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Accident # | 156198 |
State Police # | 14-02266 |
Accident Date | 2014-05-23 |
Report Date | 2014-05-30 |
Follow-up Date | 2014-07-22 |
Follow-up: | Yes |
Pollutant | Duration | Point Source | Greenhouse Gas | Criteria Pollutant | Ozone forming chemical | Amount of Release |
Sulfur Dioxide | 1h 5m | U215 hydrocracker | NO | YES | NO | 5,278.0 pounds |
Compressed Flammable Gas | 5h 47m | Tank 5000-6 | NO | NO | YES | 13,735.0 pounds |
NOx | 1h 5m | U215 hydrocracker | NO | NO | YES | 108.3 pounds |
Carbon Monoxide | 1h 5m | U215 hydrocracker | NO | YES | NO | 589.2 pounds |
Volatile Organic Compounds (VOCs) | 1h 5m | U215 hydrocracker | NO | NO | YES | 230.6 |
Particulate Matter 10 | 1h 5m | U215 hydrocracker | NO | YES | NO | 11.9 pounds |
Particulate Matter 2.5 | 1h 5m | U215 hydrocracker | NO | YES | NO | 11.9 pounds |
Highly Reactive Volatile Organic Compounds (HRVOCs) | 1h 5m | U215 hydrocracker | NO | NO | NO | 0.2 pounds |
Hydrogen Sulfide | 1h 5m | U215 hydrocracker | NO | NO | NO | 21.3 pounds |
Accident Classified As: Reportable Quantity
An emergency shutdown device was triggered due to an incorrect reading on the Treating Reactor Bed 3 temperature indicator in the U215 hydrocracker which depressurized the unit to the South Ground Flare. In response to the shutdown, operations utilized the refinery slop line to deinventory the unit, routing material to Tank 500-6. Natural gas was inadvertently routed through the refinery slop line where Tank 500-6 received the vapor, causing a release through the tank seals. Human factors also played a role in the incident.
Root causes were identified as equipment difficulty and procedures followed incorrectly.
Root causes identified as Equipment Difficulty-Design Specs and Procedures Followed Incorrectly. At the time of the release, the emergency shutdown system was activated as designed shutdown the hydrocracker. Multiple recommendations have been identified to prevent a recurrence. The Tech Services Department at MPC has been tasked with mitigating the hazards of a single point of failure due to false temperature indication (anticipated completion 1/31/15). The operations department will develop and implement a system to verify all steps are completed and signed off when following procedures. A team will be developed to conduct a hazard analysis on the entire refinery slop system to implement necessary safeguards to prevent unwanted material from entering the slop system.
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