Skip to content

Goodyear Heat Exchanger Rupture

Overview

On June 11, 2008, at The Goodyear Tire and Rubber Company plant in Houston, Texas, a heat exchanger ruptured during a maintenance operation when ammonia overpressured inside the exchanger. One worker was killed and six workers were injured. The rupture released ammonia. The incident also exposed breakdowns in work order, lockout/tagout, and emergency accountability systems.

Incident Snapshot

Field Value
Facility / Company The Goodyear Tire and Rubber Company
Location Houston, TX
Incident Date 06/11/2008
Investigation Status The CSB investigation is completed.
Accident Type Chemical Manufacturing - Fire and Explosion Investigation
Final Report Release Date 01/27/2011

What Happened

  • 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 over-pressure protection.
  • Maintenance workers replaced the rupture disk that day. 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.
  • 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 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. 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.
  • The Emergency Operations Command (EOC) declared all Goodyear employees accounted for at about 8:40 a.m.
  • Accounting for the contract employees continued until about 11:00 a.m., at which time the EOC ended the plant-wide evacuation and disbanded.
  • Only the immediate area involved in the rupture remained evacuated.
  • At about 1:20 p.m., an operations supervisor assessing the damage to the incident area discovered the victim buried in rubble in a dimly lit area and contacted City of Houston medical responders.

Facility and Process Context

  • The Goodyear Tire and Rubber Company plant is in Houston, Texas.
  • The Houston facility, originally constructed in 1942 and expanded in 1989, produces synthetic rubber in several process lines.
  • The facility includes separate production and finishing areas.
  • In the production area, a series of reactor vessels process chemicals, including styrene and butadiene.
  • Heat exchangers in the reactor process line use ammonia to control temperature.
  • Goodyear uses three ammonia heat exchangers in its production process lines.
  • The ammonia cooling system supplies the heat exchangers with pressurized liquid ammonia.
  • A pressure control valve in the vapor return line maintains ammonia pressure at 150 psig in the heat exchanger.
  • Each heat exchanger is equipped with a rupture disk in series with a pressure relief valve, both set at 300 psig, to protect the heat exchanger from excessive pressure.
  • The relief system vented ammonia vapor through the roof to the atmosphere.

Consequences

  • Fatalities: 1 worker was killed.
  • Injuries: 6 workers were injured.
  • Environmental release: Ammonia was released.
  • Facility damage: The heat exchanger violently ruptured. Debris blocked access to the area immediately surrounding the heat exchanger. The victim was discovered under debris in a dimly lit area.
  • Operational impact: Goodyear evacuated the plant. The EOC ended the plant-wide evacuation and disbanded. Other areas of the facility resumed operations while the immediate area involved in the rupture remained evacuated.

Key Findings

Immediate Causes

  • 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.
  • This isolated the ammonia side of the heat exchanger from all means of over-pressure protection.

Contributing Factors

  • Workers told the Chemical Safety Board (CSB) that such drills had not been conducted in the four years prior to the June 11, 2008 incident.
  • Some employees had not been fully trained on these procedures.
  • Some workers reported that the system was unreliable.
  • Ammonia vapor released from the ruptured heat exchanger and water spray from the automatic water deluge system prevented responders from reaching the alarm pull-box in the affected process unit.
  • A malfunction in the badge tracking system delayed supervisors from immediately retrieving the list of personnel in their area.
  • Handwritten employee and contractor lists were generated, listing the workers only as they congregated at the muster points or sheltered in place.
  • Not all supervisory and security employees, who were to conduct the accounting, had been trained on them.
  • Some of the employees responsible for accountability were unaware prior to the incident that their jobs could include this task in an emergency.
  • Area supervisors did not consider her absence from the muster point unusual.
  • Operators reported that maintenance personnel did not always obtain production operators’ signatures as required.
  • Work order documentation was not kept at production control stations.
  • Operators used the lockout/tagout procedures to manage the work on the heat exchanger rupture disk, but did not clearly document the progress and status of the maintenance.
  • Information that the isolation valve on the safety relief vent remained in the closed position and locked out was limited to a handwritten note.
  • Whether this occurred during the June 10 dayshift is unclear, and Goodyear was unable to produce a signed copy of the work order.
  • Goodyear’s maintenance procedures did not address over-pressurization by the ammonia when the relief line was blocked.
  • It did not require maintenance and operations staff to post a worker at the vessel to open the isolation valve if the pressure increased above the operating limit.

