Appendix C: Safety Article Review

Heat Exchanger Rupture and Ammonia Release in Houston, Texas. U.S. Chemical
Safety Board. January 2011. Available at
http://www.csb.gov/assets/1/19/Case_Study.pdf. Accessed October 13, 2014.

On June 11, 2008, a heat exchanger ruptured at the Goodyear Tire and
Rubber Company plant in Houston, Texas. The shell- and- tube heat exchanger
was used to cool synthetic rubber chemicals with anhydrous ammonia. Goodyear
maintenance workers replaced a rupture disk underneath the relief valve on the
heat exchanger on the afternoon of June 10, 2008. Before the maintenance work
began, an isolation valve was closed between the heat exchanger and the relief
valve. ButHowever, once when the rupture disk was replaced, the isolation valve
was not reopened to allow excess pressure to escape the heat exchanger.
The next morning, an operator cleaned the piping by connecting a steam line
to the process line and closing a valve to isolate the heat exchanger from the
ammonia pressure control valve. The pressure in the heat exchanger increased
until it surpassed the operating limit, causing the heat exchanger shell to rupture.
Flying debris killed one employee and released ammonia gas injured five other
employees. A lack of organization in emergency response prevented the discovery
of the employee injured by debris until almost six hours after the incident.
Several major problems in the Goodyear safety protocol contributed to the
severity of the ruptured heat exchanger. The first issue was the lack of emergency
drills conducted at the plant. Emergency drills had not been performed in the four
years leading up the accident, and some employees were not fully trained on
emergency procedures. The second problem was the inefficient alarm system.
Only location specific alarms were sounded when an emergency alarm was pulled.
In this situation, theThe alarm could not be reached due to the released ammonia,
so the emergency situation was communicated by radio and word of mouth. The
reason the injuredinjured employee was not found for several hours was due to
athe lack of employee accountability. The badge tracking computer system
malfunctioned, and delayed delaying the accounting of all employees. The
employee injured by debris was a member of the response team, so her absence
was not counted as unusual or alarming. The primary maintenance safety concern
was the lack of documentation of work being done on the heat exchanger. ; tThe
closed safety relief valve was only recorded on a handwritten note.
This incident demonstrates the importance of being prepared for
emergencies by conducting regular drills, having an organized way to account for
all employees, and thorough documentation of all maintenance work being done on
equipment.