Learning From AiChE

Major incidents in the History of Ammonia Plant around
the world – AiChE
(Phase-1)
Prepared By: Zain Arshad Khan

Reviewed by: KAC & AJAS
Approved by: AN
OBJECTIVE & STRATEGY
Purpose:
To compile key learnings for Fatima Group from the events reported in AiChE articles since its
inception regarding Ammonia plant.
Strategy:
Considering the quantum of scope, phased out strategy is opted for effective and
comprehensive analysis to facilitate the audience by limiting the content to 15 years in each
phase.
Phases are launched in reverse chorology to bring relevancy owing to the fact of engineering
& design improvements over the past 60 years
As Said:
“Incidents on the job don’t “just happen”, either.
They are caused by the actions or inactions of one or
more people.”
Phase-1
Scope:
Year 2000 to 2011
Approach:
433 articles were studied out of which 24 were selected based on the severity of the incident
causing injury, sufficient downtime and asset & environmental loss.
It is worth mentioning, that each of the event is categorized in following four types of failure:
1. Mechanical/Metallurgical Failure
2. Operational Failure
3. Design Failure
4. Instrument Failure
Summary of selected articles
Mechanical/
Operational Design Instrument
Article Metallurgic
Failure Failure Failure
Failure
Front End
1 Primary Reformer Tubes Failure Due to Corrosion Attack  
2 Failure of Ammonia-1 Natural Gas line 

3 Fire in Secondary Reformer Outlet Line to Waste Heat Boiler 
4 Failure of Damaged Tubes of the Reformed Gas Waste Heat Boiler at Profertil  
5 A Damaged Expansion Turbine 
6 Failure and Damage of HT Shift Converter 
7 Hot Spot and Ruby Formation in Secondary Reformer 
8 Primary Reformer Failure 
9 Explosion of Hydrogen in a Pipeline for CO2 
11 Explosion of Auxiliary Boiler 
12 Thermal fatigue failure phenomena in steam piping systems at Ammonia plant  
Actuation of the Methanator High Temperature Shut Down Security after Semi-lean
13 
Solution Pump Change Over
14 Catastrophic Failure of Reformer Tubes at Courtright Ammonia Plant 
15 Lessons Learned from an Unusual Hydrogen Reformer Furnace Failure  

Summary of selected articles
Mechanical/
Operational Design Instrument
Article Metallurgic
Failure Failure Failure
Failure
Back End
16 Fire in an Ammonia Synthesis startup heater 
17 Syn-Loop Waste Heat Boiler Exit Line Failure 
18 Explosion in Purge Gas Recovery Unit 
19 Severe surge incidents at Process Air Compressor 
20 Self-Supported Flare Stack severe Vibrations in Ammonia Plant 
21 Failure Analysis of High Pressure Synthesis Gas Compressor Cooler 
22 Failure of Internals of Ammonia Converter 
23 Launching of the upper part of a 24” valve during disassembling 
24 Synthesis Converter Start Up Heater Failure 

Analysis
Overall Percentage of distribution of incidents
Mechanical/Metallurgic Conclusion:
17% Failure
33%
Operational Failure
Study revealed that around 50% of total
failures incurs at Ammonia Plant is due
Design Failure to misoperation
50%
Instrument Failure
Ammonia Plant Front End Incidents Ammonia Plant Back End Incidents
Mechanical/Metallurgic Mechanical/Metallurgic
Failure
5% Failure
33% Operational Failure 33% Operational Failure
44%
Design Failure Design Failure
62% 22%
Instrument Failure
Instrument Failure
Front End
Primary Reformer Tubes Failure Due
to Corrosion Attack
Qatar Fertilizer Company, QATAR
Capacity 2200 MTPD
Commissioned on 1979
For the last 30 years reformer tubes had gone
through numerous changes in material of
construction to improve performance and reliability.
Incident (Operational &
To increase plant throughput, QAFCO replaced the
Metallurgical Failure)
old HK40 tubes with HP modified alloy but within
(2009)
twenty-four months of operation, unexpected
corrosion attack was observed on some of the
reformer tubes
to Corrosion Attack
A combination of the burner geometry anomalies, over firing and
insufficient or poor combustion air flow distribution created
localized sub-stoichiometric (reducing) conditions within the
radiant section of the primary reformer, resulting in poor
combustion, irregular flame patterns and high levels of CO
Root Cause indicated by protective oxide layer damage caused by surface
pitting and scale formation.
The mixture of oxides and sulfides present in the corrosion
products indicated that the flue gas around the affected tubes was
not constant and alternating between oxidizing and reducing
atmosphere due to imbalance Reformer.
Sweetening unit installation to reduce H2S contents in the fuel to
Preventive action
reformer & burner alignment for equal distribution of air.
to Corrosion Attack
Both Yara, Quest Reliability and Literature Survey indicates that,

