Case His¢ories
Incidents that could have been prevented by HAZOP
The incidents described below would
p r o b a b l y n o t h a v e o c c u r r e d if a h a z a r d
and operabdlty study (HAZOP) had
been earned out durmg the design of
t h e p l a n t O f c o u r s e , t h e r e is n o g u a r a n -
tee that a HAZOP would have pre-
vented the incidents a HAZOP m only
as g o o d as t h e H A Z O P t e a m , a n d ff
they lack experience and k n o w l e d g e the
s t u d y will p r o d u c e h t t l e o r n o t h i n g B u t
a reasonably competent team should
foresee the hazards described below
T h e t a n k s h o w n m F~gure 1 w a s
b e i n g filled f r o m a n o t h e r t a n k s o m e
dastance a w a y T h e p u m p u s e d f o r
cmptymg the tank was not runmng but
its l o c k - b a c k h n e h a d b e e n left o p e n
W h e n t h e t a n k w a s n e a r l y full t h e h i g h
l e v e l trap c l o s e d t h e v a l v e m t h e filling
h n e T h e g a u g e p r e s s u r e m t h e filling
h n e r o s e to 20 b a r (300 psi) a n d b u r s t
t h e p u m p w i n c h n o r m a l l y o p e r a t e d at a
g a u g e p r e s s u r e o f 3 b a r (45 p s 0 A tunately, the designers o v e r l o o k e d the
H A Z O P h a d b e e n e a r n e d out on the
p l a n t b u t thin s e c t i o n w a s n o t studaed as
it w a s ' o n l y a n o f f - p l o t ' , a t a n k , a p u m p
and a few valves, too snnple for any
h a z a r d s t o pass u n n o t i c e d , o r so it w a s
thought Conslderalaon of 'reverse flow'
through the lock-back hne (or ' m o r e off
p r e s s u r e ' m t h e filling h n e ) w o u l d h a v e
dasclosed t h e h a z a r d A f t e r t h e m c l d e n t
the kink-back hne was r e r o u t e d back to
the tank
T h e s u m p s h o w n m Ftgure 2 c o n -
tamed water with a layer of hght od on
top Welding h a d to take place n e a r b y
so t h e s u m p w a s e m p t i e d c o m p l e t e l y
Shut
R g u r e I W h e n t h e automatic valve closed, t h e p u m p w a s overpresaured
128 J. Loss Prev. Process Incl., 1991, Vol 4, J a n u a r y
with an ejector and fdled with clean
w a t e r t o t h e l e v e l o f t h e o v e r f l o w p~pe
W h e n a s p a r k fell i n t o t h e s m n p , t h e r e
w a s a n e x p l o s i o n a n d fire T h e U - b e n d
h a d n o t b e e n e m p t a e d a n d tt is b e h e v e d
t h a t t h e r e w a s a l a y e r o f oll m t h e b e n d
on top of the water A HAZOP would
h a v e d i s c l o s e d t h e h a z a r d if t h e p r e -
paration of the equipment for mainten-
ance had been considered Here again,
the e q m p m e n t r e c e w e d httle consldera-
taon d m m g d e s i g n as it w a s n o t p a r t o f
t h e m a m p l a n t , o n l y a s y s t e m f o r col-
lecting a waste w a t e r s t r e a m
A reactor was fitted with a head
t a n k c o n t m m n g w a t e r (Figure 3) I f t h e
contents of the reactor got too hot and
the reaction started to run away, the
o p e r a t o r was supposed to o p e n the
r e m o t e l y o p e r a t e d v a l v e so t h a t t h e
w a t e r w o u l d f l o w b y g r a v i t y into t h e
reactor a n d cool the contents Unfor-
fact t h a t w h e n t h e r e a c t i o n s t a r t e d t o
run away the pressure m the reactor
w o u l d rise W h e n t h e v a l v e w a s o p e n e d
the w a t e r was blown out of the ventf
T h e reactor exploded and the subse-
q u e n t fire d e s t r o y e d t h e u m t ~
A fuse b l e w a n d p a r t o f a n i n s t r u -
m e n t panel was de-energized T h e trip
