AVU & SR-LPG Treatment Unit

Paradip Refinery
DATED:25.06.2023
Topic Covered: Root cause analysis of fatal incident near exchanger (12-E3) of VDU column at Mathura Refinery
Faculty: MD ARIF
Training Session Attended By:
Sl. Sl.
Name Signature/Date Name Signature/Date
No. No.
1 MR. RAKESH 8
MR. BHABANI
2 9
MR. DHEERAJ
3 10
MR. AJEET
4 11
MR. CHANDAN
5 12
MR. DHARMENDRA KUMAR
6 13

7 14

Discussion Points:

Executive summary:

On the day of incident (27th May 2023) AVU unit was running normal at throughput of - 1430 m3/hr in HS mode. LVGO
CR cooler (12-E-03) of VDU column was under maintenance for attending suspected tube leak. On 27th Ma'/23, 12-E-03
floating head cover opening job was planned and accordingly permit was released by Production. At around 11.15 hrs.,
during the execution of job, one of the contract worker became unconscious on the scaffolding's platform. He was
shifted to First Aid Center in Refinery and from there, he was immediately shifted to Swarna Jayanti Samudaik Hospital,
Mathura. However, after his initial treatment, he expired due to cardiopulmonary arrest (Diagnosis- Hypoxia) as
reported in death certificate issued by Swarna layanti Samudaik Hospital, Mathura.

Brief description of incident:

At - 11:15 hrs. on 27.05.23, floating head cover openingjob of LVGO cR cooler (12-E-03) was going on for attending
tube leak. One worker (Sh. Om Prakash) working on scaffolding platform (- 3 meters height from ground) of E03 cooler
was found lying on scaffolding platform by area operator. He was wearing safety belt tied with scaffold. Due to
faintness, he could not have unlocked his safety belt at the time of incident and could not come out of the scaffolding
platform before losing consciousness. By this time, area operator and maintenance engineer also reached the site on
their regular round. Another contract worker working on ground floor spotted his condition and rescued the person
with the help of area personnel and called for ambulance. He was sent to first aid center and from there, he was
immediately shifted to Swarna JayantiSamudaik Hospital, Mathura. However, after his initial treatment, he succumbed
to death due to cardiopulmonary arrest (Dia8nosis- Hypoxia) as reported in death certificate issued by Swarna Jayanti
Samudaik Hospital

AVU & SRLPG Treatment Unit - Skill DevelopmentPage 1 of 2

 Terms of Reference:

Finding out the details of the incident by interaction with operating &/maintenance crew/ contract workers . Review
of operating parameters which can cause giddiness and faintness .Review the compliance of work permit procedure for
the job . Fix the responsibility for the incident, if any.

Brief description of the Unit / Area / location of incident:

Atmospheric and Vacuum unit (AVU) of Mathura refinery is designed with name plate capacity of g MMTPA of High
Sulphur crude (Arab Mix) and Low Sulphur crude (Bombay High). High and Low Sulphur is processed in block mode with
a run of 3-4 days. The Unit is divided in two main sections CDU (Crude Distillation Unit) and VDU (Vacuum Distillation
Unit). VDU column overhead vapors first gets condensed in five parallel pre-condensers. post separation of liquid and
gas phases in accumulator (V02), liquid goes to Hotwell vessel (via drip leg), whereas vapors are routed to ejector
system. There are four parallel (two stage) ejector sets (LLL/2A, B, c, D), normally 2 kept in line and 2 remains as stand-
by. Non-condensable gases from vacuum column finally reach the seal gas KOD which has water seal and pressure
controller. Gases from Seal Gas KoD can be diverted to VDU fired furnace and ABD (Atmospheric Blow down drum)'
These gases have good calorific value and are normally burnt in fired furnaces in low pressure burners. ln Seal gas KOD,
water seal is provided to protect sour gases release to atmosphere in case pressure rise and also avoid air ingress in
vacuum system in the event of ejector failure. To control the pressure of Seal gas KOD, pressure controller is provided
(12P1C02) which releases the excess pressure towards ABD. VDU Overhead schematic is attached as Annex-2. VDU
column top temperature is maintained by tVGo CR stream. Location of LVGO CR cooler in the circuit is attached as
Annex-3 on 24th May'23, LVGo cR cooler (12-E-3) was handed over to mechanical maintenance to attend the suspected
tube leak, and was blinded on 25th May,23. LVGO CR cooler (12-E03) has two exchanger shells vertically stacked.
Floating head cover bolts of bottom exchanger had been opened on 26rh Ma\/23 permit. On 27th Mat23, permit was
issued for floating head cover opening job of upper shell of 12-E-03 (work permit details attached as Annex-4). lt was
raining till 1000 hrs so job was started around 1030 hrs and continued till the time of incident.

