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CSB Investigation Report No. 2021-07-I-TX 2021 Toxic release Toxic Safety Safety
LyondellBasell La Porte 醋酸装置柱塞阀压力保持件误拆致命泄漏
LyondellBasell La Porte Complex, La Porte, Texas
Related equipment → Control valve (control_valve)Related equipment → piping (piping)
2Fatalities
2Injuries
FailureMechanism code FTC
Failure Mode · ISO 14224 Mapping
Damage mechanism (recorded in KB)
FailureFTC
Internal damage-mechanism code (not ISO 14224)
ISO 14224:2016 functional failure code
OTH · Other
Mapped to ISO OTH — Other.
1What Happened

承包商误拆柱塞阀压力保持螺栓(本为拆执行机构)→阀塞弹出,164,000 磅 238°F 醋酸混合物喷出,2 死 2 重伤

2Root Cause

阀门设计未防人误拆(同类事故重复发生);无拆卸程序与培训;承包商与公司均未识别风险

3Reliability Lessons (from investigation root cause)
  • The 'Root Cause' above is the core lesson of this accident; not split further.
4Associated Failure Mechanisms (Keywords)
柱塞阀 阀门 压力保持 误拆 醋酸 泄漏 维护 培训 MOC
About the Failure-Mode Code (click to expand)

The mechanism code FTC shown on this card is the KB's internal damage-mechanism abbreviation (not an ISO 14224 code); it describes how the equipment failed. The 'ISO 14224 Mapping' block above maps it to the correct ISO functional failure code (which describes what the equipment failed to do) — these are two distinct dimensions in ISO 14224. The mechanism follows the narrative in the card body.

5Evidence Source (transparent)
Authority:U.S. Chemical Safety and Hazard Investigation Board (CSB)
Official Report:www.csb.gov ↗
Data Verification:verified_url_csb_2026-07-24
Related Failure Modes · Traceability
Valve Body Corrosion / Erosion fmValve-seat Surface Damage -> Internal Leak fm_2Valve-plug Erosion fm_3Valve Stem Sticking / Bending fm_4Packing Wear -> External Leak fm_5Diaphragm Rupture fm_6Spring Fatigue / Fracture fm_7I/P Converter Failure i_pFeedback Link Loosening fm_8Coil Burnout fm_9Valve Plug Sticking -> Failure to Actuate fm_10Contact Corrosion / Poor Contact fm_11Filter-element Blockage -> Insufficient Supply fm_12Pressure-Relief Valve Set-point Drift fm_13内腐蚀(Internal Corrosion) internal_corrosion外腐蚀(External Corrosion) external_corrosion保温层下腐蚀 CUI(Corrosion Under Insulation) cui冲蚀-冲刷腐蚀(Erosion-Corrosion) erosion_corrosion死角/滞留区腐蚀(Dead-Leg Corrosion) dead_leg_corrosion热疲劳(Thermal Fatigue) thermal_fatigue振动疲劳(Vibration Fatigue) vibration_fatigue应力腐蚀开裂 SCC(Stress Corrosion Cracking) scc氢致开裂 HIC(Hydrogen-Induced Cracking) hic脆性断裂(Brittle Fracture) brittle_fracture高温蠕变(High-Temperature Creep) creep法兰-垫片密封泄漏(Flange/Gasket Leak) flange_gasket_leak焊缝缺陷/未熔合(Weld Defect) weld_defect水击(Water Hammer) water_hammer堵塞/沉积(Blockage/Deposit) blockage机械损伤/第三方破坏(Mechanical Damage) mechanical_damage阀座工艺介质泄漏 seat_leakage_process阀门卡涩(机械卡阻) valve_sticking_through弹簧松弛整定漂移 spring_relaxation_setpoint_drift喉部冲蚀 nozzle_erosion阀盖泄漏 bonnet_leakage整定压力错误 improper_set_pressure异物堵塞 foreign_object_blockage起跳颤动 chatters_on_lift选型过小排量不足 sizing_undersized结垢/堵塞 MECH-FOULING均匀/局部减薄(通用减薄) MECH-THINNING机械疲劳 MECH-MECH-FATIGUE脆性断裂 MECH-BRITTLE-FRACTURE
Report No. 2021-07-I-TX · 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.