system shut d o w n the plant safely a
turbine and p u m p s stopped, flows
stopped and the furnace tripped T h e
c o n d e n s a t e p u m p s c o n t i n u e d t o r u n , as
p l a n n e d , so t h a t t h e s t e a m d r u m , c o n -
n e c t e d t o t h e w a s t e h e a t b o i l e r s , dad n o t
g e t e m p t y I n fact it filled u p c o m p l e t e l y
q5 p s i g Shut
~ ~ To
t Open r ~ Y plant
KIck-~ck hne
Line used for filling tank
m two minutes and the condensate
o v e r f l o w e d into the s t e a m m a r e (Fzgure
4) T h e t u r b m e w a s d r i v e n b y h o t g a s e s
from the furnace but could be started
with steam The operators decided to
roll t h e t u r b i n e s l o w l y ( t o p r e v e n t d a m -
age to the shaft) A s no furnace gas was
avadable they cracked open the steam
valve Condensate ~ e into contact
with the hot hne from the furnace and
the hne ruptured Three men were
sprayed with s t e a m and hot c o n d e n s a t e
a n d t w o o f t h e m w e r e lolled H A Z O P s
should consider the results of p o w e r and
other service failures, a n d the action to
b e t a k e n s h o u l d b e c o v e r e d xn p l a n t
t r a l m n g and instructions The plant
instrumentation had onganally been
v e r y well o r g a m s e d b u t as i n s t r u m e n t s
w e r e r e m o v e d a n d o t h e r s a d d e d it
J
(12" diameter)
R g u r e 2 The s u m p w a s e m p t i e d and
filled with clean water, but oil was left m
the U-bend
~- V e n t
too0o ,
Remotely operated valve
Reactor
F~Bure3 W h e n a r u n a w a y r e a c t m n o c -
curred, instead of the water entering the
reactor, the Increased pressure b l e w out
the w a t e r

Hot furnace gas ~ ~lt
Rupture Turbine
(normal power vv~ ~11 ~_/
supply) &l~Steam [start-up
~ power supply)
From!elsie T! woste~her~Stco~eu'sert~
heat boilers heat boders make-up
Figure4 When the steam valve was
opened, condensate entered the hot hne
f r o m the furnace
AIChE Loss Prevention Symposium
San Diego, CA, USA, 20-22 August 1990
The twenty fourth annual AIChE Loss
PrevenUon Symposmm was held on
2 0 - 2 2 A u g u s t 1990 m S a n D i e g o , C a h -
f o r m a T h e r e w e r e o v e r 160 a t t e n d e e s
f o r t h e six s e s s i o n s , a t w h i c h 3 6 p a p e r s
were presented The first sessmn dealt
wath t h e u s e a n d m m u s e o f P L C / c o m -
puters m control/safety apphcat~ous
The use of such devaces can enhance
process momtormg and control capabd-
rues, but the complexity and versatthty
of the systems can lead to new problems
t h a t wall r e s u l t m p r o c e s s u p s e t s a n d
hazards Case hmtorms of such prob-
lems were dmcussed Also, many PLC
based systems were not demgned for
high risk mstallaUons and have lm~ted
&agnostics, parUcularly for covert (un-
revealed) fadures Such systems reqmre
a d d m o n a l t e s t i n g f o r f a u l t d e t e c U o n as
well as r e d u n d a n c y O n e p a p e r dis-
cussed the estlmaUoa of digital control
s y s t e m s r e h a h i h t y b a s e d o n a c t u a l ex-
p e r i e n c e wath r e d u n d a n t c o m p u t e r sys-
tems
T h e s e c o n d s e s s i o n c o n t a i n e d six
excellent papers on new tmtlatwes m
Safety and Loss Prevention Trmnmg
Trmnmg programmes recently deve-
loped to include safety mstructmn m
exmUng undergraduate chemical en-
b e c a m e d i f f i c u l t t o tell w h i c h m s t r u -
ments were connected to which power
supply All modtficattous, mchidmg
modlfieatmns to instrument and elec-
