PLANT UTILITIES AND MAINTENANCE (CPB 20004)

ASSIGNMENT 2

GROUP NAME: PROFESSIONAL MAINTENANCE ENGINEERING (PME)

MEMBERS: PUGALLAN A/L NADARAJAH (55213114377)

PRESANTH A/L VIJAYAKUMARAN (55213114458)

EZRA EDEN A/L BIDEMAN (55213115353)

MUHAMMAD HAFIZUDDIN BIN KAMARUDIN (55213114476)

LECTURER: EN. SYAHIDI FADZLI BIN ALFAN

MALAYSIAN INSTITUTE OF CHEMICAL & BIOENGINEERING TECHNOLOGY

UNIVERSITI KUALA LUMPUR

The following indicates the Cases Study for Failures And Accidents In Chemical Plant taken
from Plant And Machinery Failure Prevention By A.A. Hattangadi. Choose ONE ( 1 ) from
EACH section only.

A. Chemical Plant Failures Due To Mechanical / Electrical Failures. (Total Marks = 20)

Case # 2.

A Reactor Vessel, which was one of a number of similar vessels connected in series, developed a
crack and was taken out for repairs. In order to keep the plant in operation, a Temporary Pipe
was manufactured locally and fitted to replace the Reactor Vessel. Due to deficiencies in the
design of the pipe and the flexible bellows, it broke under the effect of the high pressure of the
gas within. The Highly Inflammable Gas (Cyclohexane) poured out and produced a Vapour
Cloud. It ignited when it reached an Operating Furnace in the plant and 28 Workers were killed.
A Major Part of the plant was destroyed.

Tasks:

First and foremost, you need to take the position of being a Maintenance/Service Personnel.
Treat this exercise as training or exposure towards your job for the future. Here are the guides
which might help you in handling this assignment:

Answers

1.) Try to understand each Case Study by answering the question. What Went Wrong? (8
Marks)

One of the reactor vessels that are connected in a series developed a crack and was removed
for repair.

In order to maintain production a temporary pipe was installed in its place. Bellows were
installed between each reactor and these were left at each end of the temporary pipe.

A massive leak of Cyclohexane happened resulting from rise in pressure and the temporary
pipe collapses.

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 Leak of Cyclohexane from the temporary pipe reached to the source of ignition which was an
operating furnace at some distance away.

The resulting explosion was produced worst cloud explosions, which destroyed the oxidation
unit, caused extensive damage to the rest of site and caused the death of 28 workers.

2.) Try to find the most possible cause, by asking the question. How This Can Go Wrong? (2
Marks)

The men who were charged with the task of making and installing the temporary pipe were not
professionally qualified and did not realize that the pipe and its supports should have been
designed by an expert in piping design. It is a specialized branch of mechanical engineering
works but it was mainly chemical engineers who constructed it. Thus, the design of long pipe
which were bending was strong enough to tear the bellows and holes appeared contributing to
the leakage of Cyclohexane. To ensure it does not repeat again several things should be take
account. One of it is reduction of inventory by develop process with low inventory especially of
flashing liquids. If the inventories reduced than the plants are cheaper as well as safer. They are
cheaper because the needed protective equipment will be less and testing and also maintenance
of smaller inventory of the operating equipment.

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3.) Finally, in order to give suggestion of possible solution, ask the question. What Can You Do
To Ensure This Does Not Happen Again? (10 Marks)

Then, it is important to control of process modification. Before modifying a process carry

out a systematic technique to search for unforeseen consequences and authorized by a
professionally qualified manager such as the cracking of reactor and develop an alternative
unsafe temporary pipe. Good industry practices require that modification should not be
carried out without having undertaken a safety, engineering and technical review.

Moreover, the next suggestion is to control of plant modification by construct modifications

to same standard as original design. In addition, there should be a check list to help the
competent person identify the consequences and training program is needed in modification
control procedure.

Besides that, it is important for suitably qualified staff to work in such as make clear who is
responsible for safety in design and operation. The person who constructed this temporary
pipe did not have knowledge to design an unrestrained pipe between two bellows. This
mechanical design error should be handling by professionally qualified mechanical engineer
on site or a senior engineer for consultation.

