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UreaKnowHow.com Urea Incident Database:

Share for Safety

Conference Paper · September 2015

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 UreaKnowHow.com
Urea Incident Database:
Share for Safety
Incidents happen in the chemical Industry. Many of these incidents do not surface but one should be
aware of the fact that every incident has a learning factor and may avoid another incident in the
future. UreaKnowHow.com has a Urea Incident Database in which the incidents are described and
welcomes everybody to share an incident, anonymous or not in order to avoid a new incident.
Sharing incidents will increase the safety of the industry.
Avoiding incidents is of key interest for all stakeholders in the industry.

Jo Eijkenboom
UREAKNOWHOW.COM

Mark Brouwer
UREAKNOWHOW.COM

measures are provided to avoid these incidents

from happening again in the future.
Purpose
Introduction

T his paper categorizes known incidents in

the urea industry and draws conclusions regard-

History shows that organizations do not have a
memory. Incidents often repeat themselves and
often are not shared. UreaKnowHow.com is an
internet platform facilitating communication
ing causes, which are common in several inci- between all urea plants worldwide with the tar-
dents. Also, lessons learned and practical get to improve safety and performance in the
urea industry. UreaKnowHow.com has estab-
lished an Incident Database to facilitate the shar- 10. Incident 10-001: Fire in compressor section
ing of incidents. urea plant  
11. Incident 09-002: HP gas pipeline ruptured  
UreaKnowHow.com’s Urea Incident Database 12. Incident 05-002: Rupture HP flange connec-
currently contains more than 45 incidents, rang- tions  
ing from severe explosions with casualties to 13. Incident 09-001: Accident during Prill tower
near misses. We are also aware of the fact that construction  
because most incidents are not reported, the da- 14. Incident 05-001: Urea Reactor explosion  
tabase cannot be considered a complete collec- 15. Incident 04-001: Failure Reactor 200 mtpd  
tion of all incidents. This Urea Incident data- 16. Incident 02-002: Two people suffocate due
base describes incidents and near misses as far to welding gas  
as known and reported. It also gives a possibil- 17. Incident 02-001: Casualties during prill tow-
ity to anonymously report incidents. We hope er cleaning  
and trust this database will avoid future inci- 18. Incident 01-002: Casualty valve mainte-
dents in our industry. This Urea Incident Data- nance  
base can be found on the UreaKnowHow.com 19. Incident 00-001: Catastrophic failure of a
Round Tables weld-o-let  
(http://www.ureaknowhow.com/ukh2/round- 20. Incident 98-002: NH3 leak in urea plant  
table/viewforum.php?f=33). 21. Incident 98-001: HP Pump NH3 leak  
22. Incident 97-001: Fire in Cooling Water
We urge all urea producers worldwide to share Tower  
more frequently their incidents and near misses 23. Incident 95-001: Urea Reactor explosion  
to fellow urea plants for the benefit of all. This 24. Incident 93-001: NH3 leak in urea plant dur-
Incident Database is the right place to file an ing shutting down  
irregularity. This paper will finally provide an 25. Incident 92-003: HP NH3 pump NH3 leak  
example of such a success story. 26. Incident 92-002: NH3 gas explosion NH3
pump  
Find below the list of the incidents described in 27. Incident 92-001: Urea Reactor explosion  
the UreaKnowHow.com Urea Incident Database 28. Incident 91-001: HP stripper explosion  
to date (March 2015): 29. Incident 90-001: Reactor explosion  
30. Incident 87-001: Urea Melt splashes on per-
1. Incident 14-001: Fatality during hot bolting   son  
2. Incident 13-001: Fatal liquid NH3 pipeline 31. Incident 79-001: Reactor leak  
leak   32. Incident 78-001: Urea Reactor Leak  
3. Incident 12-001: Failure of bends in HP car- 33. Incident 77-001: Urea Reactor explosion  
bamate gas lines   34. Incident 74-001: HP scrubber explosion  
4. Incident 11-003: Rupture HP gas line   35. Incident XX-012: Anhydrous NH3 Sam-
5. Incident 11-002: Fire   pling procedure benchmarking  
6. Incident 11-001: Dismantling pressure 36. Incident XX-011: Leak in liquid NH3 pipe-
gauge of HP flush pump   line  
7. Incident 10-004: Lump falling down from 37. Incident XX-010: CO2 can ignite a flamma-
prill tower   ble mixture  
8. Incident 10-003: Corrosion HP NH3 line 38. Incident XX-009: Leak in liquid NH3 pipe-
due to backflow   line  
9. Incident 10-002: Twisted Butterfly Valve   39. Incident XX-008: Fall of scaffold from
height  
40. Incident XX-007: Explosion CO2 vent pipe Note the significant difference between equip-
ex CO2 compressor   ment and piping when one considers corrosion
41. Incident XX-006: Leak HPCC tube causes inspection:
corrosion tubesheet   - High pressure equipment is designed in such a
42. Incident XX-005: Collapsed wooden Cool- way that all parts in contact with the process
ing Towers   can be inspected during a turnaround and all
43. Incident XX-004: Rupture Urea Reactor due urea producers do these inspections. Con-
to Nitrate SCC   versely most of the high pressure piping can-
44. Incident XX-003: Severe nitrate SCC Urea not be inspected from the process side as it is
reactor   simply not accessible. Inspection techniques
45. Incident XX-002: Severe corro- of pipe line systems also have its limitations.
sion HP NH3 pipeline   - When manufacturing High Pressure equip-
46. Incident XX-001: Rupture HP ment, welds are executed in a workshop under
CO2 line   ideal conditions, while many welds in high
pressure piping are executed in the field. Of-
The Incident number format is following: Year- ten these welds are done in difficult positions
Sequential number. XX means the year is not and under difficult circumstances that impede
known. the required and necessary quality.
- It is not yet common practice to perform cor-
Overlooking all incidents, one can conclude that rosion inspections to high pressure piping,
the safety risks in a urea plant are related to: valves and accessories on a regular basis. Al-
• High pressures so the execution of the inspection of a piping
• Corrosive properties of ammonium- system is time consuming, and the interpreta-
carbamate tion of the inspection results is not that sim-
• Ammonia release ple.
• Atmospheric corrosion, Corrosion under
insulation