under reducing conditions in the fire box fuel gas containing more
than 0.6% Hydrogen Sulfide can lead to sulfidation attack on the
(Nb-modified HP alloy) reformer tubes
Furnace balancing to be ensured by analyzing draft, burner
Learning for FG
positions and flame patterns.
O2 & CO2 analysis should be conducted at various locations to
gauge complete combustion.
All the conditions leading to sub-stoichiometric conditions to be
avoided.
Visuals
Failure of Ammonia-1 Natural Gas line
Qatar Fertilizer Company, Qatar
Technology ICI
Capacity 900 MTPD
Commissioned on Dec 1993
While restarting the ammonia plant after a shutdown, the

pipe line supplying natural gas to the sulfur removal section
preheat coil in the primary reformer convection section
Incident (Design Failure)
ruptured. High-pressure natural gas from the rupture
(2001-2002)
ignited leading to significant fire. The gas line rupture was
determined to have been caused by corrosion.
Failure of Ammonia-1 Natural Gas line
Qatar Fertilizer Company, Qatar
The corrosion was a result of direct water injection into
gas stream containing CO2 at a location where there
was insufficient energy in the gas to completely vaporize
Root Cause
the water which Led to formation of carbonic acid and
hence depletion. The water was being injected to
control outlet T of Natural Gas Preheat Coil in
Convection Section
25 % of the coils were bypassed to control T without

Preventive Action
water injection
De-superheating of Gas containing CO2 with Water can

lead to acid formation and design should be reviewed
Learrning for FG
for T and Partial Pressure before any such activity to
avoid Carbonic Corrosion
Visuals
Fire in Secondary Reformer Outlet Line to Waste Heat
Boiler
Krishak Bharati Co-Operative Ltd. (KRIBHCO), Gujarat, India
Technology M.W Kellogg
Capacity 1,350 MTPD
Commissioned on August 1988

The failure of the pressure shell of the
interconnecting pipe between the secondary
reformer and primary waste heat boiler, resulting
Incident (Design Failure)
in a fire in Ammonia Unit-I after 13.5 years of
(2001-2002)
operation. The fire incident resulted in a plant
shutdown of 15 days.
Boiler
The reasons for the failure of the pressure shell could be

hydrogen attack on the pressure shell of ASTM A-516 Gr 70
material or metal creep of the pressure shell. In fact, it was
Root Cause evident that failure of the shroud has to occur first before
refractory and shell so that the pressure shell is exposed to high
temperatures in excess of 343.4°C, which is the design metal
temperature of the pressure shell
To avoid hydrogen embrittlement, the shroud material was

changed to Inconel-601 instead of SS-310. Jacket water level
Preventive Action and flow indicators were brought on DCS for close monitoring.
Four Thermocouples were also added on jackets. Monitoring of
Jacket vent w.r.t explosive gases.
Boiler
Plants with Jacketed secondary reformer system are required to

be vigilant for such failures and should consider Shroud design if
Learning for FG applicable. Skin temperature and jacket vent could be
monitored. Refractory inspection should be performed with
predefined frequency and observation based.
Failure of Damaged Tubes of the Reformed Gas Waste
Heat Boiler at Profertil
Profertil SA , Bahía Blanca, Argentina
Technology Haldor Topsoe technology
Capacity 2050 MTPD
Commissioned
2001
on
In Nov, 2005, decrease in WHB outlet gas temperature was

observed due to pH excursion in DMW. Leading to tubes failure. 3
Incident Tubes were found leaked and 7 were plugged. One tube was pulled
(Operational and out for detailed testing. Again in Dec, 2006, decrease in boiler
Design Failure) outlet gas temperature was detected, similar to that of November
(2007) 2005. The difference was that no operative abnormal event had
taken place at the plant, so that it was decided to take early Turn
Around to avoid serious damage to the equipment.
Failure of Damaged Tubes of the Reformed Gas Waste
Heat Boiler at Profertil
Profertil SA , Bahía Blanca, Argentina
Since commissioning, plant faced BFW quality issue owing to
inadequate deaerator design and ineffective treatment.
Subsequently, Boiler was exposed to BFW with high O2 content (2
Root Cause PPB) and issue was intensified with low pH (2-3) excursion of
about 6 hrs leading to tubes failure. Detailed investigation of failed
tube revealed Cu, Zn, O2, P, Ca, Na and Mg presence in the
deposits which is an indication of insufficient BFW quality.
Ensure BFW O2 content < 7 PPB. Also, develop procedure to avoid
Preventive Action O2 ingress to the boiler during TA. Monitor Cu content in BFW
periodically. 2nd incident was a continuity of previous one.
BFW chemistry including Cu to be kept in control all the times.
Periodic inspection of tubes should be considered through IRIS
Learning for FG
technique to detect defects. Periodically inspect Deaerator
including the calibration of spargers and distributors.
A Damaged Expansion Turbine
MOPCO, Egypt
Technology Udhe
Capacity 1100 MTPD
Incident A complete liquid processing rotating train consisting of a

