A naphtha hydrotreater heat exchanger ruptured during a startup operation, releasing flammable hydrogen and naphtha
at over 500 °F. The U.S. Chemical Safety Board investigation found that the unit had been operating for years inside
conditions for which the controlling integrity assumption — the API 941 carbon-steel Nelson curve — was simply not conservative enough.CSB
"Tesoro did not monitor actual operating conditions of two of the exchangers, including the badly degraded one
that ruptured, even though it would have been technically feasible to do so."
Inadequate IOW management is not a paperwork problem. It is the gap between what the equipment is rated for
and what it is actually being asked to do — and when that gap stays invisible, people die. Every operator on the
Gulf is one undetected damage-mechanism interaction away from its own version of this incident.