CUI Major Incident# 5: Notre-Dame de Gravenchon Butane Release
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:
- A gas cloud formed in the middle of the steam cracker prompting leak detection alarms and a vertical gaseous spray.
- 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.
- An emergency and evacuation plan was conducted to mitigate the effect of butane release.
Root Cause of the Incident:
- Corrosion under insulation was the root cause of the incident.
- Drops of melting ice from a refrigerated ethylene pipe above the butane pipe caused the highly-localized external corrosion.
- 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:
- Lack of appropriate visual assessment and inspection for potential corrosion of pipes.
- Failure to implement proper monitoring and control protocol for pipes handling inflammable, toxic or corrosive products.
- No quality assurance process for pipe linings.
Recommendations to Avoid Corrosion:
- Apply supplemental visual inspection and non-destructive control for all pipes handling inflammable, toxic or corrosive products.
- Perform adequate pipe inspection practices extending to the pipe structures (i.e. racks).
- Proper monitoring and treatment of specific aggressions in the facility.
- 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.