Analyzing more in detail the incidents of the General measures and attention
UreaKnowHow.com database shows that some points to avoid / minimize high
35% of the incidents are related to the high pres- pressure equipment and piping
sure equipment, some 40% to high pressure pip- incidents in urea plants1)
ing, valves and accessories, and some 25% to
others such as cooling towers, prill towers and During the design and engineering phase one
compressors. should pay attention to:
- Correct choice of materials of construction
It is our firm belief that fairly simple measures according to licensor’s specification; or bet-
and adhering to some critical points of attention ter, choose a more corrosion resistant materi-
can avoid a significant part of these incidents. al of construction in certain cases
In this paper we will summarize these critical - Design avoiding crevices and dead legs. In-
points for high pressure equipment and high stall a state of the art leak detection system
pressure piping and valves for each phase of the (active system with a continuous analysis) in
lifetime of a urea plant. equipment with a loose liner or at other areas
where it is needed.
- Specify application of adequate coating sys- - A continuous check on proper functioning of
tems in case of risk of atmospheric corrosion Leak Detection System
(chlorides, nitrates and sulphides) - The blow down steam/condensate of HP heat
- Specify adequate insulation/tracing system to exchangers to be monitored on conductivity,
avoid ingress of moisture and condensation of pH and chloride content
gas phases - In case of any doubt analyze end product for
- Lay-out of grass root plant with location of Nickel content
cooling towers opposite prevailing wind direc- - Proper inspection/maintenance of insula-
tion tion/tracing systems to avoid ingress of mois-
ture and condensation of gas phases
During the fabrication, construction, storage and - In case of a leak, stop the plant and repair the
shipping phase one should pay attention to: leak
- Quality control of materials of construction
according to licensor’s specification. The use
of Positive Material Identification (PMI) tech-
niques in this stage is unavoidable
- Guidance and control during manufacturing of
equipment and erection of plant
- Choose qualified and experienced fabricators.
- Maximize prefab welding of high pressure
piping and make use of qualified and experi-
enced welders
- Guidance and control during application of Let’s analyse a specific case of a high pressure
coating and insulation systems piping incident and see which lessons can be
- Guidance and control during pressure testing drawn.
and flushing of equipment
- During storage and transport/shipment in a
chloride-containing atmosphere the equipment Case Study 1: General measures
should be inerted with nitrogen and attention points - Incident with
a weld-o-let in a pipeline1)
During operation and maintenance phase one
should pay attention to: Just before a planned plant turn around in the
- Proper operation within the windows of li- year 2000, a leak occurred in a 316L Urea grade
censer’s manual weld-o-let present in a 8 inch diameter 316L
- Perform regular inspections based on Risk Urea Grade High Pressure pipe line between the
Based Inspection philosophy to be able to set Urea Reactor and the HP stripper.
up predictive maintenance programs For ex-
ample for HP piping one can consider to in- Figure 1 shows the exact location of the weld-o-
spect high pressure carbamate gas lines for let while Figure 2 shows the corroded areas
condensation corrosion and weld-o-lets for where the material of this weld-o-let failed.
higher corrosion rates.
- Perform maintenance/repair according to
specifications
- Continuous monitoring to be performed on
addition of oxygen in CO2 supply
 During the preparations for the installation of
such clamp, the weld-o-let ruptured, a substan-
tial amount of process fluid consisting of am-
monium carbamate solution at a temperature of
180 oC (356 oF) and a pressure of 141 kg/cm2
(2245 psi) escaped, and, as a result of this escap-
ing fluid, four people died and four people got
seriously injured. All affected personnel were
in the near vicinity of this weld-o-let. This cata-
strophic failure occurred after 24 years on-
stream time.