(Operational recovery expansion turbine, an HP-solution pump and a high
Failure) voltage electric motor at the bottom of the CO2 absorber
(2007) column, was completely damaged during normal operation.
A Damaged Expansion Turbine
MOPCO, Egypt
The inspection of the machinery parts showed clearly that the damage
was caused by an instantaneous break. An immediate re-start (within
30 seconds) of the high voltage motor after a trip (which was done
Root Cause
manually) will cause a high transient torque in opposite direction
(counter torque). This transient torque is app 15 to 20 times the
nominal torque.
Motor speed must be zero before re-start. A hydraulic coupling (break-

Preventive
away coupling) between pump and turbine has to be used instead of
Action
normal coupling.
Procedures must be reviewed keeping in view of this voltage dip

Learning for
possibility and restarting of machines safely. Modification of break-away
FG
coupling to be considered to enhance reliability
Failure and Damage of HT Shift Converter
PT Pupuk Kujang, Cikampek, West Java,Indonesia.
Technology Kellogg
Capacity 1000 MTPD
HTS was being heated during start up after attending the leakage
of Fuel Preheat Coil. Upon completion of heating the steam vent
was being shifted when the HTS outlet pipe found glowing.
Accordingly, plant was again shut down to check pipe health which
Incident
was declared ok. Plant was restarted but high CO slip (9.8%) was
(Operational
reported from HTS. The slip could only be reduced to 5.6% by
Failure)
increasing the inlet temperature to max limit of 365 oC epitomizing
(2002)
problem in HTS. Plant was shut down again for detailed HTS
investigation which revealed catalyst height level reduced by
1.55m. Bottom screen was missing with bottom catalyst converted
to dust and damaged unloading chute.
In conclusion, it is clear that the damage of the HTS bottom part was
caused by excessive heat, generated by oxidation of the catalyst,
Root Cause
that led to melting of materials. The oxidation occurred because of
the leakage in process air valve.
During shut down, the air compressor should be stopped if some

leak indication is found in air compressor valves or alternatively
steam cooling down step should be extended in order to make sure
Preventive that the catalyst is completely oxidized.
Action To prevent another possibility of entering air into catalyst bed, the
vent valve at downstream of HTS should be closed soon after
primary reformer steam cooling step was completed.
Care should be taken to handle the nitrogen hoses management.
All the possible reasons which can lead to oxygen ingress should
be explored and take necessary steps to ensure safe operation.
Learning for FG
Also consider shutdown and startup to avoid any upset.
Hot Spot and Ruby Formation in Secondary Reformer
PT. Kaltim Pasifik Amoniak

HaldorTopsoe A/S
Technology
Capacity 2,000 MTPD
On 8 October 2001 at about 09:00 a.m., when the regular
checking on the skin shell temperatures of the secondary
reformer was being done by the inspector, it was found that the
Incident temperature on a basketball size area located at the level of the
(2002) catalyst bed top (eastside) had increased to 390-400oC (750oF).
(Design limitation) This area had been closely monitored since 10 September 2001
upon discovery of a color change of the thermoindicative paint
used on the outside of the secondary reformer.
Ruby consists of α-Al2O3 with a minor content of Cr2O3. (Natural

ruby contains approx. 2.5% Cr2O3 and deposits in reformers
approx. 0.5-2%).The alumina originates from the refractory lining
materials in equipment upstream of the catalyst bed and from
the target bricks. The chromium oxide originates from the
Root cause
protective surface layer of chromium oxide found on all stainless
steel equipment (i.e. reformer tubes, hairpins, etc.). It is the
chromium oxide which gives the rose/pink colour tone of the
ruby.
Replacement of the present alumina tiles with the following

hexagonal type tiles to improve the gas distribution.
Application of nickel coating to the hot face refractory in the
conical part of the secondary reformer. The rationale behind this
is to promote reforming reaction on the wall of the reactor. The
Preventive Action
reaction is endothermic and will thus cool the walls.
Close monitoring of the reactor pressure shell surface
temperature (includes maintenance of thermoindicative paint)
and close observation of the possible development of catalyst
bed pressure drop

