Chapter 46 • Avoiding Death and Disaster 357

Thus when a repair weld was made many years later, the repair weld was not postweld
heat treated either. What the engineering design contractor had missed was that:
• Amine treating of H2S extraction is a potentially corrosive service.
• MEA is more corrosive than DEA or MDEA.
• When steel corrodes, one product of corrosion is iron sulfide (HS).
• The other product of corrosion is a hydrogen ion (H+).
Ionic hydrogen will penetrate welds and will accumulate as molecular hydrogen in
unstressed relieved welds and cause the welds to fail. Neither Unocal, nor the engineering
contractor was found liable for this explosion. But my client, Nooter Engineering, who did
the repair weld, was found, quite unjustly, to be at fault.

Shell Norco Explosion

Six operators were killed, the FCU (Fluid Catalytic Cracking Unit) was destroyed, and
thousands of homes damaged, when a Cracking Unit blew-up in Norco, Louisiana. The
origin of the explosion was a free air detonation of a cloud of propane from a blown-
out 800 overhead vapor line, from the FCU depropanizer. I saw the failed pipe elbow in
an inspection laboratory a year after the explosion. It was obvious what had happened
(see Fig. 46.4).
Wash water injected into the 800 overhead vapor line had cut a groove in the outer radius
of the elbow. It’s true that the water wash nozzle should not have been pointed straight
down at the elbow, 2 ft below. It’s true that the nozzle should have been a dispersion, or
fog-type nozzle, not just a section of ¾00 tubing cut at a 45 degree angle. It’s also true that
the water wash flow should have been directed in the horizontal run of piping, 100 –200
upstream of the first elbow.
But the main problem was that the wash water was just plain Mississippi River water
that had not been de-aerated. This caused, “Cavitation,” as the high velocity water

Aerated
60% Propylene wash
40% Propane water

Vapors

Hole
LPG
Vapor
cloud

FIG. 46.4 Acidic water impinged on pipe causes erosion and pipe failure—6 killed—Shell.
358 UNDERSTANDING PROCESS EQUIPMENT FOR OPERATORS AND ENGINEERS

released oxygen bubbles at the point of impact. Shell should have used de-aerated water
as wash water, from the Boiler Feed Water De-aerator Plant.
Apparently, the installation of the ¾00 wash water injection was a retrofit project that
had not been reviewed by Shell’s engineering department. It was considered to be just
a minor piping project to be implemented by a local piping contractor.
I was the expert witness for the lawyers suing Shell on behalf of the homeowners who
had sustained very minor property damage. The case was settled by Shell for $300,000,000.
The deceased operators’ families did not share in the settlement. They were covered by
“Workman’s Comp,” which prohibits such legal action by employees. But the lawyers
representing the homeowners received $120,000,000 for their “work.”

Union Carbide—Bhopal Disaster

Union Carbide’s Pesticide Plant killed over 10,000 people in Bhopal, India. As a conse-
quence, this large, famous, chemical company was liquidated. Bhopal is the worst acci-
dent that has ever happened in the process industry.
The cause of this incident has been attributed to a faulty mechanical seal on the Methyl
Isocyanate pump. The pump had been designed with a marginal available Net Positive
Suction Head (NPSH), which caused persistent cavitation at the entrance to the pump
impeller, which caused damage to the seal and frequent seal leaks (see Fig. 46.5).
The resulting methyl isocyanate leaks were an irritant, but not fatal. To avoid this rel-
atively minor problem, plant operators devised a clever solution:
• The pump was shut down.
• The bypass valve around the pump was opened (see Fig. 46.5).

Phosgene

Methyl–Isocyanate

To reactor

By pass NC
Wash water
FIG. 46.5 Bhopal, India—10,000 + killed. Union Carbide.
 Chapter 46 • Avoiding Death and Disaster 359