Organizational and Systemic Factors

  • Goodyear maintained a trained emergency response team, which attended off-site industrial firefighter training, conducted response drills based on localized emergency scenarios, and practiced implementing an emergency operations center.
  • Other employees received emergency preparedness training primarily as part of their annual computer-based health and safety training.
  • Goodyear procedures required that a plant-wide evacuation and shelter-in-place drill be conducted at least four times a year.
  • Operating procedures discussed plant-wide alarm operations and emergency muster points for partial and plant-wide evacuations. Some employees had not been fully trained on these procedures.
  • Facility operating procedures also outlined Goodyear’s worker emergency accountability scheme.
  • The CSB found evidence of breakdowns in both the work order and lockout/tagout programs that contributed to the incident.
  • Communicating plant conditions between maintenance and operations personnel is critical to the safe operation of a process plant.
  • Good practice includes formal written turnover documents that inform maintenance personnel when a process is ready for maintenance and operations personnel when maintenance is completed and the process can be safely restored to operation.

Failed Safeguards or Barrier Breakdowns

  • Plant-wide alarm system
  • Emergency alarm pull-boxes
  • Employee tracking system
  • Work order system
  • Lockout/tagout procedures
  • Rupture disk in series with a pressure relief valve
  • Automatic pressure control valve
  • Over-pressure protection
  • Plant-wide evacuation and shelter-in-place drill
  • Formal written turnover documents

Recommendations

  1. Recommendation ID: Not provided. Recipient: Not provided. Status: Not provided. Summary: The final report excerpt did not include formal CSB recommendations.

Key Engineering Lessons

  • Do not isolate a pressure relief path without ensuring an equivalent, reliable means of over-pressure protection remains available.
  • Maintenance and operations handoff must clearly document the status of isolation valves, lockout/tagout conditions, and readiness to return equipment to service.
  • Procedures for maintenance on equipment that can be pressurized by adjacent process conditions must explicitly address blocked relief lines and credible over-pressurization scenarios.
  • Emergency accountability systems must be reliable enough to support rapid and accurate personnel accounting during a plant-wide evacuation.

Source Notes

  • Consolidated from the final report (source_priority 1) only; no lower-priority source was needed to resolve conflicts.
  • The final report excerpt did not include formal CSB recommendations, so the recommendations array remains an empty template object.
  • All facts are limited to the provided source text; no external information was added.

Similar Incidents

Incidents sharing the same equipment, root causes, or hazard types.

Same Equipment

Same Root Cause

  • MFG Chemical Inc. Toxic Gas Release — Shared failure mode: Communication Failure · Emergency Response Failure · Operator Error · Procedural Failure · Relief System Failure · Training Deficiency
  • Sodium Hydrosulfide: Preventing Harm — Shared failure mode: Communication Failure · Emergency Response Failure · Maintenance Error · Operator Error · Procedural Failure · Training Deficiency
  • Formosa Plastics Vinyl Chloride Explosion — Shared failure mode: Communication Failure · Emergency Response Failure · Operator Error · Procedural Failure · Training Deficiency
  • Hazards of Nitrogen Asphyxiation — Shared failure mode: Communication Failure · Emergency Response Failure · Operator Error · Procedural Failure · Training Deficiency
  • Technic Inc. Ventilation System Explosion — Shared failure mode: Communication Failure · Emergency Response Failure · Maintenance Error · Operator Error · Procedural Failure · Training Deficiency

Same Hazard

← View in Knowledge Graph