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Giant Industries Refinery Explosions and Fire

Overview

On April 8, 2004, a sudden release of flammable liquid occurred at Giant Industries' Ciniza oil refinery in Jamestown, NM, during maintenance on an alkylate recirculation pump in the hydrofluoric acid (HF) alkylation unit. The release ignited and caused fire and explosions. Six employees were injured. Refinery equipment and support structures were damaged. Non-essential employees and nearby customers were evacuated.

Incident Snapshot

Field Value
Facility / Company Giant Industries
Location Gallup, NM
Incident Date 04/08/2004
Investigation Status The CSB issued a case study report on this accident on October 26, 2005.
Accident Type Oil and Refining - Fire and Explosion Investigation Status
Final Report Release Date 10/26/2005

What Happened

  • The day before the incident, alkylation unit operators attempted a regularly scheduled switch of the alkylate recirculation pumps in the Iso-Stripper unit.
  • The primary electric pump was to be taken out of service and the spare steam-driven pump started up.
  • The switch was scheduled because of recurring problems with the spare pump’s mechanical seal leaking.
  • While attempting to put the spare pump in service, operators found it would not rotate.
  • The next morning, the maintenance supervisor assigned a mechanic specialist and a mechanic to repair the seal on the spare pump.
  • An operator prepared a work permit that outlined the work to be done and the safeguards required for a safe repair.
  • The operator relied on the valve wrench to determine that the suction valve was open and moved the wrench to what was believed to be the closed position with the wrench perpendicular to the flow of product.
  • The valve was actually open.
  • The mechanic noticed that the valve position indicator on the suction valve body showed that the valve was open.
  • The plant operator placed tags and locks on the suction and discharge valves to prevent inadvertent opening and to indicate that the valves had been closed.
  • The mechanic specialist then placed tags and locks on the suction and discharge valves.
  • The operator disconnected the pump’s vent hose to verify that no pressure was in the pump case.
  • The low point drain plug was not used because it was not equipped with a valve to isolate it from the line used for depressuring the pump.
  • After uncoupling the hose at the connection to the flare line, a stream of alkylate flowed from the pump housing through the hose and subsided after a few seconds.
  • The operator and the maintenance mechanics believed the pump had been depressured and was ready for removal.
  • Actually, the vent line was plugged, and the pump was not depressured.
  • The pump shaft coupling and the flange connecting the pump to the pump case were unbolted.
  • As the pump case flange was separated, alkylate was suddenly released at about 150 pounds per square inch gauge (psig) and 350 degrees Fahrenheit.
  • The release produced a loud roaring sound that could be heard throughout the refinery.
  • The mechanic was blown over an adjacent pump and suffered broken ribs.
  • Material was blown into the mechanic specialist’s eyes, so he made his way to an eyewash station, cleared his eyes, and then quickly exited the unit.
  • Alkylate, which covered the plant operator’s clothing, quickly ignited, seriously burning the operator in the ensuing fire.
  • About 30 to 45 seconds after the initial release, the first of several explosions occurred.
  • The refinery’s safety officer advanced towards the release in an attempt to turn on a fire monitor to suppress escaping vapors.
  • He was caught in the fire and injured.
  • Two other workers suffered slight injuries escaping the area.

Facility and Process Context

  • The parent company, Giant Industries Arizona, Inc., which is headquartered in Scottsdale, AZ, owns and operates the Ciniza refinery in Jamestown, NM.
  • Subsidiaries of Giant Industries Inc. own and operate refineries in Bloomfield, NM and Yorktown, VA.
  • The incident occurred at the refinery’s hydrofluoric acid (HF) alkylation unit.
  • HF, a highly hazardous, toxic, and corrosive chemical, is used as a catalyst in the alkylation process.
  • In HF alkylation, olefin and isobutane feedstocks are combined, then mixed with HF in a reactor vessel, where the alkylate forms.
  • The Giant Ciniza refinery is located 17 miles east of Gallup, NM, and processes up to 22,000 barrels of crude oil per day.
  • The refinery was purchased by Giant Industries in 1982.

Consequences

  • Fatalities: None reported.
  • Injuries: The incident injured six employees.
  • Environmental release: The document states there was a sudden release of flammable liquid; no significant amount of HF was released in this incident.
  • Facility damage: Refinery equipment and support structures were damaged. Damage to the unit was in excess of $13 million.
  • Operational impact: Production at the unit was not resumed until the fourth quarter of 2004. The incident caused evacuation of non-essential employees as well as customers of a nearby travel center and truck stop.

Key Findings

Immediate Causes

  • As the pump case flange was separated, alkylate was suddenly released at about 150 pounds per square inch gauge (psig) and 350 degrees Fahrenheit.
  • The vent line was plugged, and the pump was not depressured.

Contributing Factors

  • The operator relied on the valve wrench to determine that the suction valve was open.
  • The valve was actually open.
  • The mechanic noticed that the valve position indicator on the suction valve body showed that the valve was open.
  • The low point drain plug was not used because it was not equipped with a valve to isolate it from the line used for depressuring the pump.
  • The operator and the maintenance mechanics believed the pump had been depressured and was ready for removal.
  • The valve wrench collar was installed in the wrong position.
  • Some plant employees used the wrench to determine valve position, partly because the wrench was much more visible than the actual valve position indicator.
  • They had not adequately verified that the pump was isolated or drained before locking and tagging it out.

Organizational and Systemic Factors

  • Giant’s mechanical integrity program did not effectively prevent these repeated failures of the pump seals.
  • Giant’s approach to these frequent pump seal problems was an example of breakdown maintenance.
  • Giant management did not investigate why excessive iron fluoride generation in the process caused the mechanical seals on the alkylate recirculation pumps to fail repeatedly.
  • Giant did not consider the design or engineering safety implications of changing from a gear-operated valve actuator to using a wrench as a valve handle.
  • Giant’s use of the wrench instead of the original valve actuator was a significant equipment change and should have been included in the company’s MOC program.
  • Effective LOTO procedures include specific requirements for testing machines to determine and verify the effectiveness of lockout devices, tagout devices, and other energy-control measures.
  • The facility lacked procedures to verify that the pump had been isolated, depressurized and drained.

Failed Safeguards or Barrier Breakdowns

  • The valve position indicator on the suction valve body showed that the valve was open, but the operator relied on the valve wrench.
  • The plant operator placed tags and locks on the suction and discharge valves, but the pump was not adequately verified as isolated or drained.
  • The low point drain plug was not used.
  • The vent line was plugged.
  • The pump was not depressured.
  • The valve wrench collar was installed in the wrong position.
  • An MOC hazard analysis was not conducted.
  • The facility lacked procedures to verify that the pump had been isolated, depressurized and drained.
  • Giant’s mechanical integrity program did not effectively prevent repeated pump seal failures.

Recommendations

  1. Recommendation 1
  2. Recipient: Not specified in the provided extract
  3. Status: Not specified in the provided extract
  4. Summary: Not specified in the provided extract

Key Engineering Lessons

  • Lockout/tagout programs should require effective verification that equipment has been isolated, depressurized and drained.
  • Mechanical integrity programs should prevent breakdown maintenance.
  • A significant equipment change, such as substituting a wrench for the original valve actuator, should be included in management of change review.

Source Notes

  • Consolidated from the provided final report extract only (source_priority 1).
  • Location in the final report is given as Jamestown, NM; incident metadata provided by the crawler lists Gallup, NM and was not used where it conflicted with the higher-priority source.
  • The final report extract states no significant amount of HF was released.
  • https://www.csb.gov/giant-industries-refinery-explosions-and-fire/

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