Natech Accident
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Natech Accident
2013/04/02
19:45
10 hour(s)
Published

Units Involved

  1. Coking oven
    Process: Reactor
    tar distillate is converted to coal
  2. Storm water collector tank
    Other: Waste disposal
    Rainwater is collected and decontaminated and treated before being emitted to the nearby watercourse
  3. Topping unit
    Process: Column

Event Sequences

  1. Water polluted by hydrocarbons ignites
    2. Storm water collector tank
    A fire started after flooding caused by a major rain storm cut electricity to the entire refinery.
    1. Waste hydrocarbons
    Initiating EventCritical EventMajor Event
    Natural Hazard: Floating oil in drainage systems due to inundation
    Water polluted by hydrocarbons overflowed from stormwater catchment network.
    Release: Gas, vapour, mist, or smoke release to air
    Hydrocarbons floating on flood water reached the coke furnace and produced vapours, due to heat.
    Contributing Factors
    Organisational: Design of plant / equipment / system: Inappropriate
    To contain possible spills of hydrocarbons, the ground below the oven was at a lower level than the street. This allowed rainwater and hydrocarbon accumulation below the coke oven.
    Fire: Conflagration
    Even though the unit was shut, the temperature of the unit walls was still high enough to ignite vapors. A fire started in the furnace unit.
    Contributing Factors
    Organisational: Management organization: Inadequate
    The decision to stop the facility was taken at the very last minute when the site was already flooded. Had the plant been shut for a long time, the coke oven temperature would have been lower.
  2. Explosion and fire at the coking furnace
    1. Coking oven
    1. Mix of flammable gases
    Initiating EventCritical EventMajor Event
    Event Sequence: Water polluted by hydrocarbons ignites
    Contributing Factors
    Organisational: Design of plant / equipment / system: Non-existent
    The device "did not have the proper safety technology" to prevent fires. Two fires had already occurred earlier the same year.
    -
    Fire: Conflagration
    Gas accumulated inside the oven ignited and exploded. A big conflagration started.
    Contributing Factors
    Measure: Emergency shut off / safety valves: Unavailable
    The employees found it impossible to access the gas stopcock, which was under water at about 200 meters
    Explosion: Pressure burst
    The oven at the Topping plant exploded "opening like a flower"
  3. Fire spread to the topping unit
    3. Topping unit
    1. Crude Oil and other hydrocarbons
    Initiating EventCritical EventMajor Event
    Event Sequence: Explosion and fire at the coking furnace
    -
    Fire: Conflagration
    Two fires started at the crude distillation unit

Weather Conditions

Rain
Heavy rainfall and flooding

Emergency Response

Emergency response plan takes Natech events into consideration: No
Emergency response plan is sufficient in taking Natech events into consideration: No
Insufficient personnel and equipment to respond to both emergencies: No
Natech event prevents access of personnel to natural hazard affected area: No
Natech event prevents efficient operation of personnel in the natural hazard affected area: No
Insufficient personnel and equipment to respond to both emergencies: Yes
Damage to lifelines (e.g. water, power, communication, transportation): Yes
  • On-site systems (e.g. sprinkler, water cannon)
  • On-site fire fighting team
  • On-site hazmat team
  • Local fire fighting team
  • Fire fighting teams of nearby plants
  • Regional / national fire fighting teams
During the night, the fire departments of different localities of the Region (La Plata, Berisso, Ensenada, Quilmes) had intervened on the site.

When the fire started, the plant was guarded by three operators, a supervisor, and a console operator.

Employees were unable to access the locker room to wear the proper security uniform.

The man of the on-site team that first tried to put out the fire had their clothes soaked with hydrocarbons floating on the water.

Consequences

500 M USD
The production was shut for about one week.
The refinery production suffered a significant reduction for months.
The coking plant was replaced two years later.
Over $500 million equipment damage.

Remedial Activities

The coking oven was replaced with a new one and the topping unit repaired for a total cost of $500 million

Lessons Learned

The foam reserves were insufficient for the task and finished quickly. The fire fighting operations were halted for two hours, waiting for new foam supplies.
A better training of the personnel and of local firefighter was needed.
"Many of the firefighters were not trained for this type of fire."
Incorrectly, they "began to attack gases that burned." Since the passage of the gas was not shut, when the flames were put off, the gases could spread into large flammable clouds, which ignited again.
The on-site fire fighting teams should be bigger.
In a refinery of that size, only 2 employees were trained fire fighters.
The units should have all the safety equipment needed to prevent such fires.
Automatic water systems should be installed to prevent fire propagation from one unit to another.
Adequate protection should be provided to all the personnel and in particular to the fire brigade.
During the accident, the personnel could wear neither breathing apparatus or proper uniforms to protect themselves.
ID: 62, Created: Amos NECCI, 2016-09-16 14:41:07 – Last Updated: Amos NECCI, 2021-11-09 13:32:07

Attachments

NoDescriptionFile Size
1.Click here to select record 100 Largest losses 23rd edition7.89MB
2.Click here to select record La Plata Flooding WSJ472.12KB
3.Click here to select record Moreno, 2015 999.91KB
4.Click here to select record YPF Indipendent 644.48KB
5.Click here to select record YPF OSDir122.59KB
6.Click here to select record YPF reuters 345.25KB