Accident Lesson Card · Real investigation (tap external link for official report)
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CCPS Case Report No. CCPS-BEACON-2025-10 2013 Fire Fire Explosion Explosion
Refinery Cooling Tower Explosion and Fire (CCPS Process Safety Beacon, 2013 India refinery case)
Refinery in India (CCPS Process Safety Beacon case study, published Oct 2025)
Related equipment → Cooling Tower (Cooling Tower)
29Fatalities
30Injuries
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

Light hydrocarbon from a leaking exchanger accumulated at a cooling-water line high point; commissioning a new cooling tower unit and opening valves introduced it into the cooling tower, causing fire/explosion (29 dead, many burned)

2Root Cause

Exchanger bundle corrosion leak -> hydrocarbon entered cooling water; no cooling-tower high-point vent/gas detection; commissioning without isolation, violated shutdown-work-stop rule; contractor unfamiliar with petrochemical hazards

3Reliability Lessons (from investigation root cause)
  • The 'Root Cause' above is the core lesson of this accident; not split further.
4Associated Failure Mechanisms (Keywords)
cooling tower hydrocarbon contamination exchanger leak commissioning fire/explosion open venting contractor
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：Center for Chemical Process Safety (CCPS) — AIChE
Official Report：www.aiche.org ↗
Data Verification：verified_url_aiche_ccps_2026-07-20
↗Related Failure Modes · Traceability
Structural Corrosion / Wood Grid Decay structure_corrosionFan Motor Failure fan_motor_fail结垢/堵塞 MECH-FOULING轴承失效（磨损/剥落） MECH-BEARING-WEAR微生物腐蚀 MECH-MIC润滑失效 MECH-LUBRICATION-FAILURE冷却水腐蚀 MECH-CWC不对中 MECH-MISALIGNMENT转子不平衡 MECH-UNBALANCE冲蚀/冲刷腐蚀 MECH-EROSION齿轮磨损/点蚀 MECH-GEAR-WEAR均匀/局部减薄（通用减薄） MECH-THINNING大气腐蚀 MECH-ATMOS联轴器失效 MECH-COUPLING-FAILURE
Report No. CCPS-BEACON-2025-10 · Data from CCPS 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.