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Case 11 Date: 16.11.2019 Time: 10:10 hrs.
Incident
While dismantling 10-PA-SC-01A (Bitumen R/D pump), bitumen product came out from the suction flange of
the pump, resulting in smoke and spillage of Hydrocarbon in nearby area. Parallel activity of reactor outlet line
flushing while opening of suction flange of the pump for dismantling from foundation was going on. As FLO is
lighter HC and having pressure in the range of 8-9 kg/cm2, this FLO could have passed through the suction
valve (which was not tightly closed) and spilled through the flange along with bitumen.
Root Cause
Execution of two Parallel activity of conflicting nature.
Recommendations
1. Avoid any parallel activity in associated equipment, which may alter the working condition.
2. For handing over of equipment, where positive isolation is not possible and product has tendency to
congeal, drain line is to be checked for choking and it is to be ensured that the line is properly
flushed/purged.
Case 12 Date: 19.11.2019 Time: 21:0 hrs.
Incident
During normal shift round in PSV platform area at 21:00 hrs an abnormal sound observed near to 06-V-203.
High LEL and Hydrogen observed at V-203 top platform and on checking, leak identified at a flange in
06-V-203 O/L line to reformer off gas which is not in use and kept blinded near control valve 06-FV-1007.
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