• The Isocyanate vessel was pressured-up by several Bar’s, using an existing plant
nitrogen purge connection.
As a consequence of the Isocyanate vessel operating at a higher than normal pressure, the
vessel pressure alarm would periodically be activated. To avoid the annoyance of the
alarm, the alarm was deactivated.
During World War One (1914–18), the Germans introduced poison gas. The most ter-
rible being phosgene. To produce phosgene:
• Step 1—Take Methyl Isocyanate.
• Step 2—Add water.
• Step 3—Mix gently for 5 min.
At the Bhopal Plant, wash water (Fig. 46.5) was used periodically to flush out the feed line
to the reactor. With the Methyl Isocyanate pump running, and the pump bypass valve
shut, water could never flow back into the vessel.
However, with the pump out of service, and the bypass valve open, water could—and
did—one evening, back-up into the vessel. The result was a rapid evolution of phosgene
vapors that caused the vessel to overpressure. The relief valve opened, and fatal phosgene
gas settled over the city of Bhopal, India. The water injection continued even as
people died.
But why?
Because the high pressure alarm had been deactivated, due to running the vessel at a
higher than normal pressure with nitrogen. Thus the control panel operator was not
alerted to the problem of the excessive vessel pressure.
The real cause of the Bhopal disaster was not a faulty pump mechanical seal. It was not
an equipment failure or a design error. It was a failure to follow my Mother’s advice:
“Norman, listen. Hope for the best, but plan for the worst.”
“Mom, what does that mean?”
“Norman, you have to examine the consequences of your actions. Think things through
before you make changes. You’re not a child anymore. Bad things happen to people that
act without thinking carefully first. Just following all the rules is not good enough. Try to be
more like your Uncle Herb. He’s an engineer!”

Amoco, Texas City—Death by Nitrogen

Three contractor maintenance workers died from nitrogen suffocation in a hydrocracker
reactor. The reactors had been purged with nitrogen prior to issuing entry permits. Two
identical reactors had been tested for breathability. The third was full of nitrogen only.
The three workers entered the wrong reactor, collapsed, and died. This happened
around 1970.
One only feels difficulty in respiration due to ½% CO2 in air. If no CO2 is present, regard-
less of lack of O2, no respiration discomfort will be experienced.
360 UNDERSTANDING PROCESS EQUIPMENT FOR OPERATORS AND ENGINEERS

I once (1982) connected plant N2 to the instrument air system. I almost killed everyone
in the control room. Our air operated instruments displaced the actual air with N2 emitted
by the instrument panels. Fortunately, a low O2 alarm sounded, and I realized my error.
“God watches over the feeble minded.” (Good Hope Refinery, Norco, Louisiana).

Summary
“Lieberman,” Harvey said, “what’s the point of all these stories? They are certainly tragic –
but seem disconnected. Accidents will happen! The best way to minimize accidents, is for
all employees to have a positive attitude towards safety awareness.”
“No Harvey. The best way to avoid accidents is to understand when to:
• Stress relieve vessels and piping welds.
• Know when equipment or piping has been properly depressured.
• Understanding how level measurements vary with liquid density.
• Not using air saturated wash water without a spray nozzle that impinges on piping.
• Which alarms should never be deactivated.
That is Harvey, to understand how the process equipment actually works and the experi-
ence to anticipate what can go wrong, when lessons learned from past experience are
ignored.”
“Those who do not study history, are condemned to repeat it.”
 47
Our Engineering Function in an Era
of Global Warming

As a refinery process engineer, my work brings me into contact with technical and
operational management. These individuals determine implementation of energy saving
projects such as:
• Training operators to run process units in an energy-efficient manner.
• Power recovery turbines.
• Air preheaters.
• Frequency control for electric motor-driven pumps.
• Recovery of steam condensate.
• Maximizing heat recovery from product.
• Recovery of low BTU waste gas streams.
When I discuss with these decision makers their objectives for operations, I have found
their main concerns are [1] as follows:
• Maximizing short-term return on investment.
• Plant safety and operability.
• Maximizing heavy gas oil recovery from vacuum tower residue.
• Maximizing crude rates.
• Avoiding labor relations problems.
• Minimizing maintenance expenses.
I have found a lack of interest in what I would consider longer term objectives:
• Energy conservation.
• Climate change.
• Composition of the atmosphere.
• Global warming.
• Sea level rise.
• Ocean pH decrease.
• Loss of biodiversity.
The individuals who manage and direct petroleum refineries are typically Chemical Engi-
neers in their early 40s to late 50s, married, with grown children. Most do not know the
current or past CO2 levels in the atmosphere, or the rate of increase of ambient global

Understanding Process Equipment for Operators and Engineers. https://doi.org/10.1016/B978-0-12-816161-6.00047-3 363

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