Flashback from Waste Gas Incinerator into Air Supply Piping

S. E. Anderson, A. M. Dowell, III, P.E., and J. B. Mynaugh Rohm and Haas Texas Inc Deer Park, TX 77536

Prepared for presentation at the 25th Annual Loss Prevention Symposium, August 18-22, 1991 Session: Case Histories Abstract: A flashback with pressure wave damaged equipment in the air piping supplying a waste gas incinerator. The air supply included organic emissions from tanks and process vessels at concentrations designed to be less than the lower flammability limit. The investigation found that unusual circumstances of human factors, unsteady state events, and a rapid challenge combined to overcome the well-designed safety systems. Recommendations made for prevention have general application. Summary A waste gas incinerator experienced a flashback with a pressure wave in the Suction Vent Gas (SVG) system. Extensive damage resulted to the SVG flame arrestor, SVG fan, SVG valves, and incinerator piping. There were no injuries. The primary cause of the incident is believed to be a fuel rich SVG stream which was rapidly introduced into the incinerator creating a "puff". This "puff" allowed flame from the natural gas ring burner to blow back into the windbox igniting the fuel rich SVG. The combustion of gas in the ducting then created a pressure wave that blew apart the flame arrestor and caused the remainder of the damage. Background The Waste Gas Incinerator uses natural gas as its primary fuel and is designed to incinerate waste gasses (called AOG) from a plant unit as well as the minor organic constituents found in the SVG (suction vent gas). A sketch of the incinerator system is shown in Figure 1. The SVG is the primary source of combustion air. It is intro duced to the incinerator wind box (D) to provide air for the main natural gas burner (E). Some SVG is also used as quench air (I) to the fire box (J), entering the AOG nozzles. Combustion air can also be supplied by a running combustion air fan (C). The SVG system is a vacuum collection system that picks up volatile compounds from tank working losses and distillation system vents from all areas within two units. Each major branch of the SVG is continuously sampled and analyzed for combustibles. The SVG system is designed to run at less than 10% of the Lower Explosion Limit (LEL). These analyzers sound an alarm when the fuel content of the gas reaches 25% of the lower explosion limit and activate controls that switch the SVG to the flare when the fuel content reaches 50% of the LEL. Motive force for the SVG system is provided by a large fan (A) located in the incinerator area. A crimped metal ribbon type flame arrestor (B) is located just downstream of the fan and protects the SVG system from a flashback from the incinerator or flare. Downstream of the flame arrestor, the SVG is diverted either to the flare or to the incinerator via two 30 inch butterfly switching valves. These valves are normally remotely operated from the control room but are also equipped with hand wheels for manual operation.

Figure 1: Waste Gas Incinerator Schematic

AQO
I

Incident Seauence:

Normal Flaws

Key to Major Equipment A SVG Blower G Incinerator H Boiler Transition B Flame Arrestor I Quench Air Bustle C Combustion Air Fan D Windbox J Fire Box K SVG Valve to Flare E Natural Gas Inlet L SVG Flare to Incinerator F AOG Bustle

Numbers Refer to Damage Descriptions in Text

At the time of the incident, the reactor system feeding waste gas to the incinerator tripped off line. The reactor system shut down safely and the operator began preparations for a restart by switching the waste gas (AOG) to its dedicated flare. Once the valves were switched, the control room operator noted that the indicator lights on both valves were showing open, and he instructed the outside operator by radio to "Close the 'A' train AOG valve to the incinerator." Either through miscommunication or because the outside operator was in a relatively high noise area, the outside operator thought he was instructed to close the SVG valve to the incinerator. Working now with a second person, they climbed up to the platforms to access the SVG valves and proceeded first to manually close the valve to the incinerator (L) and then to begin opening the valve to the flare (K).

