IR03 DETAILED INVESTIGATION REPORT

Incident Category Near Miss Incident Incident Sub Category Near Miss

Report Code NMI-NM-68-Nitric Acid-2017 Report Target Date 1/5/2018

Employee Type FFL Contractor Name

Date of Incident 12/15/2017 Time of Incident 08:30

Incident Score 55 Repeated Incident No

Plant / Unit Nitric Acid Section Absorption Area

IRRC Score Attachments View

Description

Cooler condenser-I (H-107B) shell near its welding joint with H-113D (BFW preheater) observed slightly bulged during
field visit.

Action Taken

Shell thickness was measured and found normal. Expansion bellow installed at upstream of H-113D observed deformed
and expanded state.

Sequence Of Events

15-12-17: The observations were taken by Field Maintenance Supervisor during field visit of H-107B after repair carried
out on H-113D to H-107B nozzle joint repair during catalyst campaign. Bulging / depression was visually identified.
15-12-17: Expansion bellow on upstream of H-113D was also seemed to be deformed inside insulation by Maintenance
team.
16-12-17: Insulation was removed by Maintenance team from the bellow and angular deformation was found. 01 tie rod
(north) was found fully tight whereas there was looseness in other 02 tie rods.
16-12-17: Inspection team was involved to take the observation, physically dimensions were taken.

Key Findings
Normal working pressure at expansion bellow is 3.5-3.6 kg/cm2 @108% load; whereas the designed pressure for
expansion bellow is 4.7 kg/cm2. Normal working temperature is 170-180 degC which is within limits.
H-113 tube side service is NOx and shell side is Demin. water (inlet 43 degC & Discharge 119-121 degC). No pressure
and temperature variations are observed in any H-113 A/B/C/D. No physical isolation is present upstream of H-113 and
no flow restrictions were observed.
Repair on H-113D joint to H-107B was carried out in Catalyst campaign in Nov, 17. This was a temporary repair and
complete joint was not grinded. However complete reinforcement pad was removed and new reinforcement pad was
installed. Work was carried out as per Inspection Guidelines.
During the repair period the upstream expansion bellow was not locked, also no external supports were arranged for
H-113D (4.5 Ton weight) which directly created uneven loading on H-107B joint during this period. Also, no checks were
mentioned regarding expansion bellow in repair procedure of joint leakage.
Slight depression is observed on the shell near the reinforcement pad on H-113D to H-107B joint. Measurements were
taken on all sides of the reinforcement pad and a depression of 13mm is observed on southern side.
Thickness of the shell is carried out at multiple locations and no thickness loss was observed on the depression area i.e.
16mm.
Verticality of H-113D was also measured and a tilting of 45mm was observed at south east side. This created uneven
loading on H-107B shell.
The expansion bellow is "Tied Universal Expansion Joint", it can bear lateral and angular movement which is of the
correct design. OEM is "Bird Precision Bellows Limited, UK" which was installed in Norsk Hydro Fertilizer.
Dimensional checks of the all expansion bellows were carried out by Projects and inspection. It was revealed that lateral
movement of 45mm is observed of expansion bellow at upstream of H-113D. This is within limits as per OEM datasheet
(acceptable lateral movement +/-50mm).
Angular movement is observed between north and south side (overall 30mm in hot state flange to flange) of H-113D
which is greater than angular movement observed in H-113A/B/C.

Contributing Factors

Repair procedure did not cover expansion bellow locking.

After the removal of reinforcement pad, direct uneven loading of H-113D was exerted on H-107B joint resulting in
depression of shell.
No inspection plan is available for Expansion bellows.

Key Factors

During repair of H-107B to H-113D joint leakage in catalyst campaign, the expansion bellow was not locked; also no
support provision was envisaged for direct loading of H-113D on H-107B joint. Hence, during welding shrinkage,
H-113D tilted creating stress on H-107B shell and lateral / angular deformation in expansion bellow.
The repair was TEMPORARY REPAIR and was carried out as per Inspection Guidelines.

Investigations / Inerviews

Noor Hasan (Maintenance Supervisor) He shared that insulation on expansion bellow at upstream of H-113D was not
removed during catalyst campaign and no work was done in Nov, 17 outage on the expansion bellow. He initially
pointed out the deformation in expansion bellow.
Shafqat-ur-Rehman (Inspection Supervisor) He stated that no job was performed on H-113D and its expansion bellow
after TA-15 till date. H-113D outlet spool replacement was carried out in TA-15. All inspection NDTs were performed.
He also carried out the inspections / dimensional checks of expansion bellow.
Muhammad Javed Akhtar (Sub Engineer) He was responsible of H-113D outlet spool replacement in TA-15. He shared
that the expansion bellow was locked with tie rods bolts and extra reinforcements during this activity. However, no
record of lateral movement / verticality of expansion bellow was maintained.
Azm-ul-Haq (NA shift Engineer) He gave the data related to H-113 & H-107.
Qadir Dino (Boardman - Supervisor) He shared that previously no operational upsets in the parameter of H-113 and
H-107 were observed before and after catalyst campaign in Nov, 17. The plant is currently running at 108% load
however all parameters are within limits.
Ultaf Rasool (Draftsman) He took dimension of expansion bellows in cold and hot conditions.
Ghulam Ahmed (Project Engineer) He prepared the drawings for H-107B and H-113D upstream bellow.
 Reason for sending the report late (if applicable)

Basic Activity in Progress

Normal Operation

Risk / Culture Based PSM Elements violated

Management of Change - Facilities,

Root Cause

During welding shrinkage, H-113D tilted creating stress on H-107B shell and lateral / angular deformation in expansion
bellow.

Responsible Department for Incident (As per Investigation)

Technical Services Department

Detailed Report
Team Lead Danish Ahmed/MFG/FFL/SDQ Submission Date 12/22/2017

Team Members

Fahad Siddiqui/MFG/FFL/SDQ

Approving Authority Aleem Ansari/MFG/FFL/SDQ Reviewed By HSE

UM/Engineer
Recommendation Recommendation Responsible Responsible Responsible Target Date Status
No Description Person Department Section
003358-INSP- Detailed repair fatima-group Technical Services Inspection 5/31/2018 In
TSD procedure/ work \ghulam.ahma Department Progress
instruction to be d1
developed for
handling
expansion joints
during repair /
modifications
carried out on
associated piping.
003359-INSP- Risk based audit fatima-group Technical Services Inspection 3/31/2018 Complete
TSD plan of high \danish.ahme Department d
temperature / d
plant critical
expansion bellows
of entire site to be
prepared.
003360-NA-EM- Tilting of H-113D fatima-group Maintenance Nitric Acid 4/30/2019 In
MAINT to be rectified by \fahad.siddiqu Equipment Progress
proper grinding i Maintenance
& welding of
H-113D to H-107B
nozzle joint.
003361-PROJ-E- Proper thorough fatima-group Technical Services Project 3/31/2018 In
TSD repair procedure \ghulam.ahma Department Engineering Progress
for H-113D to H- d1
107B joint to be
prepared.