Friday Learning From Incident Dt. 14.06.

2012

Weekly Theme Management of Modifications Sr. No : 10

Incident:

Incident can also occur because changes to process materials or conditions had
unforeseen results. Change of charcoal size in charcoal bed for hydrogen purification
system lead to production loss.
A hydrogenation reactor developed a pressure drop. Various causes were considered
like, catalyst quality / size / distribution / activation, reactant quality, distribution and
degradation of catalyst before the true cause was found.

The hydrogen came from another plant and was passed through a charcoal filter to
remove traces of oil before it left the supplying plant. Changes of charcoal were
infrequent, and the initial stock lasted several years. Reordering resulted in a finer
charcoal being supplied and charged without the significance of the change being
recognized.
Over a long period, the new charcoal passed through its support into the line to the
other plant. Small amounts of the charcoal partially clogged the 0.375” inch distribution
holes in the catalyst retaining plate.
The cause of the pressure drop was difficult to find because it was due to a change in
another plant. This was resulted in a big loss of production.

Key Findings:

1. The hydrogen supplier plant might not have carried out thorough HAZOP and
or PHA study to identify the process hazards associated with the change
2. The affected plant might have carried out the hazard review according to the
modifications made in hydrogen supplier plant if communicated.
3. Modification made in hydrogen supplier plant was not communicated to the
receipt plant.
Key Learning :

1. Any modifications made in plant must be communicated to the affected

personnel as well as plants
2. All the modifications must be done through MOC and thorough hazard review
must be done to identify hazards.
3. Make sure that personnel from affecting plants also must be included in the
hazard review team

Reference: What Went Wrong?

By Trevor Kletz