When the SVG flow was blocked in, a low SVG flow alarm sounded in the controlroom. The control operator, responding to the alarm and recognizing what was occurring, radioed to the outside operators that they had closed the wrong valve and instructed them to reopen the SVG valve to the incinerator. One operator began closing the valve to the flare (and the other operator reopened the SVG valve to the incinerator). Since the valve to the incinerator was still commanded open by the automatic controls, the operator simply disconnected the manual wheel from the actuator and assisted the valve movement by pushing on the actuator piston. The valve rapidly reopened. Once the SVG valve to the incinerator was 100% opened, or nearly so, an explosion occurred. Damage Description Listed below is a detailed list of the damage. The numbers shown indicate the location of the damage as shown on Figure 1. Number 1. 2. 3. 4. 5. Description The elbow in the combustion air line feeding the windbox was pushed west one to two inches (0.03 to 0.5 m). The expansion joint connecting this elbow to the piping run was stretched and deformed. The check valve at the combustion air fan was broken from its supports and blown back towards the fan casing. The piping supports (concrete bases) for the combustion air piping were cracked and broken. The quench air control valve (butterfly valve) was sheared from its mounting pins and blown west into the quench air bustle. Two holes, approximately one inch (0.025 m) in diameter, were found in the end plate of the bustle that connects to the quench air duct. Our belief is that parts of the quench air valve caused this damage. The entire quench air bustle was moved off its pipe supports approximately 14 inches (0.36 m) west. The expansion joint in the quench air duct was stretched and distorted. The counterweight on the check valve in the SVG line feeding the combustion and quench air header was broken from its mounting bracket. The SVG switching valve to the flare was broken from its supports and the manual valve wheel was broken off at the gear box casing (note: an operator was holding onto the manual wheel for this valve when the explosion occurred). The rupture disk (polyethylene sheet) in the SVG line to the flare was blown. The rain hat covering the plastic was also snapped from its fasteners and was found laying b elow on the ground. The duct work directing SVG gas to the flare was badly wrinkled. The SVG flame arrestor was broken free from its mounting bolts and sheared into two pieces. Several arrestor elements were severely distorted and pushed west towards the fan. The tubesheet supporting the arrestor elements was bowed -- again indicating a pressure wave coming from the incinerator. The piping connecting the SVG flame arrestor to the SVG fan was broken free from its supports and came to rest partially on top of the SVG fan. The butterfly damper in the SVG discharge was bent into the shape of a pipe saddle and was torn loose from its mounting bracket. The SVG fan was broken from its base. The fan housing was pushed approxi mately three inches (0.08 m) west and one inch (0.03 m) south. The bearing housings on the fan shaft were also snapped.

6. 7. 8.

9. 10. 11.

12.

13.

14.

Piping connected to the suction side of the SVG fan was sheared and broken from its supports (note: all suction piping in the SVG system is fiberglass reinforced plastic (FRP); all piping after the fan discharge is stainless steel).

15.
16.

An "S"in the SVG piping going up in the reactor rack fell from the third level to the ground -damaging a safety shower, some insulation, and a pump oiler during its fall (not shown in Figure 1).
Numerous piping supports for the FRP piping in the reactor rack were found broken or stretched (not shown in Figure 1). The incinerator had several radial cracks in the refractory brick -- indicating an overpressure in the fn-ebox.

17.

Incident Analvsis : We concluded that this incident was primarily caused by the rapid introduction of a fuel rich SVG stream which initially ignited in the incinerator firebox. The sudden shock of fuel -- along with sufficient air -- caused the incinerator to "puff", momentarily stopping or reversing the flow of SVG, and allowing a flame front to proceed into the windbox and back into the codustion air header. (See Figure 2.)

Figure 2: Incinerator Detail

This flame front generated or sustained a pressure wave which caused the damage in the combustion air header; quench air header; SVG piping, flame arrestor and SVG fan. Damage indicates that the flame continued to propagate past the SVG fan and up into the Reactor Rack SVG header piping until the fuel content of the gas dropped below flammable limits. The ignition source for this segment is not positively known. Although the flame arresbr was blown into two sections, the section of the arrestor containing the crimped metal ribbons was intact and we believe it should have been capable of halting the flame front. We feel it is more likely that movement of the SVG fan -- possibly the fan wheel contacting the housing -- generated sparks or a hot spot which again ignited the fuel-laden SVG.

