Goodyear Tyre

CASE STUDY
Heat exchanger rupture and ammonia release in Houston, Texas
(One Killed, Six Injured)
2008-06-I-TX January 2011

This case study examines a heat exchanger rupture and ammonia release at The Goodyear Tire and Rubber Company plant in Houston, Texas. The rupture and release injured six employees. Hours after plant responders declared the emergency over; the body of an employee was discovered in the debris next to the heat exchanger.

Introduction

The Goodyear Tire and Rubber Company
Houston, TX June 11, 2008

Key Issues:
• • • Emergency Response and Accountability Maintenance Completion Pressure Vessel Over-pressure Protection

INSIDE . . .
Background Analysis

Incident Description Lessons Learned

Goodyear Houston Case Study

January 2011

1.0 Incident Description
This case study examines a heat exchanger rupture and ammonia release at The Goodyear Tire and Rubber Company (Goodyear) facility in Houston, Texas, that killed one worker and injured six others. Goodyear uses pressurized anhydrous ammonia in the heat exchanger to cool the chemicals used to make synthetic rubber. Process chemicals pumped through tubes inside the heat exchanger are cooled by ammonia flowing around the tubes in a cylindrical steel shell. On June 10, 2008, Goodyear operators closed an isolation valve between the heat exchanger shell (ammonia cooling side) and a relief valve to replace a burst rupture disk under the relief valve that provided overpressure protection. Maintenance workers replaced the rupture disk on that day; however, the closed isolation valve was not reopened. On the morning of June 11, an operator closed a block valve isolating the ammonia pressure control valve from the heat exchanger. The operator then connected a steam line to the process line to clean the piping. The steam flowed through the heat exchanger tubes, heated the liquid ammonia in the exchanger shell, and increased the pressure in the shell. The closed isolation and block

References: Occupational Safety and Health Administration (OSHA) Process Safety Management Standard. 29 CFR 1910.119, 1992. American Society of Mechanical Engineers (ASME). Boiler and Pressure Vessel Code, Section VIII, Division I, 2004. Center for Chemical Process Safety (CCPS). Plant Guidelines for Technical Management of Chemical Process Safety (revised ed.). American Institute of Chemical Engineers (AIChE), 2004. CCPS. Guidelines for Engineering Design for Process Safety, AIChE, 1993, p. 539. 9 Goodyear Houston Case Study January 2011 The U.S. Chemical Safety and Hazard Investigation Board (CSB) is an independent Federal agency whose mission is to ensure the safety of workers, the public, and the environment by investigating and preventing chemical incidents. The CSB is a scientific investigative organization; it is not an enforcement or regulatory body. Established by the Clean Air Act Amendments of 1990, the CSB is responsible for determining the root and contributing causes of accidents, issuing safety recommendations, studying chemical safety issues, and evaluating the effectiveness of other government agencies involved in chemical safety. No part of the conclusions, findings, or recommendations of the CSB relating to any chemical accident may be admitted as evidence or used in any action or suit for damages. See 42 U.S.C. § 7412(r)(6)(G). The CSB makes public its actions and decisions through investigation reports, summary reports, safety bulletins, safety recommendations, case studies, incident digests, special technical publications, and statistical reviews. More information about the CSB is available at www.csb.gov. CSB publications can be downloaded at www.csb.gov or obtained by contacting: U.S. Chemical Safety and Hazard Investigation Board Office of Congressional, Public, and Board Affairs 2175 K Street NW, Suite 400 Washington, DC 20037-1848 [phone] CSB Investigation Reports are formal, detailed reports on significant chemical accidents and include key findings, root causes, and safety recommendations. CSB Hazard Investigations are broader studies of significant chemical hazards. CSB Safety Bulletins are short, general-interest publications that provide new or noteworthy information on preventing chemical accidents. CSB Case Studies are short reports on specific accidents and include a discussion of relevant prevention practices. All reports may contain safety recommendations when appropriate. 10