Case Studies training courses will present various incidents in fertilizer industry detailing the incident causes, consequences, and lessons learned. This training series introduce a process safety analysis of each incident and the impact in Operational Excellence program.

This incident is related to a top fired primary reformer exploded in an ammonia plant. Incident investigation concluded that the direct cause of the accident was the introduction, by error, of a large amount of fuel gas through unlighted arch burners.

This case study is an excellent lessons learned for operators and engineers involved in both operation and design of new ammonia plants.