Next recommendation would be on a good plant layout and location so that injuries and
damage are minimized if an explosion occurs. There were 28 workers who killed by the
explosion and collapsing building on them so it is essential to have built blast-resistant
rooms to withstand one explosion. Prepare and locate assembly points outside plant area by
congregate people when a warning sound is alarmed.

Lastly, new regulations and public should concern on compelling companies to improve
standards and demonstrate that they are safe. The Health and Safety Executive (HSE) are the
one responsible for enforcing Health and Safety at Work Act. Moreover, companies should
exchange information on accidents that have happened and the action needed to prevent
from happening again.

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B. Chemical Plant Failures Due To Chemical Reactions. (Total Marks = 20)

Case # 3.

In an Ethylene Plant, a ID pipe carrying fluids at very high pressures was provided with
joints of a very special and precise design. These called for special skills and the Staff had to be
given special training. As a result of Staff re-shuffles included in Cost Reduction Schemes, the
work got re-assigned to Staff without adequate training and experience. One badly fitted joint
developed heavy leaks, leaked Inflammable Gases and these eventually ignited causing an
explosion, 4 Workers were killed and several more injured. There were no devices for detecting
Inflammable Gases that they may have leaked although the Plant was dealing with Highly
Inflammable Gases.

Tasks:

First and foremost, you need to take the position of being a Maintenance/Service Personnel.
Treat this exercise as training or exposure towards your job for the future. Here are the guides
which might help you in handling this assignment:

Answers:

1.) Try to understand each Case Study by answering the question. What Went Wrong? (8
Marks)

Leak of ethylene occurred from a badly made joint on a small diameter line about inch
(12mm) internal diameter.

Some of the newly trained men did not have the necessary skill or perhaps did not understand
the importance of using their skill to the full and the standard of joint making deteriorated.

Ethylene gas leak and ignited causing an explosion had occurred.

Four men were killed and several more injured from the explosion.

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2.) Try to find the most possible cause, by asking the question. How This Can Go Wrong? (2
Marks)

The main possible causes are the ignorance of the management of the plant toward the poor joint
making had been neglected and the management also less willing to work with experience
workers. It is almost impossible to eliminate all sources of ignition and there is no prevention to
eliminate ignition had been done.

3.) Finally, in order to give suggestion of possible solution, ask the question. What Can You Do
To Ensure This Does Not Happen Again? (10 Marks)

The first recommendation would be to minimize the effects of leaks by install gas detectors
to give early warning that a leak has occurred, thus action can be taken to isolate the leak,
evacuate personnel, call the fire service in case the leak ignites and so on.

Next, if a leak of flammable or toxic gas is detected by people or by gas detectors, all people
who are not required to deal with the leak should leave at once. There should be a
recognized alarm signal, actuated automatically or by a responsible person and a known
assembly point not too near the plant.

Next recommendation is to remotely operate emergency isolation valves should be

provided.

In addition, a roof or canopy over equipment handling flammable liquids and gases should
be located in the open air so that small leaks are dispersed by natural ventilation.

Moreover, the walls of the building have to be made of light plastic sheets fixed by special
fastenings which easily break so that as explosion occurs, building walls of such light
construction would blow off quickly before the pressure causes serious damage.

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 Lastly, recommendation of standard for the quality of joints was specified and a system of
inspection was set up.

REFERENCE

1. Trevor Kletz (2001). Learning from Accidents, Third Edition, Gulf Professional
Publishing, pg 40-51.
2. Trevor Kletz (1999). What Went Wrong? Case Histories of Process Plant Disasters,
Fourth Edition, pg 145-146.
3. Trevor Kletz (2001). An Engineers View of Human Error, Third Edition, pg 112-114.
4. A. A. Hattangadi (2005). Plant and Machinery Failure Prevention, McGraw Hill, pg 441-
449.
5. Martin Muckett and Andrew Furness (2007). Introduction to Fire safety Management, pg
134.