Major Ammonia leak from HP

Ammonia Feed Pump

This paper discusses a major ammonia leak due to failure of a high pressure ammonia feed pump in
the urea plant owing to detachment of the HP locknut of a plunger. During the incident, HP packing
rings and lantern “O” rings got ripped off and liquid ammonia gushed out. This led to an on-site
emergency and shutdown of the plant.

Though the incident had the potential to cause fatalities, the situation was well managed without any
injury due to the strengths & practices inculcated in the organization. Furthermore, the deficiencies
in mechanical integrity were exposed, leading to improvements in reliability and safety.

P.Hari Narayana Reddy, R. Raghavan and Ramashray Singh

Nagarjuna Fertilizers and Chemicals Limited

H andling of liquid ammonia always poses a

great challenge in terms of safety &
environment.

In the history of the chemical industry, there have

annual production capacity of 1.6 million MT of
Urea.

Streams I and II were commissioned in July 1992

been many accidents involving major ammonia and March 1998 respectively. Each stream
leaks which have lead to losses in terms of human consists of a 900 MTPD ammonia plant and a
life and property. 1500 MTPD urea plant, each based on natural gas
as both feed and fuel. The ammonia plants are
based on Haldor Topsoe’s conventional steam
reforming technology and the urea plants are
Introduction based on Snamprogetti’s ammonia stripping
technology.
M/s Nagarjuna Fertilizers & Chemicals Limited
(NFCL) is one of the fertilizer giants in India, Due to recent debottlenecking, both the ammonia
with manufacturing facilities at Kakinada, a port and urea plant capacities have been upgraded to
city in the southern region of India. 1325 MTPD and 2325 MTPD respectively.

It operates two ammonia and urea streams and

associated offsite facilities, Figure 1, with an

2010 85 AMMONIA TECHNICAL MANUAL

 Description of Urea Plant
Typical process steps involved in a urea plant are
urea synthesis, urea purification, concentration &
prilling and process water treatment, Figure 2.

Figure 1: General Layout of Complex

Occupational Fire Utility Air

& Cooling Towers for Compression
Health
Safety Ammonia-1& Urea-1 Units
Centre

Ammonia-1 Urea-1
Power
Generation
Unit-1

Central Control room

for Power Generation
Ammonia-1& Urea-1 Unit-2

Ammonia-2 Urea-2

The booster pump discharge is fed to the

The urea plant where the incident took place
reciprocating HP ammonia feed pumps and
operates with all the latest features, such as:
pressure is further increased to around 23500KPa
(240 Kscg) before it is fed to the urea reactor for
1. 14 improved Casale Sieve trays in the urea production of Urea, Figure 3.
reactor.
2. Bi-metallic HP stripper
The reciprocating pumps were supplied by M/s
3. Dedicated vacuum section for the pre-
Peroni, Italy. The pumps have five horizontal
concentrator
type plungers, with oil lubrication / sealing for
4. Pre MP decomposer to utilize the excess low
packings / plungers. Table 1 shows pump
pressure steam generated in the plant.
specification sheet and Figure 5 the plunger
5. Wet and dry de-dusting systems for the prill
packing arrangement.
tower and conveyor gantry.
Incident
Ammonia coming from the ammonia plant or
ammonia storage is drawn into a receiver tank and
On 04th May 2007, at around 03.33 hrs, Urea
pressure is initially boosted via centrifugal pumps
plant-1 field operators, who were in the field
to around 2000 KPa (21Kscg).

AMMONIA TECHNICAL MANUAL 86 2010

 room, heard some sound in the field and came out.
They noticed a heavy ammonia leak from the HP
ammonia feed pump (P101-C) and immediately
informed the control room via the paging system.