Microscopic investigations (Figure 3) showed

Figure 1. Location of weld-o-let that the corrosion took place in the weld-o-let
material adjacent to the connection welds with
the 8” diameter pipe and the 11/2” diameter pipe
end.

Figure 2. Failure of weld-o-let

Plant management did not want to stop the plant

because of this leak and decided to run the plant
until the planned turnaround some two weeks
later. It was decided to contract a company spe-
Figure 3. Corrosion on the weld-o-let’s Heat Affected
cialized in stopping leakages by on-line clamp-
Zones (HAZ)
ing.
The material of both pipes showed some overall - Apply better designs (zero dead zone) for a
corrosion that can be considered normal for thermowell, like the one by BHDT (refer to
pipelines of that age. Reviewing the microstruc- Figure 5)
ture (Figure 4), the expectation was that one
would find chromium carbides (Cr23C6) on the
grain boundaries near the corrosion but no
chromium carbides were found.

Figure 4. Inter-crystalline corrosion in the Heat Af-

fected Zones (HAZ)

Although analyses showed that the material of

the weld-o-let was of an inferior material quality
with the amount of alloying elements present,
the chromium content of the weld-o-let ap-
peared to be only 15.3%, while the minimum
Figure 5: BHDT zero dead volume thermowell
required chromium content of a 316L Urea
Grade material should be 17.0%. This fact, in
combination with the location of this inferior - Pay attention to the right location of the weld-
material in a dead-end T-joint where insufficient o-let (avoid gas phase in case one uses 316L
refreshment of carbamate solution took place, Urea Grade material).
resulted in an increase of the corrosion rates. Fabrication phase
- Assure the quality of the installation and
welding services.

The lessons learned: Maintenance phase

- Perform proper inspections and testing during
Design and Engineering phase installation and after repair procedures (hy-
- Assure that the quality of the applied materials drotest, X-ray test of weld-o-let).
fulfils the minimum requirements; Or even - Perform regular corrosion inspections of criti-
apply better materials like 25-22-2 or Sa- cal areas especially in older plants.
furex® to obtain a safety margin and minimize - Do not apply a clamp to stop a carbamate con-
active corrosion. taining leak. It is dangerous as it creates a
 crevice where active corrosion can start lead- ing, under the corrosion product and the depos-
ing to a potential bigger catastrophe. its numerous micro cracks were found, see Fig-
ure 7.

Further to the previous case, which highlights

general measures and attention points to follow,
we realize sometimes it is all about certain de-
tails. Let’s discuss a typical case example:

Case Study 2: It is all about details

- Incident with steam /condensate
flushing of the leak detection sys-
tem

A multi-layer urea reactor commissioned in

1976 started leaking in the liner top part in Figure 7. Cracks in multilayer inner surface
2001. A temporarily repair was executed. The
area underneath the liner was visually inspected
and no deposits were found at that time. Due to A sample from the carbon steel core layer con-
the condition of the liner in the top part of this taining cracks was removed and investigated.
reactor, it was decided to reline the top cylindri- This investigation revealed that a leak in the
cal section during the next turnaround. protective 316L Urea Grade liner resulted in the
presence of aggressive ammonium carbamate.
The consequence of carbon steel in contact with
During the 2003 shut down, the 316L Urea ammonium carbamate at elevated temperatures
Grade lining in the top of the reactor was re- is well known; corrosion rates of 1000 mm/year
moved for relining. Underneath the lining, areas and more have been reported. The reason for
with severe general and local corrosion were the local corrosion was the presence of ammo-
found with brownish corrosion products on the nium carbamate.
high strength C-Mn-Mo-Ni steel. Also white
crystalline solid deposits were present, see Fig- The steel sample containing cracks was cut out
ure 6. of the pressure vessel under the stainless steel
liner. Further investigation was performed in
order to try to find the cause of the cracks. The
cracks detected in the core layer of the multi-
layer C-Mn-Mo-Ni-steel urea reactor were
caused by environmentally induced stress corro-
sion cracking (SCC) see Figure 8.

