Scribd
Upload
274 views5 pages

Heat Exchanger Failure Analysis

The document summarizes a heat exchanger catastrophic failure at a Tesoro Anacortes Refinery in Washington in April 2010 that resulted in 7 fatalities. The incident occurred when hot liquid was introduced into the naphtha hydrotreater heat exchanger after maintenance, causing a shell rupture that released hydrogen and hydrocarbons. This led to an autoignition and explosion. The investigation found the exchanger was operating above the safe limits for temperature and hydrogen pressure, increasing the risk of high temperature hydrogen attack (HTHA). There were also inadequate controls, instrumentation, and safeguards to prevent this type of failure.

Uploaded by

Vitaliy Yashchenko
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
274 views5 pages

Heat Exchanger Failure Analysis

The document summarizes a heat exchanger catastrophic failure at a Tesoro Anacortes Refinery in Washington in April 2010 that resulted in 7 fatalities. The incident occurred when hot liquid was introduced into the naphtha hydrotreater heat exchanger after maintenance, causing a shell rupture that released hydrogen and hydrocarbons. This led to an autoignition and explosion. The investigation found the exchanger was operating above the safe limits for temperature and hydrogen pressure, increasing the risk of high temperature hydrogen attack (HTHA). There were also inadequate controls, instrumentation, and safeguards to prevent this type of failure.

Uploaded by

Vitaliy Yashchenko
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
You are on page 1/ 5

Heat Exchanger

Catastrophic Failure
Tesoro Anacortes Refinery, WA April 2010

June 24th, 2023

© 2020 Chevron
Incident Description
What went wrong?

Business Unit / Site


• Tesoro Anacortes Refinery, WA April 2010

Facility/Process Unit

• Naphtha Hydrotreater heat exchanger shell rupture


• Heat exchanger - hot liquid introduction after maintenance

Consequences
• Release of hydrogen and hydrocarbon
• Hydrocarbon autoignition and explosion
• 7 fatalities
• 6-month downtime
• 90 minutes to put out the fire

©2019 Chevron. 2
Incident Description
What went wrong?

Gap Analysis
• API-941 standards provide guidance on operating limits
for steels in hydrogen service

• Investigation outcomes
Inadequate Controls and Safeguards were in place to
ensure that the exchangers were operating within safe
operating limits, i.e., below the Nelson Curve • Previous analysis indicated potential for High
Temperature Hydrogen Attack (HTHA) within the
exchangers and outlet piping.

• Lack of instruments (TI/PI) and Process Data on piping


between the exchangers

©2019 Chevron. 3
TC&S
Technical Codes and Standards

• HTHA: H2 permeates the steel and reduces iron


carbide (Fe3C) in the steel to form methane (CH4),
causing fissuring between grains

• Fissuring: the ductility of the metal is significantly


and permanently reduced. The severity of hydrogen
attack increases with increasing temperature and
hydrogen partial pressure.

©2019 Chevron. 4
Prevention Safeguards
Failure Analysis

!
Hazard
Ha
z ar d Ina
no De de
- Hydrocarbon
t re s ig qu
- High Temperature co nr ate Initial event
gn ev in
ize iew
RM FD&C De
TC&S sig
n
Failures in Preventive Safeguards: Wrong Material Selection
• Risk Assessment: Hazard not recognize
• Technical Codes and Standards: Insufficient application of
• HTHA not identified as potential failure mechanism Safety in Design
for the ‘B’ and ‘E’ exchangers
• Not provide Instrument to detect process operating data
• FD&C: Insufficient in HEX Engineering Design (TC&S)
(Process & Mechanic)
• Not provide Control and Safeguard (TC&S)
©2019 Chevron. 5

You might also like