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CSB Investigation Report No. 2004-08-I-NM 2004 Safety Safety
Giant Ciniza Refinery Alkylation Reflux Pump Seal Failure Explosion
Giant Industries Ciniza Refinery, Jamestown, New Mexico
Related equipment → Centrifugal pump (centrifugal_pump)
0Fatalities
6Injuries
ExplosionMechanism code ELP
Failure Mode · ISO 14224 Mapping
Damage mechanism (recorded in KB)
ExplosionELP
ISO functional code (as recorded)
ISO 14224:2016 functional failure code
ELP · External leakage - process
ISO ELP — External leakage - process.
1What Happened

Alkylation reflux pump mechanical seal leak -> failed isolation/pressure-relief verification -> alkylate spray -> explosion

2Root Cause

Missing pump mechanical integrity + recurring seal failures not root-caused + inadequate isolation/relief procedures (MOC gap)

3Reliability Lessons (from investigation root cause)
  • Missing pump mechanical integrity
  • recurring seal failures not root-caused
  • inadequate isolation/relief procedures (MOC gap)
4Associated Failure Mechanisms (Keywords)
pump mechanical seal leak explosion isolation bearing mechanical integrity
About the Failure-Mode Code (click to expand)

The recorded code ELP is an ISO 14224:2016 functional failure code (describes what the equipment failed to do). The damage mechanism (how it failed) is shown in the Mapping block above. The two are distinct dimensions in ISO 14224.

5Evidence Source (transparent)
Authority:U.S. Chemical Safety and Hazard Investigation Board (CSB)
Official Report:www.csb.gov ↗
Data Verification:verified_url_csb_report_2026-07-20
Related Failure Modes · Traceability
Cavitation Pitting cavitation_pittingErosion Wear erosion_wearCorrosion Perforation corrosion_perforationFatigue Fracture fatigue_fractureFlow Passage Blockage flow_passage_blockageImbalance imbalanceClearance Wear clearance_wearSeizure/Galling seizure_gallingUneven Wear uneven_wearInternal Corrosion Thinning internal_corrosion_thinningCrack/Perforation crack_perforationFlange Leakage flange_leakageVolute Erosion volute_erosionCavitation Damage fmBlade Fracture / Breakage fm_2Face Leakage face_leakageO-ring Aging o_ring_agingSpring Sticking/Fracture spring_sticking_fractureSecondary Seal Failure secondary_seal_failureDry-running Burn dry_running_burnFilter Clogging filter_cloggingBarrier Fluid Loss barrier_fluid_lossBladder Failure bladder_failureOrifice Clogging orifice_cloggingSurface Wear surface_wearCorrosion Pitting corrosion_pittingO-ring Groove Leak o_ring_groove_leakFatigue Fracture fatigue_fracture_2Bending bendingKeyway Wear/Crack keyway_wear_crackJournal Wear journal_wearFatigue Spalling fatigue_spallingLubrication Failure lubrication_failureElectrical Erosion electrical_erosionCage Fracture cage_fractureFretting Corrosion fretting_corrosionNon-drive-end bearing failure fm_3Bearing fatigue spalling failure fm_4Drive-end bearing failure dBearing overheating failure eBearing lubrication failure fm_5Pump shaft failure fm_6Bearing failure fm_7Contamination contaminationGrease Degradation grease_degradationOil Sight Glass Leak oil_sight_glass_leakDiaphragm Fatigue Fracture diaphragm_fatigueElastomer Aging elastomer_agingBolt Loosening bolt_looseningMisalignment Overheating misalignment_overheatingSoft Foot soft_footGrout Cracking grout_crackingAnchor Bolt Loosening anchor_bolt_looseningScreen Clogging screen_cloggingScreen Damage screen_damageValve Sticking valve_stickingPositioner Failure positioner_failureSensor Drift sensor_driftWiring Looseness wiring_loosenessCavitation Pitting cavitation_pittingErosion Wear erosion_wearCorrosion Perforation corrosion_perforationFatigue Fracture fatigue_fractureFlow Passage Blockage flow_passage_blockageImbalance imbalanceClearance Wear clearance_wearSeizure/Galling seizure_gallingUneven Wear uneven_wearInternal Corrosion Thinning internal_corrosion_thinningCrack/Perforation crack_perforationFlange Leakage flange_leakageVolute Erosion volute_erosionCavitation Damage fmBlade Fracture / Breakage fm_2Face Leakage face_leakageO-ring Aging o_ring_agingSpring Sticking/Fracture spring_sticking_fractureSecondary Seal Failure secondary_seal_failureDry-running Burn dry_running_burnFilter Clogging filter_cloggingBarrier Fluid Loss barrier_fluid_lossBladder Failure bladder_failureOrifice Clogging orifice_cloggingSurface Wear surface_wearCorrosion Pitting corrosion_pittingO-ring Groove Leak o_ring_groove_leakFatigue Fracture fatigue_fracture_2Bending bendingKeyway Wear/Crack keyway_wear_crackJournal Wear journal_wearFatigue Spalling fatigue_spallingLubrication Failure lubrication_failureElectrical Erosion electrical_erosionCage Fracture cage_fractureFretting Corrosion fretting_corrosionNon-drive-end bearing failure fm_3Bearing fatigue spalling failure fm_4Drive-end bearing failure dBearing overheating failure eBearing lubrication failure fm_5Pump shaft failure fm_6Bearing failure fm_7Contamination contaminationGrease Degradation grease_degradationOil Sight Glass Leak oil_sight_glass_leakDiaphragm Fatigue Fracture diaphragm_fatigueElastomer Aging elastomer_agingBolt Loosening bolt_looseningMisalignment Overheating misalignment_overheatingSoft Foot soft_footGrout Cracking grout_crackingAnchor Bolt Loosening anchor_bolt_looseningScreen Clogging screen_cloggingScreen Damage screen_damageValve Sticking valve_stickingPositioner Failure positioner_failureSensor Drift sensor_driftWiring Looseness wiring_looseness轴封泄漏 shaft_seal_leak火灾时无法启动 fwp_fail_to_start叶轮磨损/汽蚀 fwp_impeller_wear密封泄漏 fwp_seal_leak稳压泵(jockey)失效 fwp_jockey_fail止回阀失效/回流 fwp_check_valve_fail吸水口堵塞/液位低 fwp_suction_loss联轴器不对中/失效 fwp_coupling_fail测试/泄压阀卡涩 fwp_test_relief_fail泵体/管路腐蚀(长期备用) fwp_corrosion同步齿轮齿面磨损 timing_gear_wear同步齿轮断齿 timing_gear_tooth_fracture螺杆/转子磨损·间隙增大·内漏 rotor_wear_clearanceNPSH 不足 cavitation对中不良·不平衡·振动 misalignment_imbalance温升过高 overheating基础松动·共振 foundation_resonance柱塞填料泄漏 packing_leakage阀片断裂 valve_disc_fracture柱塞磨损/划伤 plunger_wear_scoring液力端裂纹 liquid_end_cracking排量不足/打量下降 capacity_loss曲轴/连杆磨损 crank_rod_wear十字头磨损/敲缸 crosshead_knock隔膜破裂(隔膜泵) diaphragm_ruptureNPSH 不足 cavitation安全阀起跳/内漏 relief_valve_leak润滑油污染变质 lube_oil_degradation联轴器对中不良 coupling_misalignment
Report No. 2004-08-I-NM · Data from CSB public investigation conclusions, compiled by Reliability AI, for reliability demonstration purposes only. This case is derived from public incident investigation reports for learning purposes only. AIM does not endorse or guarantee its accuracy.