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CASE STUDY
THE PETROTRIN OIL
REFINERY
by
Dr. Victor Coombs
Chief Medical Officer, Petrotrin
Consultant Occupational &
Environmental Health
1970 - 1999
Type of Facility
Number of Losses
Refineries
597
Chemical Plants
75
Gas Processing
200
Terminals
30
Offshore
440
MRC 2001
Industrial Disasters
Fire
Explosion
Toxic Release
Structures
Instrumentation
Buildings
Electrical equipment
Documents Requested by
Insurers
Preliminary report by Accident Investigation Team
Medical Report and Injury List
Interviews
Photographs
Measurements and Weights of fragments
Engineering Report
Engineering data on by-pass valve around slurry
settler
Preliminary Report I
An explosion and fire occurred at the FCCU
at 2.53 am on Wednesday June 05, 1991.
The fire was brought under control by
Company Fire Services, TT Fire Services
and TT Methanol Company Fire Services
Preliminary Report II
There was one fatality, 12 injuries of which
2 were very serious and 10 were relatively
minor.
Several workers suffered Post
Traumatic Stress Disorder (PTSD).
Explosion Damage I
The Fire of the explosion at the slurry
settler caused extensive damage to N-S
piperacks and nearby equipment east of the
FCCU.
Explosion Damage II
Much of this ancillary damage was
apparently due to the shrapnel effect of
the slurry settler and was concentrated in
the NE the path of trajectory.
Fire Damage I
Near the base of the main fractionator the
slurry pumps were destroyed by fire.
Intense heat and flames damaged adjacent
equipment such as lines, heat exchangers
and the blower house roof.
Fire Damage II
On the FCCU main structure there was fire
damage mainly on the north side of the
reactor where the steam drum is located.
Some Findings
The slurry settler vessel showed tensile
failure typical of internal explosion.
Failure of the head in the area adjacent to
the reinforcing pad around the 18 manway
nozzle.
Some Findings
(contd)
Engineering Findings I
480 565 psi pressure in slurry settler was
required for rupture.
Vessel operating temperature was 610oF.
Calculations on blast effect was equivalent
to 120-200 pounds of TNT.
Engineering Findings II
A vapour space was most likely present in
the vessel. (compressible gas bubble) 420
to 1000 cu ft.
Energy required to fracture or deform the
slurry settler vessel was about 70 million ftlbs of energy 40 to 47 pounds of TNT.
Engineering Findings IV
Air was most likely trapped inside the
vessel during start up.
No evidence of an external explosive device
was found.
Personal Injuries
SR, age 22. Fatality
WM, age 35. Severe burns and shock.
RS, age 39. Severe burns, fracture right
arm, right foot and right hip, shock.
KL, age 44. Minor burns and shock.
Personal Injuries
contd)
Personal Injuries
(contd)
Fortunate Events I
Damage was mitigated because the
predominantly ballistic or impact type of
damage was confined to the NE direction
which was unoccupied hillside.
Fortunate Events II
Damage was mitigated by the fact that
several workers had gone to the canteen to
eat.
85.10.17: Berth #5
Fire started
Fire service
Fire under control
All clear given
12.35 pm
12.45 pm
12.50 pm
3.00 pm
Background to Fire I
In June 1985 a decision was taken to
recommission the entire length of the 30inch diameter sealine (S/L No. 33) running
from the Pile Bent 80 manifold to No. 5
berth and terminating at No. 6 Berth.
Background II
The section of the line between No. 5 and
No. 6 Berths (length 1200 ft) was the only
inoperative part and was positively isolated
from the rest of the line in 1975. This
section had to be tested and repaired before
being brought back into service.
Background III
Between July and October 1985, the other
portion of the line was in crude oil service,
the last being the receipt of 319,000 bbls of
Algerian Condensate on September 1.
Background IV
By October 11, all activities related to the
repairs of the disused section were
completed.
Background V
On October 17, equipment was mobilized
and manpower allocated to the task of
completing the final job to allow the recommissioning of the entire length of S/L
33.
Background VI
The last task was to remove the 30 inch
diameter slip blind installed in 1975, from
between the bolted flanges on the riser
section of the line at No. 5 berth, located
approximately 22 inches above sea water
level at noon on the day of the fire.
Background VII
A Maintenance Work Permit was prepared
and signed off by (1) Assistant Area
Maintenance Superintendent West; (2) Port
Captain; (3) Oil Stocks Superintendent and
delivered on site just prior to start of the
job.
