Lesson Learnt Analysis

[tuan]

Got something very well made. Could help in HAZOP studies if team is kept informed during opening workshops.
Some of the incidents which have been included within:
1 UVCE after piping modification
2 Problem of galvanised stairs and platform walkways in fire
3 Layering in a liquefied gas accumulator lead to low temperatures and brittle fracture causing release and VCE
4 Overfilling of propane storage vessel gave condensation hammer, vessel rupture and vapour cloud explosion
5 Compressor gasket leak gave flash fire
6 Hammer in a multi product pipeline rupture the line, releasing fuel which flowed into a village and burned
7 Fire on opening a pipe flange for valve maintenance
8 Blowby when liquid was drained from a separator allowing gas to discharge though te liquid line. The LP separator ruptured
9 Damage to electrical power cables due to trench excavation
10 Condensate hammer caused a pipe rupture after a steam trap was disabled to allow confined space entry
11 Inadequate pipe support and inadequate installation and thermal cycling caused pipe rupture and fire
12 Gasket displacement due to thermal cycling causes leak and explosion
13 Flange failure due to rapid heating of reactor, giving a dangerous flange fire

[ivani1]

Missed the attachment, if there was any.

[tuan]

Don't know how I missed.
Attached now with the original post.

Missed the attachment, if there was any.

[ben]

Do you have more details available for incident happened in Beek?

Beek_Incident.jpg

[ben]

What an important thread, can lead to multiple discussions within.
Though known with few but there is a long list I am not aware of then the way lessons learnt have been mentioned.
Credits for the creator.

[tuan]

Primary cause of the incident was the material not suitable to handle low temperature as brittle fracture occurred.
This cause has now been adequately addressed in modern plants with the use of good quality low temperature resistant materials.
Some more details can be provided by our metallurgical experts.
Attached a document containing detailed report on Beek incident.

Do you have more details available for incident happened in Beek?
Beek_Incident.jpg

[tuan]

Yeah, a lot many things to learn and share during HSE meetings, interaction with field colleagues, operations staff, maintenance personnel, and the leadership teams.
We normally have a lot of forums to take up these things but compilation is challenging.
Such documents ease that part out.

What an important thread, can lead to multiple discussions within.
Though known with few but there is a long list I am not aware of then the way lessons learnt have been mentioned.
Credits for the creator.

[ivani1]

Valuable sharing @ tuan.
Going through that and a lot many incidents to learn from.
Can any one share some more details for the incident related to overfilling, hammer and vessel rupture in propane service?

[tuan]

You need to give 10 minutes to this explanation.
Hammering was not the cause of the incident happened in Texas City refinery.
Basic issue was with the level gauge which was not designed to measure any level more than 9 feet.
Many other contributing causes as well, just go through the link:

https://en.wikipedia.org/wiki/File:Upda ... losion.ogg

[ivani1]

Thank you for the link.
One of the best animated videos I have seen from CSB.