CHEMICAL PROCESS SAFETY(CPS)

ASSIGNMENT

TOPIC: SODEGAURA-1992

Prepared By: Saraiya Meet (CH114)

Saliya Nishant (CH113)
(7th sem) (L div)
Guided By: Prof. Siddharth Modi
 CASE DETAILS

• Case Name: Leakage and explosion at a heat exchanger

having a special structure caused due to insufficient
maintenance of a vacuum gas oil hydrodesulfurization unit
• Date: October 16, 1992
• Place: Sodegaura, Chiba, Japan
• Location: Refinery
• Substance: Hydrogen, Gas oil
• Type of Accident: Leakage, explosion, fire
 OVERVIEW(1)
• On October 16th, 1992, an explosion and a fire occurred on
starting a vacuum gas oil hydrodesulfurization unit after
changing a catalyst at the refinery.

• While the operating condition was being adjusted, a leak of

hydrogen and a vacuum gas oil mist was generated from
the feed-effluent heat exchanger at the reactor section. A
loud explosion and a fire followed. A channel cover and
lock bolts of the heat exchanger came off, and flew about
120 m away, severely damaging buildings of the a
neighboring factory.
 OVERVIEW(2)
• The refinery shut down the whole fuel oil refining
plant immediately. A tank of the neighboring factory
also caught fire due to the influence of the explosion.

• The cause of the accident was that internal parts of

the heat exchanger of a very large and special
structure called the bleach rock type had
deteriorated and hardened due to inadequate long-
term maintenance.
1992-10-16_SODEGAURA
PICTOGRAPH
 INCIDENT(1)
• An accident occurred at startup after finishing catalyst exchange
of a vacuum gas oil hydrodesulfurization unit in a refinery. After
restarting the unit, the operating conditions were adjusted to
almost usual levels, and hot bolting of high-temperature
equipment and piping was being done.

• At that time, an explosion and a fire occurred at a heat

exchanger E-2801. 17 persons including hot bolting workers and
supervisors near the heat exchanger were killed or injured.
Moreover, tanks and buildings of the adjacent factory were
damaged by a blast and scattered debris from this accident, and
some of leaking lubricant oil was ignited.
 INCIDENT(2)
• The operation conditions of the heat
exchanger were in the design limit at the time:
the pressure was about 8 MPaG at the tube
side and about 7 MaPG at the shell side, the
temperature was 111-199 °C at the tube side,
262-187 °C at the shell side.
 MISTAKES MADE
• Repeated ratcheting, leading to reduction in
the diameter of the gasket retainer which
keeps the heat exchanger airtight
(maintenance error)
• Incorrect replacement of the gasket retainer
• Removal of insulation
• Inadequate replacement of the internal flange
set bolts
 LESSONS LEARNT
• Regular maintenance of equipment should be
done
• Proper management should be done
• Keep Sufficient inventory
• Replacement should be done under guidance
of responsible person, and according to code
and standards.
 LOSS
• Loss of life: 9 workers were killed and 8 injured
• Consequences: An explosion sound was heard
at the point 8 km away from the site, and the
shock of the explosion was felt even at the city
hall about 6 km away, and its windows were
damaged by the blast.
• Financial Cost: F ¥2,860 million
 REFERENCES
• Desert News:
https://www.deseret.com/1992/10/16/19010
736/refinery-blast-kills-at-least-9-hurts-8-in-to
kyo
• Shippi:
http://www.shippai.org/fkd/en/cfen/CC10000
44.html
• Topic was changed due to lack of information
which was “North Rhine-1991”
THANK YOU