LA Bucket Brigade : Refinery Accident Database

About the Database

Phillips 66 (2418), Belle Chasse

Releases in 2011

LDEQ Accident Number Accident Date	Point Source/Release	Cause	Notes
134825 2011-10-24	Point Source(s): Low Pressure Flare (308F-D-1) Pollutant(s): Sulfur Dioxide - 281 pounds	Cause of Problem: Process Upset The Control Board Operator received a high temperature seal oil alarm from the Fluidized Catalytic (FCC) 1291-K-2 Compressor equipment. Operators were instructed to back flush the seal oil coolers to remove any foulant material which may have accumulated and contributed to seal oil system's high temperature. During the back flushing procedure the seal oil operating differential pressure increased due to the increased viscosity of the cooler oil. Unexpectedly the seal oil's differential pressure began to rapidly decrease below the trip pressure of the compressor causing it to trip off-line. When the 1291-K-2 compressor trips off-line, the FCC fractionator overhead flare valve opens and relieves its gases to the Low Pressure Valve (308F-D-1) until the compressor can be started.	The compressor was restarted shortly after the pressure alarm was cleared and proper differential pressures were reestablished within the compressor's seal oil system. The failed pressure regulator was replaced to minimize repeating another compressor trip due to erratic pressure readings.
133779 2011-09-03	Point Source(s): Flare Pollutant(s): Sulfur Dioxide - 1,695 pounds	Cause of Problem: Weather On 9/3/11 at 12 noon the Coker Unit was reduced to minimal operating dates due to approaching Tropical Storm Lee. This was done in an effort to extend the Coke Drum cycle time by several hours so that refinery personnel would be out of danger and not located on the tail Coke Drum structure during the highest winds of Tropical Storm Lee. The reduction in Coker feed caused the Coker compressor's surge controller kick back valve to rapidly open several times almost tripping the compressor off-line because of this surging affect. During another surge event, the compressor's kickback valve opened rapidly subsequently increasing pressure at the compressor's suction drum above its set point. When this occurred, the console board operator changed the flare valve from automatic control to manual control in an effort to prevent the flare valve from suddenly opening during future compressor surging events. When the board operator put the flare valve in manual control, the valve was already opened at 8% output and the console board operator thought he had placed the valve in manual control when the computer graphic display showed the flare valve at 0% open. When the flare valve opens, the compressor's suction steam is automatically diverted to the Low Pressure Flare (308F-D-1). The Coker compressor did not surge any further after the flare valve's control scheme was changed. The console board operator was unaware that the flare valve remained opened for hours, and when it was discovered opened, the flare valve was immediately closed and returned to automatic control status. A root cause investigation of this flaring event revealed the from the archive history of the Distributed Control System (DCS) that at the same time that the flare valve was put in manual mode it was inadvertently opened to 8% even though the control board operator and his supervisor both reported seeing the DCS Screen display 0% on the valve when it was placed in manual. It was also discovered that ie old DCS system the flare valve had an "output" alarm anytime the valve was at or above 1% open. However during the cutover from the old to the new control system the alarm was not picked up in the migration documental. Had the alarm been in place, it would have benefited the board operator to recognize the flare valve had opened and must be closed immediately. A contributing cause in preventing the board operator from recognizing the flare valve had opened 8% was the fact the board operator, for the next hour, was in a "Major Alarm Flood" (>30 alarms per 10 min period) due to major upsets at the Alkylation Unit (part of the board operator's additional responsibilities) which was enhanced because of very low unit operational rates and ever changing weather conditions from Tropical Storm Lee.	The compressor's suction drum flare valve was closed and its controller was removed from manual control and returned to automatic control. Corrective actions to address the investigation findings are the following: - Review all control valves to the flare for missing output alarm configurations - Establish the compressor's flare valve with a reoccurring high output alarm at its previous set point of 1% open - Alarm Rationalization team shall review and analyze the alarm flood period surrounding this event for possible alarm improvement opportunities. These tasks have been assigned and are scheduled to be completed before the end of 2011. Weather at the time of the event was rainy and cloudy. Wind direction: 197 degrees SSW Wind speed: 20 mph
133792 2011-09-03	Point Source(s): (308F-D-1) Low Pressure Flare Pollutant(s): Sulfur Dioxide - 1,176 pounds	Cause of Problem: Equipment Design On the morning of 9/3/11 around 4:45 am the 191 Crude Unit Fractionator Overhead Accumulator pump was on-line and tripped off-line unexpectedly. Its back up pump was started and put on-line but after only a few seconds it also tripped off-line. Electricians responded and found blown line fuses for both pump's starters. Further electrical meg testing indicated that the 191-L-10A pump was shorted internally but the 191-L-10B pump did not have any phase-to-ground failure. The blown line fuses were replaced and the 191-L-10A pump was restarted but tripped off-libe after running for only a few minutes. The 191-L-10A pump motor was troubleshooted and meg tested by the electricians at the starter, power cabling, and motor field boxes. All test results found no obvious phase-to-phase fault or issues for tripping. The 191-L010A motor starter was ever replaced and still the motor failed and tripped off line within a few minutes. With