Loss Prevention Bulletin 228

December 2012 | 11

Incident

Rupture of a heat exchanger at a refinery causes fatalities

Tony Fishwick
Summary
In April 2010, at Tesoros Anacortes Refinery in the northwest of Washington State, USA, a heat exchanger in the Naphtha Hydroheater Unit (NHU) ruptured, releasing a mix of hydrogen and naphtha. The dispersed material auto-ignited, causing an explosion and a fire. Seven employees working in the vicinity were fatally injured. Following the incident, the refinery was shut down for over six months while new heat exchangers were designed, built and installed and other equipment repaired or replaced. Laboratory tests showed advanced stages of high temperature hydrogen attack (HTHA) near the fracture areas though this was not detected prior to failure. Sufficient hydrogen partial pressure and temperature were shown to have existed in the failed heat exchanger (E-6600E) to have caused HTHA. The shell of the heat exchanger had not been post-weld heat treated after fabrication and this may have resulted in sufficient stress to cause rupture of the HTHA-damaged shell. This article is based on Tesoros investigation into, and formal report on, the incident1.

The refinery process

The Anacortes Refinery, at the time of the incident, had a total crude oil processing capacity of 120,000 barrels per day (bpd). The refinery produced gasoline, jet fuel and diesel for markets in Washington and Oregon states and also fuel oil, liquefied petroleum gas (LPG) and asphalt. Its crude oil feedstock was received by pipeline from Canada and by tanker from Alaska and foreign sources. Crude oil was separated into several intermediate products in the Crude Oil Distillation Unit, then subsequent refining stages converted these intermediates into gasoline, jet fuel and diesel. The Naphtha Hydroheater was part of the process for converting naphtha, one of the intermediates, into gasoline. The NHT removed sulphur and nitrogen from the raw naphtha before it went to a downstream process to produce gasoline. This removal required the naphtha to be heated to 330370oC at 4000kPa and mixed with hydrogen. After this reaction, the naphtha and hydrogen (effluent) were cooled in a series of heat exchangers (E-6600s) in which the effluent pre-heated the incoming feed. The NHU process is depicted in Figure 1. The heat exchanger system consisted of two parallel banks of three exchangers (E-6600A/B/C and D/E/F) designed to allow maintenance on one bank while the other continued to operate. The exchangers were shell and tube types. The incoming process feed went into the tubes where it was heated by the

Keywords: Heat exchanger, explosion, high

temperature hydrogen attack, corrosion

Naptha/ hydrogen feed Reactor effluent feed Reactor outlet ~630F710F E-6600A

Figure 1: The Naphtha Hydrotreater (NHT) process

Furnace inlet ~510F600F E-6600D NHT charge furnace

Reactor inlet ~560F660F

E-6600B E-6600E E-6600C E-6600F Reactor V-6601

Naptha & hydrogen ~80F140F

E-6600 shell outlet ~230F320F

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December 2012

Hot reactor effluent from E-6600D shell side Floating head

Heated Naphtha to E-6600D tube side

Expansion bellows Cooled reactor effluent to E-6600F shell side Naptha feed from E-6600F tube side

Figure 2: Feed/effluent exchanger E-6600E

reactor effluent passing into the shell. The effluent, conversely, was cooled by the feed. The heat exchangers were first installed in 1971 and rated at 24,800 bpd. Subsequently, this was uprated to 42,000 bpd, the current capacity. At the time of the incident on E-6600E (Figure 2), exchangers E-6600A/B/C were in the final stages of being brought back on line after cleaning.

after cleaning. The seven people were two operators required for this job, their supervisor and four men being trained.

Investigation of the incident

The Division of Occupational Safety and Health of the Washington State Department of Labour and Industries (DOSH), the US Chemical and Hazard Investigation Board (CSB) and the Tesoro Refining and Marketing Company jointly directed the investigation. They agreed the protocols for site control, field inspections and laboratory tests. The Tesoro Triangle of Protection (TOP) team (see authors note) did not play any part in setting these protocols but were responsible for ensuring that all recommendations were properly acted upon. Thus, there was a structured balance between independence of the investigation process and the implementation of its findings. In situ ultrasonic tests on E-6600E detected cracks in the shell welds near to the fractures. Subsequent comparison with E-6600B determined that these cracks were unlikely to have been detectable before the incident. Laboratory tests (wet fluorescent magnetic particle and fluorescent dye penetrant) on sections cut from the failed shell subsequently confirmed the initial findings. Metallographic tests on samples from both fractured and intact parts of E-6600E shell revealed clear evidence of advanced stage HTHA within the heat affected zones (HAZ) of the weld seams. Chemical analysis on specimens from E-6600 shell showed that the shell metal met the chemical composition design specification. Weld compositions were consistent with those used to join carbon steels. Mechanical hardness, impact,

