Animation of Explosion at Tesoro's Anacortes Refinery

WEBVTT
Kind: captions
Language: en

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Narrator: April 2, 2010,
the Tesoro Refinery in Anacortes, Washington.
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A nearly 40-year-old heat exchanger violently ruptures,
causing an explosion and fire that kills seven workers,
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the largest loss of life
at a U.S. refinery since 2005.
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The Chemical Safety Board
launched an investigation
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and determined that the heat exchanger
catastrophically failed
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due to long-term damage from what is
known as high temperature hydrogen attack.
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The Tesoro Refinery in Anacortes is an 800-acre facility
located approximately 70 miles northwest of Seattle.
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The refinery produces a variety of products
including gasoline, diesel, jet fuel and asphalt.
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Within the refinery's naphtha
hydrotreater unit, raw naphtha,
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a light component of crude oil, is treated to
remove nitrogen, sulfur and oxygen impurities.
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Before entering the unit's reactor,
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the raw naphtha and hydrogen and preheated
inside pressure vessels called heat exchangers.
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The unit contains two banks of three heat exchangers
supported by a three-level steel structure.
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Each heat exchanger consists of a
bundle of tubes inside a steel shell.
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Hot fluid exiting the reactor
flows through the heat exchanger shell
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while cool fluid headed for the reactor
flows inside the tubes.
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Heat is exchanged
through the walls of the tubes.
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Every six months the heat exchangers are
taken offline to be cleaned because of fouling,
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a common occurrence when operating
heat exchangers in this type of service.
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As the raw naphtha is heated, a scale-like
material forms and deposits onto the inside of the tubes,
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hindering the transfer of heat
in the exchangers.
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On March 28, 2010, one bank of heat exchangers
was taken offline and disassembled for cleaning
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while the other bank
remained in service.
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This allowed the unit
to continue to operate.
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By mid-afternoon on April 1,
the cleaning was complete
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and operators initiated the startup
of the offline bank of heat exchangers.
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The procedure required an inside board operator
monitoring the control console and one outside operator
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opening and closing
large manually-operated valves.
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But the heat exchangers had a
history of developing leaks during startup,
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something that refinery personnel
had come to see as normal.
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Additional operators from other nearby units
were called upon to assist with the startup,
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including mitigation
of potential leaks.
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By 10:30 p.m. the outside operator was joined by
six workers from other units within the refinery.
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The seven workers were located around the heat
exchangers where startup activities continued past midnight.
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But unknown to the workers, the steel shells of
the middle vessels in both banks of heat exchangers
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had been severely weakened due to cracking
caused by high temperature hydrogen attack.
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This occurs when tiny hydrogen atoms
diffuse into steel at a high temperature,
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then react with carbon in the steel
to form methane gas.
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The larger methane molecules, unable
to diffuse out of the steel, accumulate,
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stressing the steel and
over time causing fissures.
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In both of the middle heat exchangers the fissures grew
and connected to form large internal cracks.
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One such crack was 48 inches long and
extended more than one-third of the way
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through the vessel's
one-inch thick shell.
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Shortly after midnight the temperature of the fluid
exiting the tubes of the online bank of exchangers
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increased about 75 degrees
over the span of three minutes,
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a temperature increase that was typical
and observed in previous startups.
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But the middle heat exchanger was so severely
weakened from high temperature hydrogen attack
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that it likely could not withstand the
stress caused by the rapid temperature increase.
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At 12:35 a.m. employees working at a
nearby process unit heard a loud hissing noise,
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and vapor began to leak as the heat exchanger
cracked at its weakest point.
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Seconds later the
exchanger violently ruptured.
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Hot hydrogen and naphtha vapor rapidly vented from the
exchanger and spontaneously ignited upon contact with air,
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resulting in a massive fire that
consumed the heat exchanger structure.
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Three of the seven operators
died at the scene.
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The other four operators were transported
to local burn centers with severe injuries.
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Two died within hours.
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The other two
succumbed within days.
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