Figure 2: General Layout of Equipments in Urea Plant-1

Carbamate Urea N
Condenser Reactor
CO2
Ammonia Compressor Decomposition
Compressor House & Vacuum
House concentration

Prill
Tower
Ammonia
Syn.Loop
And
Hydrogen
Recovery
Unit
HP Ammonia Feed HP Carbonate
Pumps Pumps

Area Operators
Cabin

Figure 3: Ammonia Network in Urea Plant

NH3 from
Ammonia Plant/
Storage

Ammonia Receiver
(V-101) Urea Reactor

On - Off HP Ammonia feed pumps

Valve P-101A/B/C

Ammonia Booster Pumps

P-105A/B

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 At 03.35 hrs, the pump was tripped locally by the On-site emergency (Level-2 emergency), which
field operator. Normally, operators use has the potential to affect the neighboring plants,
radios/Walkie-Talkies only during Start-up and but not beyond the boundaries of NFCL was
Shut-down operations. declared. Assistance from Fire & Safety staff in
the form of Fire tender reached the site. Under the
Unfortunately, the leak did not rescind and guidance of the incident controller, spray curtains
ammonia vapors began spreading towards North – were arranged to contain the spreading ammonia
East/West directions (Ammonia plant-1, Urea vapour cloud.
plant, CO2 compressor house, Unit-1 cooling
towers and Unit-2 Power generation plant (Ref. Arresting leak and handling the emergency
Fig No.4)).
1. Thick Ammonia vapors started spreading to
At 03.40 hrs, it was decided to shut the plant
the Unit-2 Power Generation plant (combined
down. The other running HP ammonia feed pump
cycle gas turbine with waste heat recovery
(P101-A) was tripped from the control room and
boiler), Ammonia Plant-I back end and other
the shut-off valve in the HP ammonia feed pumps
areas as indicated in Figure 4.
suction was closed via the Shutdown System
(SDS) in the control room and the centrifugal
2. The Manual Call Point (MCP) (an alarm
booster pump was stopped from the electrical
button) was activated and a message was sent
substation. Thereafter, the leak came under
to Fire & Safety control centre.
control and plant shutdown actions were followed.
3. The Urea-I Shift in charge (SIC) (who had
Table 1: Details HP Feed Pump Specification taken charge as Incident controller) declared
an onsite emergency as the leak was not
arrested even upon tripping the besieged
pump. The other feed pump was also tripped
and then the shut-off valve in the common
suction was closed from a remote area i.e.
control room. Ammonia leaking out from the
besieged pump was completely stopped.

4. As the ammonia feed to the urea reactor got

cut off, the urea plant shutdown was initiated.

5. All important actions were carried out

immediately by the field operators by wearing
Self Contained Breathing Apparatus (SCBA)
after the urea plant shut down, viz. putting the
CO2 compressor on barring, diverting the urea
melt from the vacuum section to the storage
tank and washing different lines like reactor
feed lines, melt line etc.

AMMONIA TECHNICAL MANUAL 88 2010

 Figure 4: Spread of Ammonia Leak

Occupational Utility Air

Cooling Towers for Compression
Health
Ammonia-1& Urea-1 Units
Centre

Ammonia-1 A B C Urea-1
Power
Generation
Unit-1
Central Control room Power Generation
for Unit-2
Ammonia-1& Urea-1

Ammonia-2 Urea-2

6. Meanwhile, the Ammonia plant-1 back end plants via the paging system. Control room
(compressor house, synthesis loop and air-conditioning was switched off.
hydrogen recovery unit), which are adjacent to
the urea plant, were affected with ammonia 8. Power Generation Unit-2, which is located on
vapors. Each of the three ammonia leak the western side of the urea plant was also
detectors located in the Ammonia Plant-1 affected due to a change in wind direction.
back end responded and alerted the control Operators did not have any clue as to what
room. The compressor house operators rushed was happening for some time so they wore on-
to CO2 removal section located on the line air respirators and remained behind closed
northern side, which was unaffected. These doors.
operators were given first aid at the
Occupational Health Centre, located within 9. Meanwhile, communication was given to all
the complex. Ammonia plant operations important personnel via pagers (which will
remained unaffected. give a predetermined number against
emergency in a particular plant) and also via
7. Ammonia plant-1 and Urea plant-1 have telephone by the laboratory chemist in the
common control rooms located opposite to shift.
Ammonia plant-1 (North-West side of Urea
plant-1). The control room operators 10. The production head who reached the site first
continued operations using the on line took over as the Emergency Controller and
respirators bank (which can last long for about started guiding the Shift In Charge, effectively
90 min. upon usage by four operators). The streamlining the shut-down actions, effluent
Ammonia-1 Shift in charge alerted all other containment, Occupational Health and Fire &
Safety activities.