Situation before the lncident:

unit was operating normal at throughput of - 1430 m3/hr during HS crude processing Annex-5.

Chronology of events leading to the lncident:

 On 24th May'23, lvgo CR cooler (12-E-03) was isolated due to suspected tube leak and was blinded on 25th
May'23. 12-E-03 has two exchanger shells vertically stacked.
 Floating head cover bolts of bottom shell had been opened on 26th May'23. On 27rh Ma\/23, Permit was
issued for cover opening job of upper shell of lvgo cr cooler (12-E03).
 It was raining till 1000 hrs and job at 12-E-03 was started around 1030 hrs and continued till the time of
incident. There were two other jobs being done around the area. Maintenance engineer was reviewing the .iob
at pump (P15A), which is about 8 meters away from incident site and field operator was also reviewing the job
at SR exchanger (E15). There was no abnormality observed by any of them till the incident time.
 At around 11:15 hrs, contract worker (sh. Om prakash) working on exchanger scaffolding platform became
unconscioussince he was wearing safety belt tied with scaffold, he could not unlock the safety belt and come
out of area and became unconscious on scaffolding platform (- 3 meters from ground floor).

AVU & SRLPG Treatment Unit - Skill DevelopmentPage 2 of 2

  By this time, area operator and maintenance engineer also reached the site on their regular round. Area
operator and maintenance engineer rescued the affected worker with the help oi other area personnel and
called for an ambulance.

 Affected contract worker was sent to First Aid center in Refinery and from there, he was immediately shifted to
swarna Jayanti samudaik Hospitar, Mathura. However, after his initiar treatment, he expired due to
cardiopurmonary arrest (Diagnosis- Hypoxia) as reported in death certificate issued by Swarna Jayanti
Samudaik Hospital, Mathura .

Brief description of the Unit / Area / location of incldent:

Atmospheric and Vacuum unit (AVU) of Mathura refinery is designed with name plate capacity of g MMTPA of High
Sulphur crude (Arab Mix) and Low Sulphur crude (Bombay High). High and Low Sulphur is processed in block mode with
a run of 3-4 days. The Unit is divided in two main sections CDU (Crude Distillation Unit) and VDU (Vacuum Distillation
Unit). VDU column overhead vapors first gets condensed in five parallel pre-condensers. post separation of liquid and
gas phases in accumulator (V02), liquid goes to Hot well vessel (via drip leg), whereas vapors are routed to ejector
system. There are four parallel (two stage) ejector sets (LLL/2A, B, c, D), normally 2 kept in line and 2 remains as stand-
by. Non-condensable gases from vacuum column finally reach the seal gas KOD which has water seal and pressure
controller. Gases from Seal Gas KOD can be diverted to VDU fired furnace and ABD (Atmospheric Blow down drum)'
These gases have good calorific value and are normally burnt in fired furnaces in low pressure burners. ln Seal gas KOD,
water seal is provided to protect sour gases release to atmosphere in case pressure rise and also avoid air ingress in
vacuum system in the event of ejector failure. To control the pressure of Seal gas KOD, pressure controller is provided
(12P1C02) which releases the excess pressure towards ABD. VDU Overhead schematic is attached as Annex-2. VDU
column top temperature is maintained by tVGo CR stream. Location of LVGO CR cooler in the circuit is attached as
Annex-3 on 24th May'23, LVGO CR cooler (12-E-3) was handed over to mechanical maintenance to attend the
suspected tube leak, and was blinded on 25th May,23. LVGO CR cooler (12-E03) has two exchanger shells vertically
stacked. Floating head cover bolts of bottom exchanger had been opened on 26rh Ma\/23 permit. On 27th Mat23,
permit was issued for floating head cover opening job of upper shell of 12-E-03 (work permit details attached as Annex-
4). lt was raining till 1000 hrs so job was started around 1030 hrs and continued till the time of incident.

Situation before the lncident:

unit was operating normal at throughput of - 1430 m3/hr during HS crude processing.

