Abstract
The Raffinate Splitter of a major refinery exploded and killed 15 people. The cause of the explosion was a combination of:1.Operators not understanding how their level and flow instrumentation worked.2.Mislocation of a pressure relief valve on the vapor line well below the top of the splitter.3.Relief valve venting indirectly to the atmosphere rather than to the refinery flare.4.A loop seal between the relief valve blowdown drum and the pressurized collection header.
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