Cause & Consequence
- Uncontrolled release of a flammable gas or liquid
Specific Incident Equipment
Re-boiler channel head flange
The investigation concludes that loose bolts were the cause of the leak. One bolt was only hand tight and others were only about 80% of the recommended torque settings. The channel head had been removed during the shutdown earlier in the year.
Since that shutdown there have multiple production trips and the associated pressure and temperature changes may also have contributed to the loosening of the bolts (this is less likely).
1. Check similar joints for leaks.
2. Review incident with Contractor and review procedures followed.