Chronology of events leading to the lncident:

on 24th May'23, LVGo CR cooler (12-E-03) was isolated due to suspected tube leak and was blinded on 25th May'23.
12-E-03 has two exchanger shells vertically stacked. Floating head cover bolts of bottom shell had been opened on 26th
May'23. on 27rh Ma\/23, Permit was issued for cover opening job of upper shell of LVGo cR cooler (12-E03). It was
raining till 1000 hrs and job at 12-E-03 was started around 1030 hrs and continued till the time of incident. There were
two other jobs being done around the area. Maintenance engineer was reviewing the .iob at pump (P15A), which is
about 8 meters away from incident site and field operator was also reviewing the job at SR exchanger (E15). There was
no abnormality observed by any of them till the incident time. At around 11:15 hrs, contract worker (sh. om prakash)
working on exchanger scaffolding platform became unconscioussince he was wearing safety belt tied with scaffold, he
could not unlock the safety belt and come out of area and became unconscious on scaffolding platform (- 3 meters
from ground floor). By this time, area operator and maintenance engineer also reached the site on their regular round.
Area operator and maintenance engineer rescued the affected worker with the help oi other area personnel and called
for an ambulance. Affected contract worker was sent to First Aid center in Refinery and from there, he was immediately
shifted to swarna Jayanti samudaik Hospital, Mathura. However, after his initial treatment, he expired due to

AVU & SRLPG Treatment Unit - Skill DevelopmentPage 3 of 2

 cardiopurmonary arrest (Diagnosis- Hypoxia) as reported in death certificate issued by Swarna Jayanti Samudaik
Hospital, Mathura .

Finding out the details of the incident by interaction with operating/maintenance crew/contract workers:

Detailed review was done for the maintenance jobs carried out on 27th May'23. Out of two stacked exchanger shells of
12-E-03, de-bolting of floating head cover of bottom exchanger had been completed on 26th May itself. It was reported
that it was raining till 1000 hrs on 27th May (incident day), hence there was no job activity done till this time. Clearance
for opening the floating head cover of top exchanger was given by production after carrying out the gas test with multi-
gas detector. Meter read zero at around 1030 hrs. As per production (Sh. Ashish Saxena, JEA), he was reviewing the job
at another exchanger (E15) since 1030 hrs till the time of incident (-1115 hrs). After reaching near VDU seal gas KoD, he
saw the contract worker lying on scaffolding platform. By this time, shift in-charge and mechanical engineer had also
reached the site. He along with shift in-charge, Mechanical engineer and other personnel at site rushed to scaffolding
platform of LVGO CR cooler (12-E-03) after checking the area with H2S responder which was reading zero. Shift-in
charge called the ambulance immediately. lt was informed by field personnels that during the rescue efforts there was
no abnormal smell around the area. Sh' A K Bhoi, MLE from Mechanical maintenance was at site since 1000 hrs till the
time of incident as per his routine schedule. At around 1115 hrs (incident time), he was present near Naphtha pump
(11- P15A) which is about - 8 meters from the incident location. He also confirmed that he did not detect any
abnormality in incident area at the time. Hence rescue could be done without any trouble. lt is to be noted that rescue
operation was done without the aid of any breathing aid like BA set, online Air mask, canister mask etc. suSgesting that
presence of gas immediately after the incident was not felt by any of the personnel engaged in rescue of affected
worker.

Probable causes for unconsciousness of the worker:

Following could be the unconsciousness of the worker (Sh Om Prakash):

1. Health of deceased worker 2. Dehydration 3. inhalation of Sour gases from Seal gas KOD of VDU

1) Health of deceased worker: past health record of deceased Worker is not available with Contractor Supervisor
including the impact of COVID-19.
2) Dehydration: May'23 has been the hottest month in Mathura going on since 24th May'23. But on that day,
weather was good may be ruled out. And the job on E03 cooler was (rainy weather), this possibility
3) Inhalation of sour gases from sour gas KOD of VDU:

Non-condensable gases from Vacuum column finally reach the seal gas KOD which has water seal and pressure
controller. Gases from seal gas KOD can be diverted to VDU fired furnace and ABD (Atmospheric Blow-down
drum). These gases have good calorific value and are normally burnt in fired furnace. In seal gas KOD, water
seal is provided to protect sour gas release to atmosphere in case of pressure rise in the vessel. To control the
pressure of seal gas KOD, pressure controller is provided (12P1C002) which releases excess pressure towards
ABD. There are two seal gas KODs (V06 and V05N) with respective water seals. Old seal gas KOD (V06) was kept
in service and new gas KOD (V06N) was kept isolated. Pressure controller (12P1C02) which is common
controller for both the seal gas KODS, was kept in "Manual" mode due to erratic behavior of pressure
transmitter (PT). Seal gas KOD pressure increased to 0.09 from 0.05 kg/cm2 which is very close to maximum
allowed limit of 0.10 kg/cm2 (Annex-8) as per operating manual. As Pressure Of Seal Gas KOD Reached
Close To Design Pressure, This May Have Disturbed The Water Sealing In KOD, Thereby Releasing Sour
Gas Into Atmosphere Momentarily. Contract worker was working on scaffolding platform above the goose
neck of seal gas KOD (V06N).

