CUI Major Incident# 5: Notre-Dame de Gravenchon Butane Release

cui incidents Aug 28, 2020

Notre-Dame de Gravenchon Butane Release

Date and Place of the Incident:

On June 9, 2008, a butane release which lasted approximately 2½ hours occurred at Notre-Dame de Gravenchon, Port-Jerome-Sure-Seine, France.

Summary of the Incident:

  1. A gas cloud formed in the middle of the steam cracker prompting leak detection alarms and a vertical gaseous spray.
  2. The leak occurred from a liquefied butane pipe made of carbon steel which ruptured after significant loss of thickness permitted the thermal expansion of the contained liquid.
  3. An emergency and evacuation plan was conducted to mitigate the effect of butane release.

Root Cause of the Incident:

  1. Corrosion under insulation was the root cause of the incident.
  2. Drops of melting ice from a refrigerated ethylene pipe above the butane pipe caused the highly-localized external corrosion.
  3. Due to severe loss of thickness, thermal expansion of the liquid butane lead to pipe burst.

Financial Loss to Freedom Industries:

Four metric tons of butane leaked from the ruptured pipe which resulted in a substantial financial loss to Notre-Dame de Gravenchon.

Environmental Impact of the Incident:

Due to the good working condition of gas detection sensors and immediate emergency action response, environmental impact was mitigated.  

Fatality or injury due to the Incident:

No injuries or fatalities were recorded during the time of the incident.

 Non-Compliance of Safety Guidelines and Reliability Practices:

  1. Lack of appropriate visual assessment and inspection for potential corrosion of pipes.
  2. Failure to implement proper monitoring and control protocol for pipes handling inflammable, toxic or corrosive products.
  3. No quality assurance process for pipe linings.

Recommendations to Avoid Corrosion:

  1. Apply supplemental visual inspection and non-destructive control for all pipes handling inflammable, toxic or corrosive products.
  2. Perform adequate pipe inspection practices extending to the pipe structures (i.e. racks).
  3. Proper monitoring and treatment of specific aggressions in the facility.
  4. Implement quality assurance process dedicated to the pipe linings.

Links to the photos/videos:

The websites below provide full access to the incident report, useful insights, and related images.






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