OvV report - Butane/butene emission, Shell Nederland Chemie BV, Pernis, 1 April 2006

At Shell Nederland Chemie B.V. in Rotterdam, the production of Secondary Butyl Alcohol (SBA) was started up on 1 April 2006 after a maintenance stop. During start-up a ball valve had to be operated. The handle of this valve slipped and the butane/butene mixture present in the pipe sprayed out. The operator operating the valve received the released butane/butene in his face and suffered a burn. There was no ignition, so the incident was limited to the emission of a highly flammable gas cloud.

Significance score:

Clarity:

Shortened investigation report with lessons on: - The loosening of a spindle from the body of a ball valve in a sulphuric acid pipe due to accelerated corrosion on the inside of the valve caused by turbulent fluid conditions and choice of material for the spindle.

Target Group(s):

• HSE managers
• Site managers
• Strategic leadership
• Supervisors

Risk Theme:

• Monitoring and Learning - Learning from Incidents