• Periodic condition monitoring of the secondary reformer
refractory in the available opportunity.
• Application of the nickel coating in the conical section of the
Learning For FG secondary reformer maybe considered with the consent of
licensor.
• Skin temperature of the secondary reformer to be monitored
periodically.
Visuals
Primary Reformer Failure
Agrium Fort Saskatchewan, Alberta, Canada
Capacity 907 MTPD

The Agrium Fort Saskatchewan Nitrogen Operations
experienced a massive reformer failure after a short
maintenance outage and routine startup. During primary
Incident
reformer heating panel operator was incorrectly monitoring
(2001)
the transfer header outlet instead of flue gas temperature.
(Operational Failure)
Radiant box temperature continued to increase on burner
lit up by field operator and steam was not introduced in
time.
Primary Reformer Failure
Uneven firing and lack of monitoring led to melt down of PR
Root Cause
tubes
• It is mandatory to have an overall operations coordinator

during startup.
• It is mandatory to have two operators on the panel during
Preventive Action
startup.
• Log books would be kept of each area of the plant to
improve communication between crews.
Stringent monitoring to be maintained during furnace heating.

Area operator should take observation of radiant box during
Learning for FG
burner lit up and boardman should keep close eye on flue gas
temperature and hot collector temperature.
Visuals
Explosion of Hydrogen in a Pipeline for CO2
Hydro Agri Porsgrunn, Norway

Capacity 1000 MTPD
Plant was shut down and the line out of operation for six
Incident days. The line was purged with N2 and blinded. The cause of
(2000) the explosion has not been fully established, but an
operator was cutting a bolt on a flange shortly before. 850 m
of the line was destroyed
Oxygen ingress and combustible mixture formation in the

Root Cause pipeline. Analyzers were by passed due to faulty reading
Explosion of Hydrogen in a Pipeline for CO2
• Hydro Agri Porsgrunn, Norway
• Securities were taken into service
• Separate sampling lines with block valves have Bypass lines
have been installed around the analyzers in order to
increase gas velocity in the sample lines.
Preventive Action
• Separate sampling lines with block valves have been
installed for each analyzer in order to eliminate “common
mode failure”
Explosion of Auxiliary Boiler
Petrokemija, d.d. Kutina, Fertilizer Company, Croatia
Technology Kellogg
Capacity 1360 MTPD

Ammonia plant was being started up after a four-day shut
down. At 4 pm., while the auxiliary boiler pilot was being
Incident
lit, suddenly an explosion happened. The walls of the
(2003)
auxiliary boiler and parts of the convection section walls
(Operational Failure)
were damaged
Explosion of Auxiliary Boiler
Petrokemija, d.d. Kutina, Fertilizer Company, Croatia
The testing of the valves for leakage showed that the valves were
leaking. Long time had elapsed from the letting the gas into the
burners and lighting the pilots. This is one of the main reasons for
higher concentration of gas in the boiler firebox and creation of
an explosive gas mixture. The weaker boiler draft during the start-
Root Cause
up was normal and it is required to ensure the stability of the pilot
flame. The lack of detailed instructions for lighting the boiler and
the lack of control as to whether the procedure was correct as
well as the presence of any human factor were the reasons as to
why the explosion happened.
Modifications in the firing and burner management system.
Preventive action
Installed two safety shut off valves.
Special care should be taken during burner lit up .i.e burner
Learning for FG should be litted up right after isolation. Also, startup/shutdown
procedures should be reviewed wrt this incident.
Thermal fatigue failure phenomena in steam piping
systems at Ammonia plant
Razi Petrochemical Co.-Iran
Technology M.W. Kellogg
On May 14th 2003 a steam leakage was reported at
Incident ammonia unit I. The steam entering the pipe was at
(2005) approximately260°C (500oF) and 3.44Mpa (50 psi).
(Design + Operational Failure) Cracks were found in the pipe
The main cause of failure was thermal fatigue due

