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