P.G.

Sreejith
pillai_sreejith@hotmail.com

PROTECTION SYSTEM FAILURE

(Extracted from an article published in Hydrocarbon Processing)

CASE STUDY

Dry Blower

Dryers

Solvent

Nitrogen

Drying unit in which the accident occurred (regeneration lines are not shown)

Process

A small drying unit was added to an organic solvent manufacturing company in order to meet the
demand of the customers. The solvent (miscible with water) was passed over a drying agent for
eight hours. The solvent then was blown out of the dryer with Nitrogen and the drier regenerated.
There were two dryers, one working for and one regenerating (figure 1).

Dryer Control room-Details

• Dryer control room (located at a distance from the dryer unit) had both pneumatic
instruments and electrical equipment & associated with the changeover of the dryers
• Control panel was located in Zone 2 area
• Ordinary electrical equipment were installed inside the room where the control panel was
located

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• The electrical equipment were mounted on a sheet metal cabinet, continuously purged with
Nitrogen
• A pressure switch was installed to isolate the electrical power if the pressure in the cabinet
fell below a preset value (original ½” water gauge- 0.125 kPa)
• No solvent or other process material was connected to this room/panel

The Incident

• The unit was shutdown for a few days and was ready to restart
• An in-experienced engineer was given the job of unit start-up
• The young engineer standing in the position shown in figure 2, he switched on the power and
there was an explosion

• The front cover of the metal cabinet was blown-off and hit his legs. Fortunately, no bones
were broken and luckily he was able to return to work after a few days

WHAT
WHATWENT
WENTWRONG?
WRONG?

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P.G. Sreejith
pillai_sreejith@hotmail.com

PROTECTIVE SYSTEM FAILURE

Syndicate Exercise

WHAT WENT WRONG?

FACTS & ACCIDENT DETAILS

The Fuel

There was no leak from the dryer unit into the metal cabinet or the main panel
There was no flammable vapour present in the atmosphere
The fuel did not leak into the metal cabinet from outside, but entered with
Nitrogen
The N2 supply was connected to the dryers by single isolation valves & non-
return valves (figure1)
The gauge pressure of the N2 was nominally40 psi (almost 3 bar) & fell when the
demand was high. The gauge pressure in the dryers was about 30 psi (2 bar)
Solvent therefore entered the N2 lines through leaking valves & entered the
cabinet
Solvent had to pass through a non-return valve but these valves are intended to
prevent gross back-flow & not small leaks

The Air

 Air diffused into the cabinet as the N2 pressure had fallen to zero for some
hours immediately before the accident
 The unit was at the end of the N2 distribution network and suffered more than
Most units from deficiencies in the supply.
 It is difficult to get airtight joint in cabinet made from thin metal sheets bolted
together and air diffused in through the joints. The solvent may have affected
the gaskets in the joints and made them more porous

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The Source of Ignition

• Source of ignition was clearly electrical since the explosion occurred when the
electrical supply was switched on
• The low-pressure switch did not isolate the supply. The set point was reduced
from ½ “ water gauge to zero. Meaning that the switch cannot operate unless
the pressure inside the cabinet falls below zero, an impossible situation

Protective System

In short, the protective equipment had been effectively disarmed. The switch was
normally covered with a metal cover and the set point was not visible. Only electricians
were authorized to remove the cover.

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pillai_sreejith@hotmail.com

LOSS PREVENTION RECOMMENDATIONS

FIRST LAYER RECOMMENDATIONS (Immediate Technical Recommendations)

1. Install a low-pressure alarm on the N2 supply line set a little above the pressure in the
dryers.
2. To prevent combination of N2, it should not be permanently connected to the dryers
by single valves but by hoses, which are disconnected when not in use, or by double-
block & bleed valves.
3. In order to maintain pressure of N2 supply to the whole plant, necessary improvement
in the N2 supply is to be taken up.
4. The metal cabinet should have been made airtight
5. Alterations in the set points of trips & alarm should be made only after authorization
in writing at the management level. These should be documented and made known to
the operators.
6. Set points should be visible to the operators. The switch was flameproof and could
not be modified without invalidating its certification. Redesign has been discussed
with & agreed with the manufacturer, followed by re-certification.
7. All alarms & trips should be tested regularly. This was the practice in the plant
concerned but as the dryer unit was new, it had not yet been added to the test
schedules.

SECOND LAYER RECOMMENDATIONS (Avoiding Hazards)

1. Disarming of alarms & trips should be avoided.

In this case, the operators found it difficult to maintain a pressure of ½ “ water gauge
in the leaking cabinet. The trip kept on operating & shutting down the drying unit. On
receiving complaints from operations, the electricians reduced the pressure to ¼ “
water gauge. The problem remained unsolved. Finally, an electrician solved the
problem by reducing the set point to zero. Nobody knew how the electrician solved
the ‘tripping nuisance’.
2. Consider re-locating the cabinet to a non-hazardous area (after considering the cost
and practical aspects)

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pillai_sreejith@hotmail.com

THIRD LAYER RECOMMENDATIONS (Improving Management System)

1. The cabinet should be pressurized with air instead of N2. The purpose of N2 was to
prevent solvent vapours diffusing in from outside. Compressed air was much cheaper
& reliable.
2. A more experienced person might have foreseen the hazards & taken extra
precautions. Thus the N2 pressure should have been checked before the electricity is
switched on. It is an unsafe practice to assume that a trip will always work and rely on
it.

EXPLOSION-SEQUENCE OF EVENTS

Low N2 Pressure (allowed solvent to contaminate N2)

Complete N2 failure (allowing air to diffuse into the

cabinet)

Disarming of the Trip (which would have isolated

power in a low pressure situation in the cabinet)

Triggering event (switching on the electrical power)

For details / clarifications, please contact: pillai_sreejith@hotmail.com

Public Training Programme/November 2002/PG Sreejith