Root Cause
to insufficient flexibility and temperature difference
between bypass and piping.
The failure presented in this paper was caused by a number
of different factors including design deficiencies and upset
Preventive Action
operating condition.
Heating of the steam system to ensured at recommended

rates to avoid thermal shock. Exercise for flexibility analysis
Learning for FG may be considered if required.
Regular inspections of steam lines should be carried out as
per PM plan.
Actuation of the Methanator High Temperature Shut Down
Security after Semi-lean Solution Pump Change Over
Engro Dharki, Pakistan
Technology Bechtel
Capacity 1650 MTPD
On January 26, 2002, Ammonia plant was being operated at 138 %
Front end load. At about 1600 hrs, Ammonia-2 plant Back End was
Incident shutdown due to sudden rise in Methanator bed temperature leading
to actuation of Methanator trip logic.
Operations team lack of focus on methanator as they were only

focusing on maintaining absorber level. Semi lean flowmeter was
Root Cause
considered to be reliable. Whereas, semi lean pump was not giving the
(2006)
expected flow against experience.
(Operational
Front end load vs. minimum semi-lean flow reference chart was not
Failure)
available to avoid entry into danger zone.
Actuation of the Methanator High Temperature Shut Down
Security after Semi-lean Solution Pump Change Over
Engro Dharki, Pakistan
• Increased Alarm management

• FEL vs semi lean flow chart was provided
• Catacarb transmitters were steam traced and insulated
Preventive Action • Strainers of the pumps were checked
• modification was done as mentioned below to cool down
methanator without any temperature excursion risk in any
future event.
Plant operating procedures must be check in case low semi lean
solution flow. Refresher Training to be provided to the operations
Learning for FG
team. Front end load vs. minimum semi-lean flow reference chart
to be developed (if not available) with operation team.
Catastrophic Failure of Reformer Tubes
at Courtright Ammonia Plant
Terra Industries Courtright, Ontario, Canada
Technology ICI/UHDE
Capacity 1325 MTPD

During startup after the introduction of draft, it became
impossible to control the furnace draft and immediate very high
and erratic temperatures were observed in the flue gas section of
Incident the reformer leading to reformer shutdown.
(2006) Upon inspection it was discovered that there was a catastrophic
(Operational failure of the primary reformer tubes. Out of the total 168 tubes,
Failure) 11 tubes were broken into two or more pieces, 129 tubes had
visual cracks/split tubes and the remaining had no visual
indications. These tubes were in service since October 1999 (for
about 18months) and are HP modified micro alloy tubes.
The original set of reformer tubes were in service for 14 years and
experienced numerous plant shutdowns that followed similar
start up practices.
The only explanation that can be theorized for the initial failure(s)
is ‘thermal shock’ of the tubes in the tunnel area during
reintroduction of steam, following the trip out. As evidenced by
Root Cause
the rapid drop in temperature at TI-1251, 25 minutes after steam
reintroduction.
Another possible factor is the large amount of residual radiant
heat in the brick tunnel sections can keep the tube walls locally
hot in those sections, and a sudden reintroduction of steam flow
might give a shock in those areas, causing them to develop cracks.
Following the above incident investigation, two additional trip initiators
were added to the primary reformer trip logic – Extra High Temperature
(process gas exit primary reformer – 2 out of 4 voting), Extra High
Temperature (Mixed Feed Coil C-108B outlet, feed to primary reformer, 1
out of 2 voting).
As a preventive action, on loss of steam flow, visually check that tubes
are black before steam is reintroduced. Tubes can overheat quickly on
Preventive
lost flow. Black tubes indicate temperatures are low enough to
Action
reintroduce steam without shattering or snapping. One can use a
pyrometer or infrared gun to check tube skin temperatures.
Look in furnace regularly on start-ups. Monitor reformer visually every
time additional burners are lit.
Refresher training is a must for keeping operators upto date. Have an
extra field operator during start up’s, dedicated for reformer furnace area
only to give undivided attention.
Proper heating rate must be maintained during startup. Fuel
Learning for FG
must be immediately cut in case of steam loss.
Lessons Learned from an Unusual
Hydrogen Reformer Furnace Failure
Syncrude Canada Ltd.Fort McMurray Alberta Canada
Technology N/A
Capacity 300 MMSCFD of hydrogen
On January 30, 2005 a high-energy pressure impulse occurred within
several radiant tubes of a steam/methane reformer furnace during
startup after a partial shutdown. This impulse caused the
Incident simultaneous rupture of 5 tubes with sufficient force to eject
(2006) portions of the tubes out through the roof of the furnace.
(Design & All of the failures occurred near the inlet of each tube in the
Operational headspace above the catalyst and the 5 tubes were clustered toward
Failure) the center of the furnace in four rows.
Approximately 41 additional tubes were destroyed as a result of
impacts from ejected tube segments and the subsequent pressure
wave. Extensive damage to the refractory also occurred.
Syncrude Canada Ltd. Fort McMurray Alberta Canada
The investigation revealed that as the steam flow was increased it
picked up some remnant water and carried it into the furnace.
Under the conditions present the water underwent an
Root Cause instantaneous phase change and the energy release was sufficient
to rupture the tubes. The entire event was calculated to have
taken only a few milliseconds but involved extremely high-energy
release rates.
The system was designed with low point drains to facilitate water
removal however these were found to be inadequate in both
location and size.
Modifications to the procedure were completed that included a
longer heat up period, the addition of more detailed guidance for
Preventive actions verifying the feed system is dry and a formal sign off by both
operations and engineering personnel.
The decision to leave some steam flow in the steam generating
system for this winter shutdown was made to keep the system
warm and prevent freezing. However, no formal risk assessment
performed and no MOC was generated.
Proper draining of the steam condensate should ensured to avoid
Learning for FG
any upset.
Back End Incidents
Fire in an Ammonia Synthesis startup heater
Yara Tertre, Belgium
Technology MW Kellogg
After shutdown plant start-up 22 January 2007
Incident date September 6th 2008
Fire took place in the start up heater