High temperature hydrogen attack (HTHA)

HTHA can occur when steel is exposed to atomic hydrogen (H) at elevated temperatures and pressures. Under these conditions, some hydrogen molecules break down into atoms that can diffuse into the steel forming methane (CH4). Because methane molecules are too large to diffuse through steel, they accumulate and form extremely high pressure bubbles which connect and create micro-fissures at grain boundaries. In advanced stage HTHA these fissures connect to form cracks. Decarburation (loss of carbon) occurs and reduces the strength of the metal. The propensity to HTHA is summarised in so-called Nelson Curves (after their originator, Figure 3) which relate temperature to hydrogen partial pressure in graphic form. For a given type of steel, combinations of hydrogen partial pressure and temperature below the Nelson Curve are generally considered to be safe from HTHA. However, several recent studies2, 3, have found HTHA cracking in carbon steels operating below the Nelson Curve. These studies have a number of common factors, thus: the metallurgy was carbon steel; the welds were not post-weld heat treated; the damage was by micro-fissuring along heat-affected zones of the welds; the damage was not detected prior to failure, but by laboratory analysis after failure. Consequently, maintaining an operational safety margin of 10oC/340 kPa below the carbon steel Nelson Curve, was recommended.

100 900 TemperatureF 800 700 600 500 400 300 0 500 1000 1500 2000 2500 3000
satisfactory performance no internal decarburation or fissuring internal decarburation and fissuring present

The incident
Heat exchanger E-6600E ruptured, releasing a mixture of hydrogen and naphtha which auto-ignited, causing an explosion and fire that fatally injured seven employees who were in the area. The failed heat exchanger is shown in Figure 4, which illustrates the massive nature of the rupture. Exchangers E-6600A/B/C were being brought back on line

Hydrogen partial pressure, psia

Figure 3: Standard Nelson curve for carbon steel

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Loss Prevention Bulletin 228

December 2012 | 13

b) After Tesoro acquired the refinery in 1998, an in-depth corrosion review was carried out in 1999 and updated in 2003. c) The most recent study took place in 2008. All of these identified that HTHA was a concern in the two hottest heat exchangers, E-6600A and D but not in E-6600B or E. Thus, no prior-to-incident HTHA susceptibility was identified for E-6600E. Figure 4: The failed section (No. 3) of heat exchanger E-6600E bending and tensile strength tests all confirmed consistency with specified design materials. A second exchanger, E-6600B, was tested and inspected by the same means as E-6600E. The two exchangers had a very similar construction and service history and E-6600B had been exposed to the fire from the E-6600E rupture although it had remained intact. The results indicated that E-6600B was in a similar microstructural condition to E-6600E particularly with regard to HTHA in the heat affected zones of the weld seams.

Temperature measurement
There was no intermediate temperature instrumentation between individual heat exchangers, so very limited data existed on actual operating temperatures of E-6600E. Reactor outlet temperatures were reviewed and shown to be as per design except for very short periods, so it could be deduced that temperatures between heat exchangers had been similarly in line with design specification. One very high reactor temperature excursion to 620oC was noted in 1998, though it was likely to have been of very short duration. At the combined E-6600 shell outlet, there was a thermometer in a thermal well. This showed temperatures in the range 120150oC which was consistent with design specification. Absolute temperatures for the E-6600s would have varied during operations depending on many factors, including exchanger fouling but lacking actual process data, it was not possible to draw definitive conclusions about the temperature profile within the heat exchanger train.

Contributory factors Personnel present at the time

At the time of the incident, there were seven people in the vicinity of exchangers E-6600A/B/C, deployed as above. All of them had received appropriate training in NHU operations. Typical practice was to clean accumulated deposits from the inside of the tubes about once every six months as the deposits reduced heat transfer efficiency. Valves were available for isolation of one bank of E-6600s for cleaning while the other bank remained in operation. After cleaning, the clean bank would be returned to service. There was no evidence of any operator error in these procedures. Nonetheless, non-routine operations such as start-up or shutdown can cause problems in continuously operating plants.