The source of the fuel in the SVG was the routine collection of tank working losses and system vents. Organics built up in the system while the SVG was deadheaded and while it was slowly bled to the flare. This built up a "bullet" of fuel in the SVG which was carried along through the piping and rapidly fed to the incinerator when the operator reopened the SVG valve to the incinerator. We concluded that the normal incinerator controls, interlocks, and shut downs acted normally and were not a contributor to this event. We further found that although there was evidence of water in the instrument air system, this did not affect the performance of the instruments or controls on the night this incident occurred. We felt strongly that timing of the various actions was in itself a cause of the explosion. Had the operator opened the valve to the flare fully, and left it open long enough, the fuel rich "bullet" would have passed out the unlit flare and would have dissipated safely. In addition, a longer period at the low flow condition would have given the LEL analyzer at the SVG fan sufficient time to detect the high fuel content of the stream and then automatic controls would have prevented reintroduction of the SVG into the incinerator. The LEL analyzer response time was 20 seconds (10 seconds for the sample loop and 10 seconds for the analyzer itself). Also, had the operator reopened the SVG valve to the incinerator slowly, the fuel rich combustion air would have burned normally instead of causing the "puff" which allowed flame to enter back into the windbox. This is a complex scenario. It is complex because the incinerator is a well-designed system. For a welldesigned system to fail, a number of unforeseen failures must occur at the right time in order to defeat the safeguards which were already in place. This made the determination of the actual failure mode difficult, and it also makes it difficult to come up with additional safeguards. Before reaching this scenario we tested a total of seventeen such cases against twenty facts which had been established, using a matrix decision analysis system [1]. After this scenario was agreed upon as being the only one satisfying all of the facts, it was further tested and verified by showing that it was capable of explaining all of the observed damage. Pressures generated were not high; estimates were, for the most part, in the 15-20 psig range. Additional Causes With the unit personnel and the Plant Safety Director, the Incident Investigation Team conducted a multiple cause, system oriented incident investigation. Some additional contributing causes were identified: An upstream SVG LEL analyzer for one of the operating units feeding SVG was out of service, waiting for repair. This analyzer could possibly have warned of the buildup of flammable vapors in the SVG header while the flow was stopped. The operators thought they should have corrected the blocked in SVG valves quickly. The production culture is to correct mistakes quickly and the training system had not addressed education in what could go wrong with the SVG system. There was a history of sticking valves in the SVG system. Thus, it was easy to think "same problem again." Efforts were underway to repair the sticking valves, but had not been successful at the time of the incident.

Corrective Actions The incident investigation team along with unit personnel developed the following corrective actions intended to prevent future incidents and/or mitigate the damage caused by any future reoccurrence of this incident. The corrective actions are grouped by mechanical, operational, and training categories. While it may seem that there are a large numb er of actions, they are system oriented and are aimed at the multiple causes identified by the incident investigation. We believe it is important to make improvements, where practical, in all the areas that contributed to the incident cause and its severity. [1] The Rational Manager, C. H. Kepner and B. B. Tregoe, (1976), describes this type of analysis.

Mechanical: 1. 2. 3. Consider pressure relief on the combustion air line and SVG line (both sides of the arrestor). (It was installed.) Critique flame arrestor design. (It is acceptable.) Improve SVG valves and actuators. These valves were relatively flimsy and have been a maintenance headache at times over the years. The Instrument Shop replaced these valves with a better design as part of the incinerator rebuild. Improve AOG valves/actuators. Failure of an AOG valve was an indirect initiator of this event. We recommend these valves be inspected and repaired or replaced. (Improved valve being identified.) Design/install facilities to ensure dry instrument air. Water in the instrument air system will disrupt controls and may prevent them from performing their function. While we do not believe that water (or ice) in the instrument air was a factor in this incident, we found evidence of liquid in several lines and suggest that prompt action be taken to eliminate this potential hazard. Consider removing a 1.5 second delay in the Lo Lo combustion air flow shutdown. This shutdown was originally intended to prevent the incinerator from shutting down when the SVG is switched out to the flare. Improve the mechanical integrity of failed components. A structural assessment of the damage shows that much of the serious damage was the result of poor construction. We suggest the following: a) b) c) d) 8. 9. Add tie-rods on the expansion joints to prevent future stretching/distortion. Dye-penetrant check or x-ray the old and repaired welds on the SVG flame arrestor. Upgrade the quench air flow control valve with stronger components. Consider additional support or better construction of the check valve in the combustion air line.

