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Case Study Published: February 13, 2019 KEY ISSUES: • Exchanger Failure Due to Thermal Fatigue

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Case Study Published: February 13, 2019 KEY ISSUES: • Exchanger Failure Due to Thermal Fatigue Loss of Containment, Fires, and Explosions at Enterprise Products Midstream Gas Plant Pascagoula, Mississippi | Incident Date: June 27, 2016 | No. 2016-02-I-MS Case Study Published: February 13, 2019 KEY ISSUES: • Exchanger Failure Due to Thermal Fatigue • Service Life Determination of Brazed Aluminum Heat Exchangers • Social Media Use in Emergency Response Photos Credit: CSB Page 1 Loss of Containment, Fires, and Explosions at Enterprise Products Midstream Gas Plant Pascagoula, Mississippi | Incident Date: June 27, 2016 | No. 2016-02-I-MS The U.S. Chemical Safety and Hazard Investigation Board (CSB) is an independent federal agency whose mission is to drive chemical safety change through independent investigations to protect people and the environment. The CSB is a scientific investigative organization, not an enforcement or regulatory body. Established by the Clean Air Act Amendments of 1990, the CSB is responsible for determining accident causes, issuing safety recommendations, studying chemical safety issues, and evaluating the effectiveness of other government agencies involved in chemical safety. More information about the CSB is available at www.csb.gov. The CSB makes public its actions and decisions through investigative publications, all of which may include safety recommendations when appropriate. Types of publications include: Investigation Reports: Formal, detailed reports on significant chemical incidents that include key findings, root causes, and safety recommendations. Investigation Digests: Plain-language summaries of Investigation Reports. Case Studies: Reports that examine fewer issues than Investigation Reports. Safety Bulletins: Short publications typically focused on a single safety topic. Hazard Investigations: Broader studies of significant chemical hazards. Safety Videos: Videos that animate aspects of an incident or amplify CSB safety messages. CSB products can be freely accessed at www.csb.gov or obtained by contacting: U.S. Chemical Safety and Hazard Investigation Board Office of Congressional, Public, and Board Affairs 1750 Pennsylvania Ave., NW, Suite 910 Washington, DC 20006 (202) 261-7600 No part of the conclusions, findings, or recommendations of the Board relating to any accidental release or the investigation thereof shall be admitted as evidence or used in any action or suit for damages arising out of any matter mentioned in such report. See 42 U.S.C. § 7412(r)(6)(G). Page 2 Loss of Containment, Fires, and Explosions at Enterprise Products Midstream Gas Plant Pascagoula, Mississippi | Incident Date: June 27, 2016 | No. 2016-02-I-MS Table of Contents Figures ...................................................................................................................................................................................5 Tables ...................................................................................................................................................................................9 Acronyms and Abbreviations ...............................................................................................................................................10 1.0 Executive Summary .........................................................................................................................................................11 2.0 Background ................................................................................................................................................................... 12 2.1 Incident Synopsis .......................................................................................................................................................................12 2.2 Brazed Aluminum Heat Exchangers ........................................................................................................................................14 2.3 Introduction to Thermal Fatigue in a BAHX .............................................................................................................................15 3.0 The Incident .................................................................................................................................................................... 17 3.1 OSHA Activities at PGP ............................................................................................................................................................ 20 4.0 Initiating Event and Likely Failure Scenario .................................................................................................................. 21 4.1 Initial Failure Point and Likely Damage Mechanism .................................................................................................................21 4.2 Configuration of the BAHX of Interest ..................................................................................................................................... 23 4.3 Most Likely Failure Scenario ................................................................................................................................................... 23 4.4 Thermal Fatigue Events Elsewhere ...........................................................................................................................................27 5.0 Thermal Fatigue in BAHXs at the Pascagoula Gas Plant ..............................................................................................29 5.1 Recognized and Generally Accepted Good Engineering Practices ......................................................................................... 30 5.2 Recommended BAHX Heating and Cooling Rates ...................................................................................................................31 5.3 PGP’s Thermal-Fatiguing Process Conditions ........................................................................................................................ 33 5.3.1 Upstream Influences and Downstream Orders to Curtail or Stop Production ................................................................................. 33 5.3.2 Compressor Shutdowns .................................................................................................................................................................... 33 5.3.3 Erratic Flow ......................................................................................................................................................................................... 33 5.4 Industry Thermal Fatigue Monitoring Guidance ..................................................................................................................... 35 5.5 Operating Conditions Can Gradually Manifest into Thermal Fatigue Failures ....................................................................... 36 5.6 Temperature Sensor Location ...................................................................................................................................................37 5.7 Lack of Industry Data Sharing .................................................................................................................................................. 38 Page 3 Loss of Containment, Fires, and Explosions at Enterprise Products Midstream Gas Plant Pascagoula, Mississippi | Incident Date: June 27, 2016 | No. 2016-02-I-MS 6.0 Process Safety Management at PGP ............................................................................................................................ 40 6.1 Hazard Assessment and Evolving Perception of Thermal Fatigue Risk at PGP .....................................................................40 6.2 Mechanical Integrity at PGP .................................................................................................................................................... 42 6.2.1 Leak and Repair History of the ACSR .................................................................................................................................................43 6.2.2 2015 ACSR Repair .............................................................................................................................................................................43 6.2.3 Recommended Thermal Fatigue Inspection Practices .....................................................................................................................45 6.2.4 PGP Inspection Practices for BAHXs .................................................................................................................................................46 6.3 Enterprise BAHX Integrity Management at Other Facilities ................................................................................................... 46 6.3.1 Enterprise BAHX Mechanical Integrity Initiative ............................................................................................................................... 47 6.4 Hierarchy of Controls and Risk Assessment ........................................................................................................................... 48 7.0 Emergency Response, Community Notification, and the Use of Social Media ............................................................49 7.1 Emergency Plan and Response ................................................................................................................................................. 49 7.2 Community Notification during the Incident ............................................................................................................................51
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