Incident
(SUH): a rupture of a coil outlet caused the fire. Huge
(2009)
flames surrounded the SUH and affected the
(Mechanical/Metallurgic
surrounding equipment. Refractory, insulation
Failure)
materials were thrown away.
Fire in an Ammonia Synthesis startup heater
Yara Tertre, Belgium

The root cause of this incident was external corrosion of the outlet
piece of one of the two coils.
Root Cause The fracture of the coil was caused by high temperature due to
radiation from the refractory and the lack of cooling as the flow
through the coil was closed.
Inspection of the other synthesis process piping which have process

Preventive conditions around 100°C (210 °F) should was investigated.
Measure Protection against humidity and a permanent small flow through the
coils in order to maintain a constant temperature.
Learning for FG Timely condition monitoring of coil and refractory.

Visuals
53
Syn-Loop Waste Heat Boiler Exit Line Failure
Agrium, Inc.
Technology Kellogg
Capacity 1000 MTPD

Two failures that occurred two years apart on the
same exit line of a Syn-loop waste heat boiler. The
Incident failures occurred at the weld joint between two
(2003) different Chrome – Moly alloys at almost the
(Mechanical/Metallurgic Failure) identical location. At the time of the second failure
the downstream inlet nozzle to the Syn-loop feed
preheat exchanger also failed.
Syn-Loop Waste Heat Boiler Exit Line Failure
Agrium, Inc.
The various metallurgical and finite element analyses have not
reached a consensus as to the root cause of the two failures at
the exit nozzle to the Syn-Loop WHB.
Root Cause There is the suggestion that the high transient stress and strains
over time may have contributed to the initiation of the crack, but
in both incidences the plant was in a steady state operation at
the time of the failures.
• Ensure a gradual start up process so that the stresses and
strains are not in excess of yield values.
Preventive action • Alter the nozzle transition from a 1:1 taper to a 3:1 taper.
• Install on line recording sensors to measure skin temperatures
and strain.
Advance repair techniques to be used on repair. Proper PM plans

Learning for FG
to be followed.
Explosion in Purge Gas Recovery Unit
Indian Farmers Fertilizer Cooperative Limited, Phulpur, India
Technology KBR
Capacity 900 MTPD
Purge gas recovery system installed on 1985
Incident date 10 January 1990
Jacket provided over tail gas career line in

coldbox had no gasket. Continuous cycles of
Incident atmospheric moisture freezing ad melting
caused stresses and cracks in gas line. H2
enriched gas leaked and exploded in jacket.
Explosion in Purge Gas Recovery Unit
Indian Farmers Fertilizer Cooperative Limited, Phulpur, India
Gasket on such critical lines to be ensured to avoid such a

Preventive Action
failure
Severe surge incidents at Process Air Compressor
Engro Chemical Pakistan Ltd.
Technology Bechtel
A 37 years old centrifugal Process air compressor suddenly

starts surging at its normal operating point, after overhaul in
Incident 2004. Detailed investigation reveals a design issue in HP case
(2005) of the machine which was hidden since 1966. Surges on the
(Design Failure) machine results in damage of downstream secondary
reformer catalyst and fouling of waste heat boilers.
Severe surge incidents at Process Air Compressor
Engro Chemical Pakistan Ltd.