4. 5.

6.

7.

Consider faster response LEL analyzers. Analyzers are now available with less than 5 seconds total response time (sample loop and analyzer). Consider reviewing the mechanical integrity of systems that didn't fail. Other areas of the incinerator could have been stressed by the pressure wave but damage may not be visible to the naked eye. Additional failures (accompanied by additional downtime) may pop up in the future if these are not identified.

Operational: 10. Consider rebalancing the SVG air flows in the unit. Considerable changes and additions have been made to the suction vent system over the years and it is not clear that operations are at the design basis of 30 ft/s (9 m/s). Consider revising the controls to automatically divert the SVG to the flare upon low flow. Develop operating strategy for lower explosion limit (LEL) analyzers that ensures that all of the SVG passes an analyzer (e.g., if the SVG fan LEL analyzer is out of service, SVG must be flared). The LEL analyzers are the first defense against generating a flammable mixture in the SVG, if flows are disrupted. Some LEL analyzers need to be added. Develop a plan that addresses how many LEL analyzers are required for operation.

11. 12.

13.

Consider a review to establish a list of all components in the SVG / Incinerator / Flare system. From this, develop a "Minimum Equipment List". This could require a fault tree. Train operators, foremen, maintenance personnel, and engineers on what is critical to safe operations of the system. Institute such training as part of the ongoing unit training. Consider adding LEL alarm status to the logs, and instituting a program for reducing the frequency of trouble. Correct the documentation to show that there is a low flow shutdown for SVG to flare. Consider alternate technology to handle the SVG stream. Consider means of exercising standby equipment on a routine basis (e.g., combustion air fan damper). Consider air-fuel ratio controllers to automatically compensate for changes in composition and/or flow.

14. 15. 16. 17. 18.

Training: 19. Consider additional operator training to emphasize the importance of not blocking in both SVG valves (i.e., to flare and to incinerator) at the same time, and to review procedures for introducing SVG into the incinerator (i.e., slowly, using automatic controls). Consider application of these Corrective Actions to construction of similar systems in the future. Consider adding a data acquisition system to the incinerator. (Some variables were recorded on strip charts, but more detailed operating data would have been helpful to the investigation.)

20. 21.

Learnings: At the end of the investigation we identified the following learnings which may be helpful in future investigations. These are in addition to the assistance listed in the acknowledgment section. 1. 2. 3. 4. 5. 6. 7. Interview all the involved personnel as soon as possible. Include instrumentation expertise on the investigation team, or have available as a resource. The damage analysis was critical in developing the correct scenario. The technique of making a list of facts and then testing each fact against each scenario in a matrix was very helpful. Early arrival of investigation team was very helpful (within 10 hours of the event). The videotape, photographs, and description of the damage (made on the first day) was very helpful to investigators who arrived later. Write the report as soon as possible after the investigation is completed.

Acknowledgments: The authors would like to express our appreciation to everyone who assisted us in the investigation of this incident. Specific thanks are due the following individuals and groups:

The unit operators, for their forthright treatment of our many questions. The Plant Protection force for their help with the video. The structural and mechanical experts from Rohm and Haas Corporate Engineering Division (D. O'Leary, and J. Brisbane) and the power specialist from Bechtel (T. McLean) without whom we could not have formulated and tested our scenarios. W. C. Stone of Stone Engineering who validated our work in a most thorough and concise manner. P. W. Davis and the unit Management team for their provision of facilities and support. The Maintenance Teams for their assistance with failure evaluation, documentation of the "as -is" systems, and other expertise.