trical systems, should be rewewed by
H A Z O P o r a s~rmlar t e c h m q u e A f t e r
the mordent the steam drum was made
l a r g e r so t h a t tt c o n t a i n e d e n o u g h c o n -
densate to remove residual heat from
the process without make-up, an inher-
ently safer destgn 2
Other accidents that could be pre-
vented by HAZOP are described m
Refs 3-5
Trevor Kletz
g m e e r m g c u m c u l a , as well a s p r a c t t e a l
examples of safety tralmng currently
being done, were presented Unfortun-
a t e l y a t t e n d a n c e a t thin s e s s m n w a s l o w
It s e e m e d t h a t o n l y t h e r e l a u v e l y f e w
w h o a r e a c t u a l l y d o i n g w o r k m this a r e a
are interested Interest may be stunul-
a t e d b y f e d e r a l leg3slatlon w h i c h is
currently under actwe consaderaUon
Two sessmns contmned miscellan-
e o u s t o p i c s as well as c a s e l n s t o n e s
Topics ranged from using thermody-
natures to determine the energy of
e x p l o m o n , t o fires a n d e x p l o m o u s m
specific pieces of process eqmpment
The teehmcal content was outstanding
a n d it is h o p e d t h a t adChtlonal c a s e
hmtorms wdl be presented at future
meetings
One sessmn covered the topic of
f l a m e a r r e s t e r s tn c o n m d e r a b l e d e t a d
With the increasing reqmrement to
mamfold vents from flammable hqmd
tanks to a central collectaon faclhty, the
need for m-hne flame arresters has
increased greatly lnstallatmn of flame
arresters, tested for end of hne use, m
m a n i f o l d s wall p r o b a b l y r e s u l t m t h e i r
fadure Test methods for m-hne arre-
sters were covered Another paper m
this session gave test results for various
J. Loss Prev. Process Ind., 1991, Vol 4, January
Conference Report
References
1 I-Idl, R J Loss Prey Process lad 1988, 1,
25
2 Gibson, T O Plant/Operanons Progress
1989, 8(4), 209
3 Kletz, T A m ' W h a t Went Wrong9 -
Case Histories of Process Plant Disasters',
2nd edlUon, G u l f Pubhshmg, Houston,
TX, U S A , 1988, chapter 18
4 Kletz, T A m ' H a z o p and H a z a n - Notes
on the Identification and Assessment of
H a z a r d s ' , 2rid edkt]on, IChemE, Rugby,
U K , 1986, chapter 2
5 Kletz, T A m 'Cntmal Aspects of Safety
and Loss Prevention', Butterworths,
Gmldford, U K , 1990, p 155
e nfevenne Uelmet
factors that influence pressures d e v e l -
oped m vented explosmus
Oxadataon reaettons and associated
p h e n o m e n a w e r e c o v e r e d b y a mx p a p e r
sessmn The papers covered autolgm-
tlon m the gas phase, spontaneous
m s u l a t m n fires, t h e r m a l s t a b d t t y o f a
reactive monomer, flammahihty of
metal packings under high oxygen con-
c e n t r a t i o n , s a f e d e m g n o f p r o c e s s e s us-
m g h y d r o g e n p e r o x i d e a n d a c a s e Ins-
tory of a deflagraUon revolving an or-
g a m e s o l v e n t / o x y g e n s y s t e m b e l o w its
flash point
T h i s y e a r , f o r t h e first t n n e e v e r ,
the proceedings were avadable at the
meeting They mchided an index by
s u b j e c t o f all p a p e r s p r e s e n t e d m t h e
first t w e n t y t h r e e s y m p o s i a ( 1 9 6 7 -
1989) C o p r a s o f t h e p r o c e e c h n g s m a y
b e o b t a i n e d b y s e n d i n g $50 ( U S ) t o W
J B r a d f o r d , 22 D e e r R u n R d , B r o o k -
field, C T 0 6 8 0 4 , U S A T h e n e x t A I C h E
L o s s P r e v e n U o n S y m p o s m m will b e
h e l d m P i t t s b u r g h m A u g u s t 1991
W J Bradford
22 D e e r R u n R o a d ,
Brookfleld, CT06804,
USA
129