Major Ammonia leak from HP

Ammonia Feed Pump

This paper discusses a major ammonia leak due to failure of a high pressure ammonia feed pump in
the urea plant owing to detachment of the HP locknut of a plunger. During the incident, HP packing
rings and lantern “O” rings got ripped off and liquid ammonia gushed out. This led to an on-site
emergency and shutdown of the plant.

Though the incident had the potential to cause fatalities, the situation was well managed without any
injury due to the strengths & practices inculcated in the organization. Furthermore, the deficiencies
in mechanical integrity were exposed, leading to improvements in reliability and safety.

P.Hari Narayana Reddy, R. Raghavan and Ramashray Singh

Nagarjuna Fertilizers and Chemicals Limited

H andling of liquid ammonia always poses a

great challenge in terms of safety &
environment.

In the history of the chemical industry, there have

annual production capacity of 1.6 million MT of
Urea.

Streams I and II were commissioned in July 1992

been many accidents involving major ammonia
leaks which have lead to losses in terms of human
life and property.
Introduction
M/s Nagarjuna Fertilizers & Chemicals Limited
(NFCL) is one of the fertilizer giants in India,
with manufacturing facilities at Kakinada, a port
city in the southern region of India.
and March 1998 respectively. Each stream
consists of a 900 MTPD ammonia plant and a
1500 MTPD urea plant, each based on natural gas
as both feed and fuel. The ammonia plants are
based on Haldor Topsoe’s conventional steam
reforming technology and the urea plants are
based on Snamprogetti’s ammonia stripping
technology.
Due to recent debottlenecking, both the ammonia
and urea plant capacities have been upgraded to
1325 MTPD and 2325 MTPD respectively.

It operates two ammonia and urea streams and

associated offsite facilities, Figure 1, with an

2010 85 AMMONIA TECHNICAL MANUAL

 Description of Urea Plant
Typical process steps involved in a urea plant are
urea synthesis, urea purification, concentration &
prilling and process water treatment, Figure 2.

Figure 1: General Layout of Complex

Occupational Fire Utility Air

& Cooling Towers for Compression
Health
Safety Ammonia-1& Urea-1 Units
Centre

Ammonia-1 Urea-1
Power
Generation
Unit-1

Central Control room

for Power Generation
Ammonia-1& Urea-1 Unit-2

Ammonia-2 Urea-2

The booster pump discharge is fed to the

The urea plant where the incident took place
reciprocating HP ammonia feed pumps and
operates with all the latest features, such as:
pressure is further increased to around 23500KPa
(240 Kscg) before it is fed to the urea reactor for
1. 14 improved Casale Sieve trays in the urea production of Urea, Figure 3.
reactor.
2. Bi-metallic HP stripper
The reciprocating pumps were supplied by M/s
3. Dedicated vacuum section for the pre-
Peroni, Italy. The pumps have five horizontal
concentrator
type plungers, with oil lubrication / sealing for
4. Pre MP decomposer to utilize the excess low
packings / plungers. Table 1 shows pump
pressure steam generated in the plant.
specification sheet and Figure 5 the plunger
5. Wet and dry de-dusting systems for the prill
packing arrangement.
tower and conveyor gantry.
Incident
Ammonia coming from the ammonia plant or
ammonia storage is drawn into a receiver tank and
On 04th May 2007, at around 03.33 hrs, Urea
pressure is initially boosted via centrifugal pumps
plant-1 field operators, who were in the field
to around 2000 KPa (21Kscg).

AMMONIA TECHNICAL MANUAL 86 2010

 room, heard some sound in the field and came out.
They noticed a heavy ammonia leak from the HP
ammonia feed pump (P101-C) and immediately
informed the control room via the paging system.