Machine surged to due different relocation condition
Root cause
and low load operation.
Check valve was installed at the discharge of the
compressor, in such a way that minimum volume
Preventive action remained between compressor discharge flange, anti
surge valve flange and the check valve.
Check valve addition to be considered. Bottlenecks to

Learning for FG be analyzed compromising machine capacity.
Self-Supported Flare Stack severe Vibrations in
Ammonia Plant
Technology Uhde GmbH, D4600 Dortmund 1, Germany
Capacity (Ammonia-3) 1500 MTPD
After shutdown plant start-up 22 January 2007
Incident date 19 February 2007
Incident Partial blockage of flare stack by ammonium

(2008) carbonates and bicarbonates salts produced by
reaction of NH3, water and CO2 at favorable
conditions.
Self-Supported Flare Stack severe Vibrations in
Ammonia Plant
Partial blockage of flare stack by ammonium
carbonates and bicarbonates salts produced by
Root Cause
reaction of NH3, water and CO2 at favorable
conditions.
Preventive Action
Learning for FG
Failure Analysis of High Pressure
Synthesis Gas Compressor Cooler
Qatar Fertilizer Company
Technology Kellog
Capacity 1320 MTPD

Traces of Syngas were detected through the analyzer installed at the
return sea water circuit. These traces were traced back to the HP
Incident Syngas cooler in Ammonia 2. This exchanger had been in service for
(2011) one and a half year. Meanwhile the rupture disc installed at the
(Mechanical return line also ruptured confirming the leakage. The Ammonia plant
/Metallurgic was shut down and the exchanger was replaced with the old
failure) exchanger which fortunately was still available. Inspection of the
damaged heat exchanger revealed cracks on the Synthesis gas out let
side tube sheet.
The subsequent Metallographic investigation revealed Hydrogen
Induced cracking had caused the failure of the HP heat exchanger
which happened due to the following reasons.
1. Presence of Hydrogen. (Syn gas reaching the cladded inter-phase)
2. Presence of moisture.(due to entrapped Syn gas)
Root Cause 3. High stresses.
The cause of failure is hydrogen, being introduced into the material

during operation and causing surface cracking of the cladded tube
sheet. The presence of hydrogen in steel reduces the ductility of the
steel and causes premature failure under a static load.
It was decided to employ a material more resistance to HIC.
Preventive Generally austenitic stainless steels, Aluminum (including alloys),
Action Copper (including alloys, e.g. beryllium copper) have shown most
resistance to Hydrogen Induced Cracking
Learning for Syn loop prone to Hydrogen attack may be inspected in the
FG available opportuniy
Failure of Internals of Ammonia Converter
PT Pupuk Kujang, Cikampek, Indonesia
Capacity 1000 MTPD
Commissioned on Nov 1978

The operating experience is described of an
Incident
ammonia converter with a modified basket retrofit
(2001)
where catalyst migration appeared four years after
(Design Failure)
plant commissioning.
Failure of Internals of Ammonia Converter

Velocity in the hose connecting pressure shell with
Root Cause cartridge nozzle than the critical velocity . Sliding
joint damage.
Modification in design in thermal joints with
uniform material Irreugular temperature rise during
Preventive Action
startup and shutdown.
This is a design problem. This problem must be

considered whenever negotiating a new basket
Learning for FG
with vendor.
Launching of the upper part of a 24”
valve during disassembling
Yara Internationals, Sluiskil.
Brown &Root purifier plants
Technology
Complex capacity 4950 MTPD

During plant shutdown, the synthesis loop was being
depressurized where a MOV at d/s of synthesis gas compressor
was dismantled. Suddenly, without any pre-warning the stem and
motor were ejected from the valve releasing a cloud of
Incident debris/dust into the surrounding of the valve.
(2007)
(Design Failure) The consequences of the accident were probably reduced due to
the fact that the pulley block was in place before the bolts were
loosened as it was needed to hold the valve in place.
To determine the root cause several tests and analysis were done:
• The inductively coupled plasma (ICP) technique and
combustion analysis were used to confirm the material quality
(AISI 410).
• The hydrogen content was also determined from the
combustion analysis. .
Root cause
• The fracture surface was examined in SEM
• Micro-hardness measurements were conducted.
• Examinations by optical microscopy were also performed.
After conducting all the tests it was evident that hydrogen

embrittlement is the root cause.
Stem material is replaced, the material ASTM A638 grade 660
Preventive Action should be used, this material is less susceptible for hydrogen
embrittlement.
All such values under high temperature and pressure hydrogen

Learning for FG
rich gas to be upgraded or inspected in available opportunity.
Synthesis Converter Start Up
Heater Failure
Incitec Pivot Ltd
Gibson Island, Brisbane, Australia
J.F.Pritchard
Designer
Complex capacity 800 MTPD

