What Went Wrong?, : Case Studies of Process Plant Disasters

433 Pages·1998·22.42 MB·English

by  Trevor Kletz

FOURTH EDITION
WHATW ENTW RONG?
This Page Intentionally Left Blank
F O U R T H E D I T I O N
Case Histories of
Process Plant Disasters
Trevor Kletz
GP
Gulf Professional Publishing
An Imprint of Elsevier
To Denise,
Who waited while I
"scorned delights and lived laborious days"
but never saw the results.
WHAT WENT WRONG?
Case Histories of Process Plant Disasters
FOURTH EDITION
ISBN-13" 978-0-88415-920-9
ISBN-10:0-88415-920-5
Copyright (cid:14)9 1999 by Elsevier. All rights reserved. Printed in the United States of
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Contents
Acknowledgments ................................. xi
Preface .......................................... xiii
Units and Nomenclature ............................ xix
Chapter 1. Preparation for Maintenance ...............
1.1 Isolation, 1
1.2 Identification, 11
1.3 Removal of hazards, 16
1.4 Procedures not followed, 24
1.5 Quality of maintenance, 32
1.6 A personal note, 44
Chapter 2. Modifications ............................ 48
2.1 Startup modifications, 48
2.2 Minor modifications, 49
2.3 Modifications made during maintenance, 55
2.4 Temporary modifications, 56
2.5 Sanctioned modifications, 58
2.6 Process modifications, 60
2.7 New tools, 63
2.8 Organizational changes, 64
2.9 Gradual changes, 66
2.10 Modification chains, 66
2.11 Modifications made to improve the environment, 69
2.12 Control of modifications, 74
Chapter 3. Accidents Caused by Human Error .......... 78
3.1 Introduction, 78
3.2 Accidents caused by simple slips, 79
3.3 Accidents that could be prevented by better training, 90
Chapter 4. Labeling ................................ 98
4.1 Labeling of equipment, 98
4.2 Labeling of instruments, 101
4.3 Labeling of chemicals, 104
4.4 Labels not understood, 106
Chapter 5. Storage Tanks ........................... 108
5.1 Overfilling, 108
5.2 Overpressuring, 110
5.3 Sucking in, 114
5.4 Explosions, 117
5.5 Floating-roof tanks, 125
5.6 Miscellaneous incidents, 129
5.7 FRP tanks, 133
Chapter 6. Stacks .................................. 136
6.1 Stack explosions, 136
6.2 Blocked stacks, 140
6.3 Heat radiation, 142
Chapter 7. Leaks .................................. 144
7.1 Some common sources of leaks, 145
7.2 Control of leaks, 154
7.3 Leaks onto water, wet ground, or insulation, 159
7.4 Detection of leaks, 160
7.5 Fugitive emissions, 162
Chapter 8. Liquefied Flammable Gases ................ 165
8.1 Major leaks, 166
8.2 Minor leaks, 174
8.3 Other leaks, 175
Chapter 9. Pipe and Vessel Failures ................... 179
9.1 Pipe failures, 179
9.2 Pressure vessel failures, 195
Chapter 10. Other Equipment ........................ 205
10.1 Centrifuges, 205
10.2 Pumps, 206
10.3 Air coolers, 208
10.4 Relief valves, 209
10.5 Heat exchangers, 218
10.6 Cooling towers, 221
10.7 Furnaces, 221
Chapter 11. Entry to Vessels ......................... 229
11.1 Vessels not freed from hazardous material, 229
11.2 Hazardous materials introduced, 231
11.3 Vessels not isolated from sources of danger, 233
11.4 Unauthorized entry, 236
11.5 Entry into vessels with irrespirable atmospheres, 238
11.6 Rescue, 239
11.7 Analysis of vessel atmosphere, 241
11.8 What is a confined space?, 241
11.9 Every possible error, 242
Chapter 12. Hazards of Common Materials ............ 244
12.1 Compressed air, 244
12.2 Water, 246
12.3 Nitrogen, 248
12.4 Heavy oils (including heat transfer oils), 255
Chapter 13. Tank Trucks and Cars .................... 262
13.1 Overfilling, 262
13.2 Burst hoses, 263
13.3 Fires and explosions, 265
13.4 Liquefied flammable gases, 266
13.5 Compressed air, 266
13.6 Tipping up, 267
13.7 Emptying into or filling from the wrong place, 268
13.8 Contact with live power lines, 270
vii
Chapter 14. Testing of Trips and Other Protective
Systems ............................... 272
14.1 Testing should be thorough, 272
14.2 All protective equipment should be tested, 275
14.3 Testing can be overdone, 279
14.4 Protective systems should not reset themselves, 279
14.5 Trips should not be disarmed without authorization, 281
14.6 Instruments should measure directly what we need
to know, 284
14.7 Trips are for emergencies, not for routine use, 285
14.8 Tests may find faults, 286
14.9 Some miscellaneous incidents, 286
14.10 Some accidents at sea, 287
Chapter 15. Static Electricity ........................ 290
15.1 Static electricity from flowing liquids, 291
15.2 Static electricity from gas and water jets, 293
15.3 Static electricity from powders and plastics, 294
15.4 Static electricity from clothing, 296
Chapter 16. Materials of Construction ................. 299
16.1 Wrong material used, 299
16.2 Hydrogen produced by corrosion, 303
16.3 Other effects of corrosion, 305
16.4 Loss of protective coatings, 305
16.5 Some other incidents caused by corrosion, 306
16.6 Fires, 306
16.7 Choosing materials, 307
Chapter 17. Operating Methods ...................... 309
17.1 Trapped pressure, 309
17.2 Clearing choked lines, 311
17.3 Faulty valve positioning, 313
17.4 Responsibilities not defined, 314
17.5 Communication failures, 315
17.6 Work at open manholes, 318
17.7 One line, two duties, 318
17.8 Inadvertent isolation, 319
17.9 Incompatible storage, 319
VI=oI= I
17.10 Maintenance~is it really necessary?, 320
17.11 An interlock failure, 321
17.12Emulsion breaking, 322
17.13 Chimney effects, 323
Chapter 18. Reverse Flow and Other Unforeseen
Deviations ............................. 327
18.1 Reverse flow from a product receiver or blowdown line back
into the plant, 327
18.2 Reverse flow into service mains, 329
18.3 Reverse flow through pumps, 331
18.4 Reverse flow from reactors, 331
18.5 Reverse flow from drains, 333
18.6 Other deviations, 334
18.7 A method for foreseeing deviations, 335
18.8 Some pitfalls in hazop, 337
18.9 Hazop of batch plants, 338
18.10 Hazop of tank trucks, 340
Chapter 19. I Didn't Know That ....................... 343
19.1 Ammonia can explode, 343
19.2 Hydraulic pressure tests can be hazardous, 345
19.3 Diesel engines can ignite leaks, 346
19.4 Carbon dioxide can ignite a flammable mixture, 348
19.5 Mists can explode, 348
19.6 The source of the problem lay elsewhere, 350
Chapter 20. Problems with Computer Control .......... 353
20.1 Hardware and software faults, 353
20.2 Treating the computer as a black box, 354
20.3 Misjudging the way operators will respond, 359
20.4 Other problems, 360
20.5 Unauthorized interference, 362
20.6 New applications, 363
20.7 Conclusions, 365
ix