Figure 2: General Layout of Equipments in Urea Plant-1

Carbamate Urea N
Condenser Reactor
CO2
Ammonia Compressor Decomposition
Compressor House & Vacuum
House concentration

Prill
Tower
Ammonia
Syn.Loop
And
Hydrogen
Recovery
Unit
HP Ammonia Feed HP Carbonate
Pumps Pumps

Area Operators
Cabin

Figure 3: Ammonia Network in Urea Plant

NH3 from
Ammonia Plant/
Storage

Ammonia Receiver
(V-101) Urea Reactor

On - Off HP Ammonia feed pumps

Valve P-101A/B/C

Ammonia Booster Pumps

P-105A/B

2010 87 AMMONIA TECHNICAL MANUAL

 At 03.35 hrs, the pump was tripped locally by the
field operator. Normally, operators use
radios/Walkie-Talkies only during Start-up and
Shut-down operations.
Unfortunately, the leak did not rescind and
ammonia vapors began spreading towards North –
East/West directions (Ammonia plant-1, Urea
plant, CO2 compressor house, Unit-1 cooling
towers and Unit-2 Power generation plant (Ref.
Fig No.4)).
At 03.40 hrs, it was decided to shut the plant
down. The other running HP ammonia feed pump
(P101-A) was tripped from the control room and
the shut-off valve in the HP ammonia feed pumps
suction was closed via the Shutdown System
(SDS) in the control room and the centrifugal
booster pump was stopped from the electrical
substation. Thereafter, the leak came under
control and plant shutdown actions were followed.
Table 1: Details HP Feed Pump Specification
AMMONIA TECHNICAL MANUAL
On-site emergency (Level-2 emergency), which
has the potential to affect the neighboring plants,
but not beyond the boundaries of NFCL was
declared. Assistance from Fire & Safety staff in
the form of Fire tender reached the site. Under the
guidance of the incident controller, spray curtains
were arranged to contain the spreading ammonia
vapour cloud.
Arresting leak and handling the emergency
1. Thick Ammonia vapors started spreading to
the Unit-2 Power Generation plant (combined
cycle gas turbine with waste heat recovery
boiler), Ammonia Plant-I back end and other
areas as indicated in Figure 4.
2. The Manual Call Point (MCP) (an alarm
button) was activated and a message was sent
to Fire & Safety control centre.
3. The Urea-I Shift in charge (SIC) (who had
taken charge as Incident controller) declared
an onsite emergency as the leak was not
arrested even upon tripping the besieged
pump. The other feed pump was also tripped
and then the shut-off valve in the common
suction was closed from a remote area i.e.
control room. Ammonia leaking out from the
besieged pump was completely stopped.
4. As the ammonia feed to the urea reactor got
cut off, the urea plant shutdown was initiated.
5. All important actions were carried out
immediately by the field operators by wearing
Self Contained Breathing Apparatus (SCBA)
after the urea plant shut down, viz. putting the
CO2 compressor on barring, diverting the urea
melt from the vacuum section to the storage
tank and washing different lines like reactor
feed lines, melt line etc.
88 2010
 Figure 4: Spread of Ammonia Leak
Occupational
Cooling Towers for
Health
Ammonia-1& Urea-1
Centre
Ammonia-1
Central Control room
for
Ammonia-1& Urea-1
Ammonia-2
6. Meanwhile, the Ammonia plant-1 back end
(compressor house, synthesis loop and
hydrogen recovery unit), which are adjacent to
the urea plant, were affected with ammonia
vapors. Each of the three ammonia leak
detectors located in the Ammonia Plant-1
back end responded and alerted the control
room. The compressor house operators rushed
to CO2 removal section located on the
northern side, which was unaffected. These
operators were given first aid at the
Occupational Health Centre, located within
the complex. Ammonia plant operations
remained unaffected.
7. Ammonia plant-1 and Urea plant-1 have
common control rooms located opposite to
Ammonia plant-1 (North-West side of Urea
plant-1). The control room operators
continued operations using the on line
respirators bank (which can last long for about
90 min. upon usage by four operators). The
Ammonia-1 Shift in charge alerted all other
2010
Utility Air
Compression
Units
A B C Urea-1
Power
Generation
Unit-1
Power Generation
Unit-2
Urea-2
plants via the paging system. Control room
air-conditioning was switched off.
8. Power Generation Unit-2, which is located on
the western side of the urea plant was also
affected due to a change in wind direction.
Operators did not have any clue as to what
was happening for some time so they wore on-
line air respirators and remained behind closed
doors.
9. Meanwhile, communication was given to all
important personnel via pagers (which will
give a predetermined number against
emergency in a particular plant) and also via
telephone by the laboratory chemist in the
shift.
10. The production head who reached the site first
took over as the Emergency Controller and
started guiding the Shift In Charge, effectively
streamlining the shut-down actions, effluent
containment, Occupational Health and Fire &
Safety activities.
89 AMMONIA TECHNICAL MANUAL
 11. Head count of the persons in the Urea Plant-I,
neighboring manned areas like Ammonia
Plant-I Compressor house, Plant-I Control
Room, Power Generation-2 Control Room,
Plant-I cooling towers was taken and the well-
being of all personnel was ensured.
12. In the meantime, the Site In charge and all
heads of departments reached the site.
Analysis and further course of actions were
finalized.
& procedures to handle such emergencies in
future.
• The investigation team swung into action and
interacted with shift personnel from the
various plants in order to gather information
about the difficulties they faced so as to
connect the events for detailed analysis. The
following were the observations made upon
inspecting the failed 4th cylinder and HP
locknut of the HP ammonia pump.