both critical (191-L-10) Fractionator Overhead Accumulator pumps off-line and unable to start, it was determined that the Crude Unit was to be shutdown. When the Crude Unit shuts down, the Saturated Gas Unit also must shutdown because of loss of its feed from the Crude Unit. Subsequently, various overhead gases from both the Crude Unit and the Diesel Hydrotreater Unit are routed to the Low Pressure Flare (308-D-1) when the Crude Unit must be shutdown quickly. The root cause investigation determined that an oil mist application called the "Lubrimist System" that had been installed on both of the 191-L-10 motors had a design flaw that allowed a fine oil mist to eventually migrate and run into the interior of the motor housing causing a significant buildup of oil and dirt on the motor's stator, windings, and housing area. The 191-L-10 motors are sleeve bearing motors that use internal fans to force air across their windings for cooling. These windings eventually became oil soaked and attract contaminants and moisture from this air flow which are conductive and degrading to the motor's performance. Contamination within the motor windings caused thermal degradation (due to blocked ventilation) and electrical tracking. Electrical tracking enables currents to flow over the surfaces of the windings insulation. These currents degrade and eventually cause the insulation to fail exposing motor wiring that should be insulated, resulting in the motor having a low resistance to ground and ultimate failing. The investigation also determined that the 191-L-10 pumps had been serviced on a frequent basis in the past but their written repair history was not detailed enough that would have enabled maintenance to anticipate and possibly prevent a motor failure.	Several attempts were made to get the alternate Crude Fractionator Overhead Accumulator pump on-line, but it continued to trip electrically off-line. Several electrical parts of the pump were replaced but the pump continued to trip electrically off-line. It was determined that the Crude Unit and its affected downstream units were to be shutdown until the pumps could be brought back on-line without tripping off-line electrically. The Crude Unit and its affected downstream units were shutdown safely. Fence line monitoring was performed with no offsite impacts noted throughout the entire shutdown event. The investigation also determined that the "Lubrimist system" had been installed on other motors within the refinery and their installation designs shall be reviewed and improved in order to minimize the chances of oil and dirt buildup on the motor's stator, windings, and housing area. Another corrective action will be to evaluate and determine the adequacy of installing air filters to minimize containment carry through into the motor housing. Weather conditions at the time of the incident: Rainy and Cloudy Wind Direction: 117 degrees ESE Wind speed: 30 mph
133170 2011-08-17	Point Source(s): Tail Gas Treater/Sulfur Incinerator Stack (591-D-21X) FLARE: Low Pressure Flare (308F-D-1) Pollutant(s): Sulfur Dioxide - 355 pounds Sulfur Dioxide - 375 pounds	Cause of Problem: Equipment Failure During operational adjustments to the air flow to SRU-592 Claus unit, the air blower discharge pressure decreased below the set point and diverted gas from the tail gas treater (TRT) to the SRU incinerator (591-D-21X) to the Low Pressure Flare (308F-D-1).	SRU operations were stabilized allowing the flare valve to be closed and the tail gas to be routed back into the Tail Gas Treater.
132895 2011-08-02	Point Source(s): FLARE: Low Pressure Flare (308F-D-1) Pollutant(s): Sulfur Dioxide - 1,664 pounds	Cause of Problem: Equipment Failure The bottoms control valve malfunctioned and could not be closed allowing the loss of all amine liquid in the contractor vessel (410-V-3). The hydrocarbon carryover prompted the amine flash drum's (591-V-38) flare valve to open to the Low Pressure Flare (308F-D-1).	The amine contractor's bottoms control valve was manually closed to re-establish liquid levels.
132791 2011-07-30	Point Source(s): FLARE: Low Pressure and High Pressure Flares (308F-D-1 and 308F-D-2) Pollutant(s): Sulfur Dioxide - 448 pounds Carbon Monoxide - 219 pounds	Cause of Problem: Equipment Failure The Unit 1291 Fluid Catalytic Cracking (FCC) Unit's slurry pumparound pump (1291 L-6C) deteriorated and was shutdown. This disrupted cooling of the FCC Unit's fractionator tower and this was also shutdown. Overhead gases were routed to the Low Pressure and High Pressure Flares (308F-D-1 and 308F-D-2).	BRQ. No Information given regarding remedial actions because gases were routed through permitted emission points. No SPOC report available. The incident date on the LDEQ report (7/30) and the Incident report (7/31) are different.
131764 2011-06-08	Point Source(s): FLARE-Low Pressure Flare (308-D-1); Crude Unit Towers (191-V-6; 191-V-3) Pollutant(s): Sulfur Dioxide - 466 pounds	Cause of Problem: Instrument Failure The Crude Unit's Vacuum Tower (191-V-6) malfunctioned and the Saturated Gas Unit compressor's first stage suction drum's (7991-V-7) level instrument also malfunctioned. Gas was routed to the Low Pressure Flare (308-D-1).	BRQ. Liquid levels at both the Crude Vacuum Tower and Saturated Gas Compressor suction drum were stabilized and flaring was secured. The incident date from the incident report does not match the SPOC and LDEQ reports. There is an e-mail string between ConocoPhillips and LA gov. regarding this discrepancy. There is a note that material did go offsite in the report.
128975 2011-02-01	Point Source(s): 301-D-3: CO Bypass Stack Pollutant(s): Carbon Monoxide - 9,458 pounds	Cause of Problem: Corrosion LDEQ and refinery letter state that false signals were being sent due to an electrical problem. More specifically, wires were damaged by corrosion due to moisture exposure. A small break in the conduit that contained the wires was found. HV-4 Limit Switch.	RQ. The broken conduit was replaced. A low point drain was installed on the electrical conduit. The system was then returned from manual to automatic.