Unidentified thermal expansion hazard causes

oil spill to secondary containment

What happened?

The fluid was trapped between a check valve and

closed tank valves at a central tank battery.

The check valve top clamp failed, releasing oil to

secondary containment.

The release was found by a truck driver and

reported.

A production specialist advised pulling the

emergency shutdown to stop the release.

The shutdown did not initiate well kill, and the

release continued.

The production specialist then contacted a field

specialist who instructed how to initiate the good
kill process on the human-machine interface (HMI)
screen.

The spill was subsequently stopped.

 Why did it happen?

Facility design did not allow for production into tank

1 (T-1 on diagram) without trapping fluid
downstream of a check valve.

The failed check valve was certified up to 720

pounds per square inch (psi). No material defects
were identified to cause failure. Testing has shown
pressure swings up to 3400 psi due to thermal
expansion. Accounting for outside temperature,
piping and valve pressure was estimated at ~ 2000
psi.

Trapped fluid combined with the increased outside

temperature of 32 degrees C (90 degrees F),
created a thermal expansion hazard, causing the
check valve top clamp failure.

Procedures did not caution that valve

configurations can create thermal expansion
hazards.

Personnel did not identify the trapped fluid on the

system or the consequences of thermal expansion.

Emergency shutdown button was not configured

into the programmable logic controller to initiate
well kill the process.
 What did they learn?

Review facility designs to determine if all existing

check valves are needed.

Ensure correct placement of the check valve and

block valve to eliminate trapped fluid and
conditions for thermal expansion hazard.

Ensure operating procedures caution against valve

configurations that can trap fluid and create
conditions for thermal expansion hazard.

Consider including notes defining thermal

expansion, associated hazards and how to
eliminate them.

Ensure equipment inspection/testing programmes

are in place and include verification of emergency
shutdown testing and functionality.

Ask yourself or your crew

How can something like this happen here?

If in doubt of the facility design, where can you find

all the necessary diagrams?

What thermal expansion hazards might we

encounter today?

What improvements to procedures or ways of

working can we make to account for thermal
expansion hazards?

How is the good kill procedure initiated on your

site? How do you know that it works?
A check valve top clamp located at a central tank battery failed, releasing oil to secondary
containment. The emergency shutdown did not stop the release. The spill was subsequently stopped
by activating the well kill on the human-machine interface (HMI) screen.