Heat Exchanger

Catastrophic Failure

June 24th, 2023

© 2020 Chevron
 Incident Description
What went wrong?

Business Unit / Site

• Tesoro Anacortes Refinery, WA April 2010

Facility/Process Unit

• Naphtha Hydrotreater heat exchanger shell rupture

• Heat exchanger - hot liquids introduction after maintenance

Consequences
• Release of hydrogen and hydrocarbon and fire
• Hydrocarbon autoignition and explosion
• 7 fatalities
• 6 month downtime
• 90 minutes to put out the fire

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 Incident Description
What went wrong?

Gap Analysis
• API standards provide guidance on operating limits for steels in Investigation outcomes
hydrogen service.
• Previous analysis indicated potential for High Temperature
• Inadequate Controls and Safeguards were in place to ensure that
Hydrogen Attack (HTHA) in A&D exchangers and outlet piping.
the exchangers were operating within safe operating limits, i.e.,
below the Nelson Curve.
• Lack of instruments (TI/PI) and Process Data on piping between
the exchangers meant engineers could not determine whether
operating above or below safe operating limits for temperature
and hydrogen partial pressure.

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 Prevention Safeguards

!
Hazard
- Hydrocarbon Ha
za De In
- High Temperature rd s ad
n ot ign eq
re co re ua
gn vie te
iz e w in Initial event
De
RM FD&C TC&S sig
n

Failures in Preventive Safeguards:

• Risk Assessment: Hazard not recognize
• HTHA not identified as potential failure mechanism for the ‘B’ and ‘E’ exchangers
• FD&C: Insufficient in HEX Engineering Design (Process & Mechanic)

Wrong Material Selection

• Technical Codes and Standards: Insufficient application of Safety in Design
•Not provide Instrument to detect process operating data (TC&S)
•Not provide Control and Safeguard (TC&S)
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 Workforce Competency
Process Safety

Actions leaders can take

Key Features
• Be sure the organization has a plan for identifying, developing
• Defines process safety skills and knowledge necessary for job and sustaining process safety competencies.
qualification.
• Demonstrate support for an organizational learning culture,
• Identifies need for process safety competency development and
including learning from industry experience.
delivery timeframes.

• Includes available and updated training materials and appropriate • Maintain your own process safety competency and support
refresher training. others in the organization to do the same.

• Requires on-going validation of program effectiveness. • Regularly review competency development efforts and set high
expectations for process safety performance.

• Support compliance with appropriate technical codes and

standards (e.g. Chevron Engineering Standards - CES).

• Engage technical experts regarding technical codes & standards

and risk management.

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 TC&S / Process Safety Competency

Designing,
operating,
maintaining

facilities handling hazardous materials requires

a high degree of technical competency. These
competencies must be maintained within an
organization as individuals come and go. It is
important that applicable TC&S are followed,
and documentation is available to help explain
interpretations and decisions involving
equipment to future generations of engineers.

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