AVU & SRLPG Treatment Unit - Skill DevelopmentPage 4 of 2

 Review of operating parameters which can cause sudden loss of consciousness:

Detailed review of operating parameters was done which can lead to the loss of consciousness. It was noted that that
after isolating the LVGO CR cooler (12-E-03) for maintenance, LVGO circulating reflux (CR) temperature had increased
by 24 'C (51 to 85'C). Due to this, VDU column top temperature was higher by 20'c (60 to 80"c) for the last 3 days
(Annex-9). However, on the incident day, LVGO CR temperature was 73"C and VDU column overhead temperature -
59"C due to rainy weather but still higher than normal operating temperature. Higher VDU column top temperature
will eventually generate higher amount of non-condensable sour gases going to two parallel Seal gas KODs (V06 and
V06N). Only one KOD (V06) was in service. Other KOD (VO6N) was kept isolated by keeping inlet and outlet valves in
closed condition. The increased load of non-condensable sour gases in Seal gas KOD increased the pressure of seal gas
KOD to 0.09 kg/cm2 (Annex-9) which is very close to maximum allowed design pressure of 0.10 kg/cm2. Pressure
controller (12P1C02) of Seal gas KOD was kept closed in "Manual" mode due to erratic behavior of pressure
transmiter. ln spite of keeping inlet and outlet isolation valves closed for new seal gas KOD (V05N), pressure in new
seal gas KOD (V06N) increased to 0.09 kg/cm2. This indicates that either the inlet isolation valve of new seal gas KOD
(V06N) or the equalization valve between both the KODs was passing (valves marked in Annex-2). Since new seal gas
KOD (V06N) was in isolated condition, water level in this KOD was not monitored or controlled by the operating crew.
Around incident time, water level in new seal gas KOD was almost zero (Annex-lo) and there was water only in neck
pipe of new seal gas KOD (V06N).

The increase in seal gas KOD pressure might have broken the water sealing which might have released the sour gases
to atmosphere momentarily from goose neck of new seal gas KOD (VO5N). As pressure got released, water seal got
re-established again. As informed by production officer, gas test with multi gas detector was done just before start of
the job ("1030 hrs) and gas reading was also zero (in H2S responder) soon after the incident (-1130 hrs) indicating
momentarily release of sour gas.

Gaps/ lapses:

 Water from Seal gas KODs is drained in OWS funnel. Gap exists in syphon drain line and OWS funnel (sour
water). Gas escape is a possible from the annular gap between drain line and OWS funnel in the event of KOD
water seal disturbance.
 Seal gas KOD (V06) level indication was 100%, needs to be checked/calibrated for its healthiness.
 Seal gas KOD pressure controller (12P1C02) was in Manual mode as pressure transmitter was found erratic.
 Real time value of Gas detectors is available in DCS with alarm but the historian trends of detectors is not
available in DCS and RTDBMS.

Conclusion and Recommendations:

There may have been momentarily break of water seal in VDU seal gas KOD (v06N), which might have released sour
gas' contract worker was working above the goose neck of seal gas KOD (V06N) may have been exposed to this
momentarily release of sour gas, leading to the unconsciousness on the scaffolding platform' Since his safety belt
harness was tied with scaffold as per the safety requirement for working at height, he could not get out of the area
during that time. After momentary release of gas, water seal got re-established as water make-up to seal gas KOD was
on. Gas test was performed by H2S responder and found zero soon after the incident (-1130 hrs). This indicates that gas
release was only for very short period.

AVU & SRLPG Treatment Unit - Skill DevelopmentPage 5 of 2

 Recommendations:

 Seal gas KODs level/pressure transmitters preventive checking/calibration should be done once in a quarter.
 Seal gas KOD pressure controller (12 PIC 02) should be operated in Auto mode to avoid any possibility of water
seal failure.
 Historical trends of all Gas Detectors (GD 05) should be available in DCS and RTDBMS along with the hooter in
field.
 Any job in the sour gas area should be considered as critical, accordingly JSA and necessary other safeguard to
be taken.
 Sour gas area should be marked at site and SOP for entering in such area.
 Currently the seal gas KOD seal water is overflowing in open funnel to OWS and gap exist in seal gas outlet line
and OWS funnel. This should be sealed.
 CCTV should be positioned in such a way so that it covers Seal gas KOD and Hot well area.

Fix the responsibility for the incident, if any:

There was no major deviation found with respect to operation or maintenance procedure adopted or any significant
deviation in process condition which sustained for longer time. Passing of the isolation valves of seal gas KOD (V06N)
being the component failure, no officer/staff personal could be held responsible.

AVU & SRLPG Treatment Unit - Skill DevelopmentPage 6 of 2

 Suggestions for Improvement of the Content:

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