Heat exchanger rupture and ammonia release in Houston, Texas (One Killed, Six Injured)
2008-06-I-TX January 2011
This case study examines a heat exchanger rupture and ammonia release at The Goodyear Tire and Rubber Company plant in Houston, Texas. The rupture and release injured six employees. Hours after plant responders declared the emergency over; the body of an employee was discovered in the debris next to the heat exchanger.
The Goodyear Tire and Rubber Company
Houston, TX June 11, 2008
• • • Emergency Response and Accountability Maintenance Completion Pressure Vessel Over-pressure Protection
INSIDE . . .
Incident Description Lessons Learned
Goodyear Houston Case Study
1.0 Incident Description
This case study examines a heat exchanger rupture and ammonia release at The Goodyear Tire and Rubber Company (Goodyear) facility in Houston, Texas, that killed one worker and injured six others. Goodyear uses pressurized anhydrous ammonia in the heat exchanger to cool the chemicals used to make synthetic rubber. Process chemicals pumped through tubes inside the heat exchanger are cooled by ammonia flowing around the tubes in a cylindrical steel shell. On June 10, 2008, Goodyear operators closed an isolation valve between the heat exchanger shell (ammonia cooling side) and a relief valve to replace a burst rupture disk under the relief valve that provided overpressure protection. Maintenance workers replaced the rupture disk on that day; however, the closed isolation valve was not reopened. On the morning of June 11, an operator closed a block valve isolating the ammonia pressure control valve from the heat exchanger. The operator then connected a steam line to the process line to clean the piping. The steam flowed through the heat exchanger tubes, heated the liquid ammonia in the exchanger shell, and increased the pressure in the shell. The closed isolation and block valves prevented the increasing ammonia pressure from safely venting through either the ammonia pressure control valve or the rupture disk and relief valve. The pressure in the heat exchanger shell continued climbing until it violently ruptured at about 7:30 a.m.
The catastrophic rupture threw debris that struck and killed a Goodyear employee walking through the area. The rupture also released ammonia, exposing five nearby workers to the chemical. One additional worker was injured while exiting the area. Immediately after the rupture and resulting ammonia release, Goodyear evacuated the plant. Medical responders transported the six injured workers. The employee tracking system failed to properly account for all workers and as a result, Goodyear management believed all workers had safely evacuated the affected area. Management declared the incident over the morning of June 11, although debris blocked access to the area immediately surrounding the heat exchanger. Plant responders managed the cleanup while other areas of the facility resumed operations. Several hours later, after plant operations had resumed, a supervisor assessing damage in the immediate incident area discovered the body of a Goodyear employee located under debris in a dimly lit area (Figure 1).
Figure 1. Area of fatality
Goodyear Houston Case Study
ammonia to control temperature. Piping carries product from the reactors to the product finishing area.
Goodyear is an international tire and rubber manufacturing company founded in 1898 and headquartered in Akron, Ohio. North American facilities produce tires and tire components. The Houston facility, originally constructed in 1942 and expanded in 1989, produces synthetic rubber in several process lines.
Ammonia Heat Exchangers
The facility includes separate production and finishing areas. In the production area, a series of reactor vessels...
References: Occupational Safety and Health Administration (OSHA) Process Safety Management Standard. 29 CFR 1910.119, 1992. American Society of Mechanical Engineers (ASME). Boiler and Pressure Vessel Code, Section VIII, Division I, 2004. Center for Chemical Process Safety (CCPS). Plant Guidelines for Technical Management of Chemical Process Safety (revised ed.). American Institute of Chemical Engineers (AIChE), 2004. CCPS. Guidelines for Engineering Design for Process Safety, AIChE, 1993, p. 539.
Goodyear Houston Case Study
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