How And Why Did This Incident Happen? Photo 1: Dislocated 4th cylinder lock nut and
Lantern
• The 4th cylinder HP locknut on the HP
ammonia feed pump (P-101C) got detached
from the cylinder The lantern, along with its
“O” rings, came out of the cylinder, the HP
packing rings and lantern “O” rings got ripped
off and high-pressure liquid ammonia leaked
out.

• Upon inspection of the failed cylinder and

lock nut, it was observed that the cylinder OD
in the threaded portion and HP lock nut
threads ID were in a worn-out condition. This
led to the unlocking of the locknut and the
failure. The HP locknuts and lanterns were
originally supplied by M/s. Peroni (OEM)
during plant commissioning in the year 1992
and have been in service since then. They are
made of carbon steel and are usually visually Photo 2: Lantern Slid from Position upon
inspected and dye-penetration tested during Slipping of HP Locknut
packing replacement. The threads are applied
with a compound called ‘Molycoat’, which
acts as an anti-seize and lubricant. The HP
nuts are tightened by hand using a large
wrench.

Investigation and root cause analysis:

• A three member multi-disciplinary team of

managers from Production, Mechanical
maintenance and Condition monitoring was
constituted by the Site In Charge to investigate
the incident, recommend various steps to
avoid such failures and strengthen the systems