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 11. Head count of the persons in the Urea Plant-I, & procedures to handle such emergencies in
neighboring manned areas like Ammonia future.
Plant-I Compressor house, Plant-I Control
Room, Power Generation-2 Control Room, • The investigation team swung into action and
Plant-I cooling towers was taken and the well- interacted with shift personnel from the
being of all personnel was ensured. various plants in order to gather information
about the difficulties they faced so as to
12. In the meantime, the Site In charge and all connect the events for detailed analysis. The
heads of departments reached the site. following were the observations made upon
Analysis and further course of actions were inspecting the failed 4th cylinder and HP
finalized. locknut of the HP ammonia pump.

How And Why Did This Incident Happen? Photo 1: Dislocated 4th cylinder lock nut and
Lantern
• The 4th cylinder HP locknut on the HP
ammonia feed pump (P-101C) got detached
from the cylinder The lantern, along with its
“O” rings, came out of the cylinder, the HP
packing rings and lantern “O” rings got ripped
off and high-pressure liquid ammonia leaked
out.

• Upon inspection of the failed cylinder and

lock nut, it was observed that the cylinder OD
in the threaded portion and HP lock nut
threads ID were in a worn-out condition. This
led to the unlocking of the locknut and the
failure. The HP locknuts and lanterns were
originally supplied by M/s. Peroni (OEM)
during plant commissioning in the year 1992
and have been in service since then. They are
made of carbon steel and are usually visually Photo 2: Lantern Slid from Position upon
inspected and dye-penetration tested during Slipping of HP Locknut
packing replacement. The threads are applied
with a compound called ‘Molycoat’, which
acts as an anti-seize and lubricant. The HP
nuts are tightened by hand using a large
wrench.

Investigation and root cause analysis:

• A three member multi-disciplinary team of

managers from Production, Mechanical
maintenance and Condition monitoring was
constituted by the Site In Charge to investigate
the incident, recommend various steps to
avoid such failures and strengthen the systems

AMMONIA TECHNICAL MANUAL 90 2010

 Photo 3: Scoring Marks of the Lantern Observations
1. The fourth cylinder threaded portion was
found to be tapered.

2. The threaded portion of the fourth cylinder

was found to be 184 mm as against 184.7mm
(worn out by 0.7mm).

3. The HP locknut threads ID found to be

183.30/183.54/184.0 mm as against 182.7mm
(reduction was varying from 0.60 to 1.1mm).
The reasons for this reduction is thought to be
due to fewer threads being in contact and wear
& tear that resulted during extended service
Photo 4: Threads damaged on cylinder (lock without inspection.
nut area)
4. 9 out of 20 threads were found to be partly
scoured out. Similarly, in the HP locknut 6 out
of 20 threads were found to be scoured out.
There was no fresh damage noticed in either
thread.

5. The lantern got detached from the inside of

the cylinder.

6. The lantern bottom “O” ring groove portion at

OD and the corresponding cylinder ID portion
at the lantern mating area had severe scoring
marks (as shown in Photo no.3).

Photo 5: Ripped out LP Packing thrown 7. All five HP braided packing rings along with
10 meters away the two PTFE support rings were found
missing inside the cylinder and they were
found scattered about 10 meters away (as
shown in Photo no.5).

