An Explosion in Ammonia Back End Process Caused by Missing Path of Maintenance Work

The objective of this paper is to share the past undesirable experience in PT Pupuk Kalimantan Timur in order to be lesson learned on Hydrogen safety. In the beginning of 2018, in Ammonia plant Kaltim 2, there was an incident in back end process that lead to damage in plant assets. The initial problem was identified from leakage of SynGas, Hydrogen content is 74%, in one of heat exchanger in Back End Process. To minimize losing of SynGas to the environment and unsafe condition due to spreading of Hydrogen to the atmosphere, corrective action has been conducted immediately. The working preparation such as Job Safety Analysis (JSA), working procedure, contingency plant was done completely before the corrective work performed. Unfortunately, the explosion occurred while the working is in progress. Although there is no fatality, but Ammonia plant must be shut down and losing of some plant assets. The investigation has been conducted by independent team to find the main cause of the incident. The result of investigation report found that the key problem is a missing path of the previous maintenance work at Turn Around (TA) in 2017. Finally, based on this incident, the author concluded that all personnel in maintenance work should take into account every step of work appropriate with standard and procedure. Also, joint inspection among related parties can be conducted to ensure no missing step in maintenance program.

Keywords : Hydrogen, SynGas, Ammonia plant