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Occupational Safety and Health Administration OSHA

Accident Report Detail

Accident: 514927 - Employee Burned In Fire After Heat Exchanger Ruptures

Accident: 514927 -- Report ID: 0625700 -- Event Date: 11/04/1990
InspectionOpen DateSICEstablishment Name
11033668211/05/19902911Mobil Oil Corporation/Chalmette Refinery
InspectionOpen DateSICEstablishment Name
11041926411/07/19901731Orleans Electric & Const. Co., Inc.
InspectionOpen DateSICEstablishment Name
11041924912/04/19902911Delta Maintenance, Inc.
InspectionOpen DateSICEstablishment Name
11041934811/05/19902911Mobil Oil Corporation/Chalmette Refinery
At approximately 11:30 p.m. on November 4, 1990, Employee #1, an assistant operator in the hydrocracker unit (HCU) of a refinery, was manually opening a bypass valve to increase the flow rate in the unit. The bypass was being used because the second-stage charge motor control valve was not working properly. As Employee #1 was opening the bypass valve, he heard a "whooshing" sound in the unit, to his west. A heat exchanger, identified as E2314, ruptured on the shell side, releasing vapors that were ignited by the first-stage prefeed heaters. Employee #1 sustained first-, second-, and third-degree burns over 70 percent of his body. The shell side of the exchanger had thinned to 0.1 inch, and failed at the normal operating pressure of 255 psi. The accident investigation revealed no connection between the failure of the heat exchanger shell and the operation of the manual bypass valve.
Keywords: flammable vapors, work rules, equipment failure, explosion, heat exchanger, burn, heater, fire, rupture, refinery
Employee # Inspection Age Sex Degree Nature Occupation
1 110336682 Occupation Not Listed
2 110419264 Occupation Not Listed
3 110419249 Occupation Not Listed
4 110419348 Hospitalized injury Burn/Scald(Heat) Occupation not reported

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