Figure 6. Deposit on multilayer inner surface

While the affected areas were cleaned by buff-
 The lessons learned:
- Use an active leak detection system so that an
early warning of a leak is ensured. Active leak
detection means either a pressurized system,
where an inert gas is circulated, or a vacuum
system plus a continuous, reliable and accurate
ammonia detector.

- Do not flush a leak detection system with

steam or condensate.

- When doing a relining job always remove the

old liner so that one takes the opportunity to in-
Figure 8. Trans granular branched cracks in core layer spect the carbon steel pressure bearing wall.

The chemicals (carbamates etc.) that had leaked

through the stainless steel lining into the gap
between the stainless steel lining and the inner
C-Mn-Mo-Ni steel core plate created an envi-
ronment that could cause trans granular stress
corrosion cracking. The introduction of steam
via the leak detection holes into the gap between
liner and the multilayer changed the conditions
in the local environment in such a way that
stress corrosion cracks in the C-Mn-Mo-Ni core
layer have been created in addition to the gen-
eral active corrosion reported from other such
incidents.
Case Study 3: Share experiences -
Cleaning the scraper in a prill
By adding water one potentially creates an at- tower
mosphere where carbonate and bicarbonate
stress corrosion cracking to the carbon steel can We are convinced that sharing experiences of
occur. Furthermore, if the water contains chlo- incidents will make this industry more safe.
rides or nitrates, chloride stress corrosion crack- This case study is a perfect example to support
ing of the stainless steel liner or nitrate stress our belief.
corrosion cracking to the carbon steel can occur.
A scraper rotates above the floor of the prill
The liner was replaced in the top section. Be- tower and moves the prills from the bottom of
cause of the fact that by no reasonable means the prill tower to the conveyor belt. At higher
the remaining carbon steel pressure vessel under plant loads and/or under summer conditions, the
the stainless steel liner could be inspected for prills are not completely solidified and still rela-
more cracks it was decided to replace the whole tively soft when reaching the bottom of the prill
reactor in the near future. tower. These soft prills clog on the scraper as a
hard layer of solid urea (Figure 9).
 Also several valuable solutions were suggested:
One solution is to use a rigid steel structure un-
der which one can safely remove the fouling
from the scraper (Figure 10).

Figure 10. Steel structure to protect people during clean-

ing of scraper

Another valuable solution is to install PolyPro-

pylene (PP) sheets on the scraper (Figure 11),
Figure 9. Removing urea fouling from the scraper which reduce the buildup of urea fouling on the
scraper and which facilitates the cleaning proce-
This kind of fouling can and will also stick on dure.
the walls and ceiling of the prill tower, and at
regular intervals cleaning becomes necessary.
At one particular site during the 2010 overhaul
activities, employees were in the prill tower for
cleaning the lumps off the scraper's arms. A
steel structure with a wooden platform on top
was used for safety of the employees. A big
lump fell down on to the steel structure breaking
the wooden platform. The shoulder of one em-
ployee was broken, luckily without further ma-
jor injuries.

A lively discussion in the Round Tables of

UreaKnowHow.com followed in which several
urea producers confirmed the risks involved in Figure 11. PP-sheets on scraper
this cleaning exercise. For example: “We have
faced several near misses during this activity. In Finally a third valuable solution is provided:
industry there are examples of unreported fatal During scraper cleaning waste oil is applied on
injuries during this operation”. the scraper arms after removal of the urea depo-
 sition, so that further cleaning / descaling of arm
can be more easily possible.

This third case is in our view a perfect example

that sharing incidents can prevent similar inci-
dents from occurring in the future.

Conclusions
Sharing incidents will increase the safety of the
industry.

Avoiding incidents is of key interest for all

stakeholders in the industry.

References
1) Giel Notten, NTT Consultancy

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