The Fire I
Around 12 noon after the flange was
loosened on S/L 33, heavy crude trapped in
the dead leg followed by light hydrocarbons
(Algerian Condensate API 64.9 and vapour
Pressure 9.1 psig) flowed at an estimated
rate of 40 barrels per minute for 8-9
minutes.
The Fire II
This line was under a positive pressure from
an operating crude transfer system in the
foreshore area. During the 8 to 9 minutes
period, the 30-inch slip blind, weighing 250
lbs was removed by the crew.
The Fire IV
The fire raged for 15 minutes after which it
was brought under control, but in all lasted
about one hour and forty-five minutes.
The Fire V
When the crude transfer operations at the
foreshore area were isolated from the sea
line the fire was finally extinguished.
Fatalities
= 6
= 6
= 2
= 14
No.
4
6
3
1
Location
Plant Type
Event Type
PD Loss ($MM)
10-23-89
Texas
Petrochemical
VCE
839
5-4-88
Nevada
Chemical
Explosion
383
5-5-88
Louisiana
Refinery
VCE
368
11-14-87
Texas
Petrochemical
VCE
285
12-25-97
Malaysia
Gas Plant
Explosion
282
7-23-84
Illinois
Refinery
VCE
268
11-9-92
France
Refinery
VCE
262
12-13-94
Iowa
Chemical
Explosion
224
9-18-89
Virgin Islands
Refinery
Hurricane
207
8-17-99
Turkey
Refinery
Earthquake
200
9-27-98
Mississippi
Refinery
Hurricane
200
5-27-94
Ohio
Chemical
Explosion
200
9-25-98
Australia
Gas Plant
Explosion
187
10-16-92
Japan
Refinery
Explosion
187
3-4-77
Gas Plant
VCE
The Loss
amounts were adjustedQatar
for inflation.
VCE Vapor Cloud Explosion
6-1-74
VCE
This listing
does not include theEngland
onshore losses to thePetrochemical
Kuwait oil fields during the Gulf
War.
Total losses are estimated at over $2,500,000,000 (US).
174
MRC 2001
164
Date
Location
Facility Type
Event Type
PD Loss ($MM)
7-7-88
North Sea
Platform
Explosion
1,085
8-26-92
Gulf of Mexico
Platform
Hurricane
931
8-23-91
North Sea
Concrete Jacket
MD
474
4-24-88
Brazil
Platform
Blowout
421
11-1-92
Australia
Jacket
MD
314
1-20-89
North Sea
Drilling
Blowout
273
11-2-99
Angola
Process Deck
MD
210
7-1-74
Dubai
Platform
Blowout
204
10-1-74
North Sea
Platform
MD
196
MRC 2001
Number of Losses
Average $ Loss
(US)
Percentage
Piping
25
61,600,000
20%
Heaters
46,800,000
4%
Pumps
20,800,000
6%
Tankers
15
35,000,000
12%
Compressors
37,500,000
2%
Heat Exchangers
28,400,000
4%
Vessels
25
17,600,000
20%
Other
42
30,000,000
32%
MRC 2001
Number of Losses
Percentage
Alkylation
4%
Catalytic Cracking
15
12%
Coking
6%
Crude Distillation
14
11%
Hydrocracking
14
11%
Hydrotreating
15
12%
Reforming
3%
Jetties
2%
Storage
15
12%
Other
35
27%
MRC 2001
Number of Losses
Average $ Loss
(US)
Percentage
Explosion
38
46,700,000
30%
Fire
60
32,870,000
47%
Vapor Cloud
19
83,000,000
15%
Mechanical
Breakdown
80,500,000
3%
Other
54,400,000
5%
MRC 2001
Number of
Losses
Average $
Loss (US)
Percentage
Piping
53,400.00
18%
Tankage
33,000.00
20.5%
Ship/Barge
58,900.00
20.5%
Other
16
32,000.00
41%
MRC 2001
Number of
Losses
Average $
Loss (US)
Percentage
Explosion
13
13,300.00
33%
Fire
16
50,400.00
41%
Vapor Cloud
38,400.00
8%
Mechanical
72,900.00
13%
Other
14,200.00
5%
MRC 2001
Number of
Losses
Percentage
Storage
18
46%
Pipeline
21%
Jetty
15%
Tanker
5%
Other
13%
MRC 2001
Lessons Learned
Conduct process hazard analyses of all process units, both
old and new
Provide regular training for all employees, including
standardized re-certification training for all operators
Institute a strong mechanical integrity program that
includes equipment inspection, piping inspection, material
verification, corrosion under insulation inspection,
vibration analysis and metal thickness verification.