On 12 February 2005, a fire occurred in synthesis converter start
Incident up heater, EF601 that resulted from a rupture in one of the four
(2006) coils.
(Operational
Failure) The failure was due to localised overheating of a coil section
because of insufficient syngas flow through the heater.
Heater Failure
Incitec Pivot Ltd
Rupture of the start up heater coil was primarily caused by an
inadequate flow of syngas through the coil.
The root cause of the incident was insufficient consideration given to
the impact of bypassing the trip system that was designed to protect
the integrity of the start up heater coils in the event of a low flow or
complete loss of flow of syngas through the tubes.
Root Cause
The root causes could be broken into two parts
a) The installation of the force and bypassing of a critical trip system
b) The failure to remove the force/trip bypass prior to starting up the
main burners.
There was no syngas flow through the coils as the inlet valve was
blocked in.
Heater Failure
Incitec Pivot Ltd
The following actions were taken:
1. A new procedure for the bypassing the trip system that includes a
rigorous risk assessment was developed.
2. The EF601 start up procedure was modified to reinforce that low
syngas flow trip on main burners should never be over-ridden.
3. A second flow meter measuring differential pressure across the coils
Preventive
was installed and a low flow trip was also connected to this instrument.
action
4. All the alarm and trip set points were updated in revised operating
instructions.
5. Thermocouples were installed on the existing 3 coils to measure
tube wall temperatures. The newly installed deltaT alarm on tube wall
temperatures would alert the operators to look for any inadequate
flow through each coil.
Heater Failure
Incitec Pivot Ltd
Stringent Review process should be considered before passing
Learning for FG
any SCD and in-depth analysis to be performed.
Thanks

Learning From AiChE

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Major incidents in the History of Ammonia Plant around

the world – AiChE

Prepared By: Zain Arshad Khan

1 Primary Reformer Tubes Failure Due to Corrosion Attack  

2 Failure of Ammonia-1 Natural Gas line 

14 Catastrophic Failure of Reformer Tubes at Courtright Ammonia Plant 

15 Lessons Learned from an Unusual Hydrogen Reformer Furnace Failure  

16 Fire in an Ammonia Synthesis startup heater 

17 Syn-Loop Waste Heat Boiler Exit Line Failure 

18 Explosion in Purge Gas Recovery Unit 

19 Severe surge incidents at Process Air Compressor 

20 Self-Supported Flare Stack severe Vibrations in Ammonia Plant 

21 Failure Analysis of High Pressure Synthesis Gas Compressor Cooler 

22 Failure of Internals of Ammonia Converter 

23 Launching of the upper part of a 24” valve during disassembling 

24 Synthesis Converter Start Up Heater Failure 

Capacity 2200 MTPD

Both Yara, Quest Reliability and Literature Survey indicates that,

Qatar Fertilizer Company, Qatar

Capacity 900 MTPD

Commissioned on Dec 1993

While restarting the ammonia plant after a shutdown, the

25 % of the coils were bypassed to control T without

De-superheating of Gas containing CO2 with Water can

Technology M.W Kellogg

Capacity 1,350 MTPD

Commissioned on August 1988

The reasons for the failure of the pressure shell could be

To avoid hydrogen embrittlement, the shroud material was

Plants with Jacketed secondary reformer system are required to

In Nov, 2005, decrease in WHB outlet gas temperature was

Capacity 1100 MTPD

Incident A complete liquid processing rotating train consisting of a

Motor speed must be zero before re-start. A hydraulic coupling (break-

Procedures must be reviewed keeping in view of this voltage dip

During shut down, the air compressor should be stopped if some

PT. Kaltim Pasifik Amoniak

PT. Kaltim Pasifik Amoniak

Ruby consists of α-Al2O3 with a minor content of Cr2O3. (Natural

PT. Kaltim Pasifik Amoniak

Replacement of the present alumina tiles with the following

PT. Kaltim Pasifik Amoniak

Capacity 907 MTPD

• It is mandatory to have an overall operations coordinator

Stringent monitoring to be maintained during furnace heating.

Hydro Agri Porsgrunn, Norway

Oxygen ingress and combustible mixture formation in the

Petrokemija, d.d. Kutina, Fertilizer Company, Croatia

Capacity 1360 MTPD

Technology M.W. Kellogg

The main cause of failure was thermal fatigue due

Heating of the steam system to ensured at recommended

Operations team lack of focus on methanator as they were only

• Increased Alarm management

Capacity 1325 MTPD

Yara Tertre, Belgium

After shutdown plant start-up 22 January 2007

Incident date September 6th 2008

Fire took place in the start up heater

Yara Tertre, Belgium

Inspection of the other synthesis process piping which have process

Learning for FG Timely condition monitoring of coil and refractory.

Capacity 1000 MTPD