AMMONIA TECHNICAL MANUAL 90 2010

 Photo 3: Scoring Marks of the Lantern
Photo 4: Threads damaged on cylinder (lock
nut area)
Photo 5: Ripped out LP Packing thrown
10 meters away
2010
Observations
1. The fourth cylinder threaded portion was
found to be tapered.
2. The threaded portion of the fourth cylinder
was found to be 184 mm as against 184.7mm
(worn out by 0.7mm).
3. The HP locknut threads ID found to be
183.30/183.54/184.0 mm as against 182.7mm
(reduction was varying from 0.60 to 1.1mm).
The reasons for this reduction is thought to be
due to fewer threads being in contact and wear
& tear that resulted during extended service
without inspection.
4. 9 out of 20 threads were found to be partly
scoured out. Similarly, in the HP locknut 6 out
of 20 threads were found to be scoured out.
There was no fresh damage noticed in either
thread.
5. The lantern got detached from the inside of
the cylinder.
6. The lantern bottom “O” ring groove portion at
OD and the corresponding cylinder ID portion
at the lantern mating area had severe scoring
marks (as shown in Photo no.3).
7. All five HP braided packing rings along with
the two PTFE support rings were found
missing inside the cylinder and they were
found scattered about 10 meters away (as
shown in Photo no.5).
8. After becoming detached from the cylinder,
the HP lock nut was found near the power end
oil seal housing.
All of the probable reasons such as process
disturbances, material failure and lapse in
maintenance practices etc. for the running
ammonia feed pump HP locknut detachment were
analyzed by the investigation team to establish the
root cause, details in Table 2.
91 AMMONIA TECHNICAL MANUAL
 Actions Implemented
1. The number of threads engaged between the
HP locknut and cylinder have been increased
from 12 to 16 with OEM Consent.
2. The criticality matrix of the Maintenance
Integrity Module was reviewed and a fresh
schedule has been drawn up for periodic
inspection of the HP locknuts of all pumps on
a half yearly basis.
3. A provision for tripping the ammonia booster
pumps, which feed to the HP ammonia feed
pumps directly from the control room, was
provided in both Urea plants.
4. An on-off valve was provided in Urea plant-2
in the same location i.e. HP ammonia feed
pumps’ common suction, as it proved very
effective in isolation from a remote location ,
rrfer to Figure 3 for the exact location.
5. The personnel whose presence of mind and
timely emergency actions helped in mitigating
the incident were appreciated and rewarded.
6. To further strengthen the emergency
preparedness of shift personnel, the concept of
conducting tabletop drills, depicting the
various scenarios, was introduced.
7. The curtain water system covering the HP
ammonia feed pumps and HP carbonate
pumps was implemented with remote
activation, Figure 6.
AMMONIA TECHNICAL MANUAL
Conclusion
1. Top level management commitment to
systems implementation and deriving benefits
helped immensely in the early control of the
emergency.
2. Innovative methods of emergency
communication (which does not require the
communicator to dial each telephone number)
helped in effectively spreading the
information to all key personnel living in the
town ~10 kms radius away from complex.
3. The on-off valve that was installed as a fall
out of a previously conducted HAZOP study
has helped immensely in quick positive
isolation from a remote location without
affecting the personnel.
4. The air respirators bank provided in all of the
main control rooms also helped in allowing
panel operators to continue and control the
critical operations from the control room
through DCS.
5. Periodic review of the criticality matrix of the
Mechanical Integrity module, even when
things are running smoothly, was introduced.
Any modifications are implemented only with
OEM consent and after HAZOP studies are
performed, which helps in improving the
reliability factor.
6. Thorough incident investigation with active
employee participation also helped to establish
the root cause and address the deficiencies.
7. Learning from the incident has been
disseminated to all relevant plant personnel in
the complex, which helps to improve
preparedness for similar incidents in the
future.
92 2010
 Table 2: Root Cause Analysis

Figure 5: General View of Plunger Packing Arrangement

Seal Flush Seal Flush HP Locknut

Outlet Inlet

HP Packing
LP Packing
Lantern
LP Locknut

Plunger

2010 93 AMMONIA TECHNICAL MANUAL

 Figure 6: Curtain Water system Installed around HP Ammonia Feed Pumps

About the authors

Mr. Ramashray Singh is a chemical engineer
working as Sr. General Manager (Plant
Operations) at Fertilizer Complex, Nagarjuna
Fertilizers & Chemicals Limited, Kakinada. He
has more than 34 years of experience in
commissioning & operation of Ammonia / Urea
Plants. He has worked in various Fertilizer
industries in India at different capacities.
Mr. P Harinarayana Reddy is a Chemical
Engineer with a Post Graduate Diploma in
Ecology & Environment, working as Deputy
General Manager (Production) at Fertilizer
Complex, Nagarjuna Fertilizers & Chemicals
Limited, Kakinada. He has more than 20 years of
experience in commissioning & operations of
Ammonia / Urea plants

Mr. R Raghavan is a chemical engineer with a

Post Graduate Diploma in Management, working
as General Manager (Plant Operations & Projects)
at Fertilizer Complex, Nagarjuna Fertilizers &
Chemicals Limited, Kakinada. He has more than
29 years of experience in commissioning &
operation of Ammonia / Urea Plants in India and
the Middle East.

AMMONIA TECHNICAL MANUAL 94 2010