Provide a well-trained emergency response organization
that can include employees and/or mutual aid agreements.
Estimated Release
(metric tons)3
80,000
Crude Il
56,300
200
400
Gasoline
1,500
Motor Gasoline
4,500
Jet Fuel
1,200
Diesel
350
Fuel Oil
7,500
SCC Gas2
6,700
Other2
1,900
Location
Amount Released
(metric tons)
Emission Route
Ammonia
HIP Azotara
250
Waste channel
Calcium ammonium
nitrate, phosphates,
potassium chloride
HIP Azotara
250
Crude oil
HIP Azotara
150
Vinyl chloride
HIP Petrohemija
460
Burned
1,2-dichloroethane
HIP Petrohemija
2,100
Mercury
HIP Petrohemija
Sodium Hydroxide
HIP Petrohemija
100
Ethyl-, propylene
HIP Petrohemija
1,900
Hydrochloric acid
HIP Petrohemija
130
85,000
Intentionally burned
Soil and waste channel
80,000 metric tons
burned, remainder
spilled onto soil
Maximum
Concentration
(g per liter)
Sampling
Point
Depth
(meters)
Maximum
Contaminant
Levels
(U.S. EPA)
(g per liter)
Factor by
which Max.
Contaminant
Level is
Exceeded
7,500,000
B-5
18
1,500,000
Vinyl chloride
70,000
B-5
18
35,000
Dichloromethane
26,500
B-21
10.5
5,300
Chloroform
100,000
P-1
80
1,250
Tetrachloroethane
40,000
P-1
N/A
N/A
1,1-dichloroethylene
5,500
B-20
21
790
1,2-cis dichloroethylene
29,200
P-1
70
420
1,2-trans
dichloroethylene
85,600
P-1
100
860
1,1 dichloroethane
95,600
P-1
N/A
N/A
Trichloroethylene
16,500
B-21
10.5
3,300
Tetra-chloroethylene
374
B-13
7.5
75
1,1,2-trichloroethane
48,000
B-20
21
9,600
1,1,2,2-tetrachloroethane
2,220
B-13
7.5
N/A
N/A
343
B-20
21
100
3.4
1,2-dichloroethane
Chlorobenzene
Maximum
Groundwater
Concentration
(g per liter)
Groundwater
Sample Depth
(meters)
Maximum
Contaminant
Levels (water)
(U.S. EPA)
(g per liter)
Factor by which
Max.
Contaminant
Level is
exceeded
Benzene
9,100
6.3
1820
Toluene
4,820
6.3
1,000
4.82
Ethyl benzene
5,330
6.3
700
7.61
Xylenes
11,500
6.3
10,000
1.15
PHCs
109,000
6.3
N/A
N/A
1,2-dichloroethane
66,900
6.3
13,380
Maximum Soil
Concentration
(mls per kgs of soil)
Benzene
2,230
58-68
Toluene
2,090
58-68
872
58-68
Xylenes
4,560
58-68
PHCs
3,490
58-68
Lead
95.2
0-10
Ethyl Benzene
Particulates (<3.5 m)
16-20
1,200-1,500
2.8-5.5
210-410
4.0-8.0
300-600
7.1-20.7
500-1,600
51.-11.6
380-870
807-829
61,000-62,000
Methane (CH4)
1.6-2.8
120-210
16-33
1,200-2,500
0.49-0.64
37-48
30-60
Estimated
Emission
Intensity
(grams per
second)
Estimated
Wind
Velocity
(meters per
second)
Estimated
Crosssectional
area of
plume (km2)
Estimated
Maximum
Concentration
(g per m3)
U.S. EPA
Air Quality
Standards
(g per m3)
Sulfur
dioxide
9600
3-5
4-8
200-800
365
Nitrogen
oxides
2200
3-5
4-8
50-200
100
PAH
220
3-5
4-8
5-20
N/A
Particulates
4800
3-5
4-8
100-400
65
Medical Management of
Mass Casualty
Search, rescue and first aid.
Transport to health facility and treatment
Redistribution of patients between hospitals
Definitions
Disaster
A Disaster situation may be defined as any
emergency that overwhelms the available
medical resources.
Triage
Triage is a French work meaning to sort.
Definitions
(contd)
MCI
A Mass Casualty Incident (MCI) is defined
as any situation in which the medical care
required exceeds the ability to provide that
care.
Scene Evaluation
Safety evaluation of all possible dangers
and assuring that none still exist.
Scene evaluation of physical site e.g. no
of vehicles in crash, fire, explosion or toxic
release.
Situation what really happened here?
Why?