Ammonia Leak

1 2 3 4

E1 Release of ammonia E4 Release of ammonia Release of ammonia Release of ammonia

E10 E13
from inlet from vessel from outlet from the filling point

E2
E3 E11 E12
E5
Pipe Rupture Flange Leaks Flange Leaks
Pipe Rupture
Over Pressure
Corrosion

B Leaks from
Leaks from nozzle
E6
E9 filter flange
Over Pressure Corrosion Over Pressure Loose nuts
Gasket Pressure Loose nuts Safety relief Corrosion Gasket Pressure
system fails Over filling Over O
temperature M Hose
A E8 Ruptures
B C D A B C D Leaks from the
joints of the
connecting pipes
P

Blockage in Pipe Exothermic Exposure

Defective valve Inlet valve Failure of NaOH N
fails to hold chemical to external
level indicator Corrosion reaction heat source

F E7
G H I K
J

Defective Defective Defective Defective Defective Defective Defective Defective Defective

Valve V1 Defective
Valve V3 Valve V4 Valve V8 Valve V10 Valve V11 Valve V17 Valve V18
Valve V5 Valve V6

17 17
a b c g h i j
d e f
Figure 1: FTA overview for Ammonia release
 Ammonia Leak

1 2 4

E1 Release of ammonia from Release of ammonia from Release of ammonia from the
E13
inlet/ outlet E4 vessel filling point

E2 E3 E6 E8 E9

Pipe Rupture Flange Leaks Safety relief Over filling Over

system fails
temperature

E7
Leaks from
filter flange Leaks from the Hose
Defective valve Inlet valve Failure NaOH Exothermic Exposure
Over Gasket Loose joints of the Ruptures
Corrosion fails to of level Corrosion chemical to external
Pressure Pressure nuts connecting pipes
hold indicator reaction heat source

B C D G H M
A I K P
Blockage J N Leaks from
in Pipe
nozzle

F
O

Defective Defective Defective Defective Defective Defective

Defective Defective Defective Defective
Valve V1 Valve V3 Valve V4 Valve V8 Valve V10 Valve V11
Valve V5 Valve V6 Valve V17 Valve V18

17 17
a b c g h j
d e f i Figure 2: Minimal Cut Sets for the FTA in Figure 1
 Formulation of Bow-tie Diagram

THREATS PREVENTIVE MITIGATIVE CONSEQUENCES

MEASURES MEASURES

Devices failure Timely checking Safe and

(include inlet, Working out systematic
maintenance &
outlet and emergency and evacuation.
replacement
vessel),such as pipe response plan Reduce fatalities
repair
rupture or corrosion & serious injuries

Strengthening
Human errors, such Liquid
the relevant Wearing personal Reduce exposure
as overfilling due to ammonia leak
training and protective to ammonia and
improper operation qualification of equipment harm to the body
workers

Natural factor, such Build a cooling Communicating Put off fire in

as over temperature system to regulate with the fire time. Reduced
due to external heat the temperature department in property damage
source and install alarm & economy
advance
temperature
monitoring

Figure 3: Bow tie diagram for ammonia release