Hydrogen partial pressure (H2pp)

The 1970 design partial pressure at the reactor outlet is quoted as 2000kPa. The corrosion studies referenced above found the following: 1990: 3100 kPa 1993: 3100 kPa 1999 and 2003: not stated 2008: 1650 kPa

High temperature hydrogen attack (HTHA)

HTHA occurs when the hydrogen partial pressure and the temperature in a given system combine to reach critical values for the metallurgy that they are associated with as described more fully above. The presence of HTHA was confirmed by metallographic evaluation of samples from the failed heat exchanger shell (E-6600E) and from the shell of E-6600B. This would have been sufficient to cause the observed damage to the carbon steel that had not been post-weld heat treated. However, this was not established prior to the incident because it was believed that these two exchangers did not operate at temperatures high enough for HTHA to occur.

The post-incident design (2010) specified a value of 1960 kPa. H2pp is known to vary with hydrogen makeup, system pressure, intermediate exchanger pressures and operation of the recycle compressor, so this disparity of readings was not surprising and the investigation could draw no firm conclusions from them. Operating conditions for H2pp and temperature could not be determined with certainty.

Fabrication of E-6600E shell

E-6600B/E shells were fabricated of carbon steel, which above certain temperatures and hydrogen partial pressure, has a lower resistance to HTHA than alloy steels. Post-weld heat treatment can reduce susceptibility to HTHA but B/C/E and F shells were not so treated. E-6600A/D were fabricated from alloy steel and were post-weld heat treated.

Corrosion reviews
Types of corrosion that could be expected in the heat exchangers had been reviewed before the incident occurred. Thus: a) The first review was completed in 1990 and updated in 1993. At the time, Shell Oil owned the refinery.

HTHA not detected prior to incident

Specific HTHA detection tests were not carried out on E-6600B/E because corrosion studies did not recommend inclusion of these items in HTHA programme.

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December 2012

Conclusion
The rupture occurred because the strength of E-6600E shell had been reduced by HTHA to the extent that the total stress that existed could not be withstood. This was primarily due to lack of post-weld heat treatment. Other factors which might have caused stress such as very high temperatures or pressures, did not exist. The potential for HTHA had not been detected before the incident.

(vii) To establish suitable training in corrosion mechanisms for operational and technical staff. (viii) To fabricate replacement heat exchangers that are not vulnerable to HTHA and to identify, inspect, protect and, if necessary, replace other non post-welded equipment in hydrogen service. (ix) To review and update the corrosion studies, to develop a guidance document for calculating hydrogen partial pressure and to revalidate the standard hydrogen partial pressures in all hydrogen processing plant.

Recommendations
The investigation team made a range of recommendations in the form of corrective actions in accordance with their terms of reference. Thus: (i) In relation to the fatalities, to re-design the heat exchanger train so as to eliminate the need for on-line exchanger cleaning and to develop policies to control the number of people present in potentially hazardous areas at plant start-ups and shutdowns. Minimising the number of people in the vicinity of such operations, as far as is reasonably practicable, is very important. (ii) To install temperature and pressure instrumentation on the inlet and outlet of each reactor feed/effluent heat exchanger. (iii) To review similar hydroprocess units to determine any need for additional instrumentation to manage HTHA. (iv) To establish the safe operating limits (integrity operating window) for hydrogen partial pressure and temperature in hydroprocessing units fabricated of carbon steel and C-Mn-0.5Mo alloys. (v) To install adequate control instrumentation to manage and indicate these parameters (iv above) and to provide a means of alerting operators to significant deviations. (vi) To increase the standard safe operating margin for equipment in hydrogen service below the Nelson Curve in accordance with evidence of occasional failure below thecurve.

Authors note The TOP programme

The Tesoro TOP (Triangle of Protection) programme is a system-based safety programme, led by workers and supported by the company. Its object is to recognise and eliminate hazards. The programme: identifies failed systems of safety (SOS); makes recommendations to correct the failures; tracks the recommendations from incident and near miss investigations; publishes and shares findings in the form of lessons learned with the aim of preventing recurrences of similar events in other facilities.

References
1. Naphtha Hydroheater E-6600E Failure, April 2, 2010; Anacortes Refinery, Washington; TOP Investigation Team Report 100402OPR038, July 21, 2010. 2. American Petroleum Institute Recommended Practice 941, 7th Edition, August 2008. 3. Cracking of Non-PWHT Carbon Steel at Conditions below The Nelson Curve, ASME Conference, July 2010.

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