8. After becoming detached from the cylinder,

the HP lock nut was found near the power end
oil seal housing.

All of the probable reasons such as process

disturbances, material failure and lapse in
maintenance practices etc. for the running
ammonia feed pump HP locknut detachment were
analyzed by the investigation team to establish the
root cause, details in Table 2.

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 Actions Implemented Conclusion
1. The number of threads engaged between the 1. Top level management commitment to
HP locknut and cylinder have been increased systems implementation and deriving benefits
from 12 to 16 with OEM Consent. helped immensely in the early control of the
emergency.
2. The criticality matrix of the Maintenance
Integrity Module was reviewed and a fresh 2. Innovative methods of emergency
schedule has been drawn up for periodic communication (which does not require the
inspection of the HP locknuts of all pumps on communicator to dial each telephone number)
a half yearly basis. helped in effectively spreading the
information to all key personnel living in the
3. A provision for tripping the ammonia booster town ~10 kms radius away from complex.
pumps, which feed to the HP ammonia feed
pumps directly from the control room, was 3. The on-off valve that was installed as a fall
provided in both Urea plants. out of a previously conducted HAZOP study
has helped immensely in quick positive
4. An on-off valve was provided in Urea plant-2 isolation from a remote location without
in the same location i.e. HP ammonia feed affecting the personnel.
pumps’ common suction, as it proved very
effective in isolation from a remote location , 4. The air respirators bank provided in all of the
rrfer to Figure 3 for the exact location. main control rooms also helped in allowing
panel operators to continue and control the
5. The personnel whose presence of mind and critical operations from the control room
timely emergency actions helped in mitigating through DCS.
the incident were appreciated and rewarded.
5. Periodic review of the criticality matrix of the
6. To further strengthen the emergency Mechanical Integrity module, even when
preparedness of shift personnel, the concept of things are running smoothly, was introduced.
conducting tabletop drills, depicting the Any modifications are implemented only with
various scenarios, was introduced. OEM consent and after HAZOP studies are
performed, which helps in improving the
reliability factor.
7. The curtain water system covering the HP
ammonia feed pumps and HP carbonate 6. Thorough incident investigation with active
pumps was implemented with remote employee participation also helped to establish
activation, Figure 6. the root cause and address the deficiencies.

7. Learning from the incident has been

disseminated to all relevant plant personnel in
the complex, which helps to improve
preparedness for similar incidents in the
future.

AMMONIA TECHNICAL MANUAL 92 2010

 Table 2: Root Cause Analysis

Figure 5: General View of Plunger Packing Arrangement

Seal Flush Seal Flush HP Locknut

Outlet Inlet

HP Packing
LP Packing
Lantern
LP Locknut

Plunger

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 Figure 6: Curtain Water system Installed around HP Ammonia Feed Pumps

About the authors

Mr. Ramashray Singh is a chemical engineer Mr. P Harinarayana Reddy is a Chemical
working as Sr. General Manager (Plant Engineer with a Post Graduate Diploma in
Operations) at Fertilizer Complex, Nagarjuna Ecology & Environment, working as Deputy
Fertilizers & Chemicals Limited, Kakinada. He General Manager (Production) at Fertilizer
has more than 34 years of experience in Complex, Nagarjuna Fertilizers & Chemicals
commissioning & operation of Ammonia / Urea Limited, Kakinada. He has more than 20 years of
Plants. He has worked in various Fertilizer experience in commissioning & operations of
industries in India at different capacities. Ammonia / Urea plants

Mr. R Raghavan is a chemical engineer with a

Post Graduate Diploma in Management, working
as General Manager (Plant Operations & Projects)
at Fertilizer Complex, Nagarjuna Fertilizers &
Chemicals Limited, Kakinada. He has more than
29 years of experience in commissioning &
operation of Ammonia / Urea Plants in India and
the Middle East.

AMMONIA TECHNICAL MANUAL 94 2010