Prevention in the Process Valves and Fittings
Industries: Hazard Identification, Assessment, and
Control, 2nd edition, Butterworth-Heinemann RP 591-1993 — User Acceptance of Refinery
Publishing, Oxford (1996), pp 12/82-83. Valves

Codes, Standards, and Applicable regulations include:

Regulations 29 CFR 1910.119 Process Safety Management
The American Society of Mechanical Engineers (ASME) of Highly Hazardous Chemicals; Explosives
has a standard for valves. and Blasting Agents.

American Society of Mechanical Engineers
345 East 47th Street FOR MORE INFORMATION...
New York, NY 10017
Fairfield, NJ 07007-2900
(800) 424-9346 OR (703) 412-9810
Phone: (800) 843-2763
TDD (800) 553-7672
Web site:
Relevant ASME standards include: ◆◆◆
ASME B16.34-1996 — Valves - Flanged,
Threaded, and Welding End, an American VISIT THE EPA CEPPO HOME PAGE ON THE
National Standard. WORLD WIDE WEB AT:
◆ http://www.epa.g ov/swercepp/
The American Petroleum Institute (API) has several ◆◆◆
relevant standards and Recommended Practices.
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