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20558 Chemical accident in USA with hydrogen (gas)
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General accident information
Class/Quality * * *
Year 2002
Summary High pressure bleed valve on lactitol
Hydrogenation unit at sugar plant was not
Listed on l/T checklist causing release of
Hydrogen and small fire
Country USA
Activity PROCESSING
Location CHEMICAL FACTORY
Chemicals Catalyst, Hydrogen (gas), Hydrogen (gas), Lactitol (sugar alcohol)
Cause Management-failure
Fatalities/Injuries 0 / 0
Occurrences or events Fire, Fire fighting/Emergency response, Ignition, Management-failure,
Mix, Release, Replace, Wrong-action,
Wrong-action
 
 
Full accident information 
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Country: UNITED STATES OF AMERICA (USA)
Date : 2002 0321


A small fire occurred after a high pressure bleed valve was replaced on a lactitol hydrogenation unit. A small amount of catalyst and hydrogen leaked and spontaneous ignition occurred. All gas detectors alarmed in the hydrogenation unit. A bleed valve was found open which was not listed on L/T checklist.
The facility has an incident investigation procedure. All incidents are documented and reviewed to determine the appropriate preventive measures. These investigations occur within forty-eight hours of the incident and involve an incident investigation team that consists of representatives of the operations staff, management, and nay contractors that may provide expertise in the investigation. Any recommendations made by the investigation team are acted upon by the facility as soon as possible. All incident investigation reports are maintained for at least five years.
The facility has a work permit procedure which includes hot work permitting. This procedure is compliant with the RMP requirements.
The company owns and operates the hydrogenation facility. It produces hydrogenated sugars (xylitol, xylose, rhamnose, mannose, glactose and lactitol) for commercial and industrial uses. The facility stores one chemical in excess of the threshold quantities listed in the US EPA Accidental Release Protection Regulations in the Clean air Act Section 112r. The facility is located in a rural agricultural setting. A river is located approximately 1.6/km west of the facility. Approximately 4.8/km south of the facility is a village. A city is located approximately 11.2/km north of the facility. The facility was built in 1979, and started up in 1980 producing crystalline fructose. In the year 2000, rare sugar development was initiated.

Lessons learned
1.
Maintenance procedures were revised to ensure proper installation of high pressure valves.
2.
Follow-up meeting reviewed and updated L/T checklist.




 
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