On July 28, 2001, the primary reactor at the Coffeyville, Kansas Farmland plant catastrophically failed, releasing a large cloud of ammonia gas into the atmosphere. Rick Hunt, a 46-year-old employee of Farmland who was working on a scaffold in the vicinity, was immediately engulfed in a large, highly toxic ammonia cloud. The ammonia seared Rick's throat and lungs causing permanent, disabling injuries to his respiratory tract. Rick is now on the recipient list for a double lung transplant.
Perhaps the most tragic aspect of Rick's injury is that it could have been prevented. The primary reactor at the Coffeyville Farmland plant was used in the manufacture of urea, or nitrogen fertilizer. A process problem resulted in sulfur contamination within the primary reactor, causing corrosion of the tubes within the tube sheet. Shortly before the explosion, in June of 2001, the damaged tube sheet was removed and sent for repairs to Cust-O-Fab, Inc. in Sands Springs, Oklahoma. To repair the tubes, the channel cover of the reactor had to be removed. The channel cover is a large disk of steel approximately four feet in diameter and six inches thick which is secured to the reactor by 16 large, metal studs measuring approximately four inches in diameter and bolted in place by 16 large hexagonal nuts.
The unit is then sealed by a gasket consisting of an inner and outer carbon steel ring and spiral wound Teflon that is placed between the outer edge of the channel cover and the reactor surface.
Cust-O-Fab encountered difficulties in its attempts to repair the tube sheet bundle. The primary reactor failed to hold pressure during the initial hydrotest when welds within the tube sheet bundle leaked. The channel cover had to be removed several times as Cust-O-Fab continued its efforts to repair the leaking tubes. As a result, the threads on a couple of the studs were damaged. One stud was damaged to the point that the nut could not be properly tightened. Cust-O-Fab employees testified that this particular nut would not tighten even when they tried to use a wrench with twice the normal hydraulic capability. As its "fix," Cust-O-Fab's employees decided to split a washer in half to use as a spacer to fill the gap that existed between the nut and the surface of the channel cover. A further complication was that the gasket used to seal the reactor was crushed following the initial hydrotest, and a new gasket had to be obtained. Cust-O-Fab called Farmland and requested that it send a second gasket. Unfortunately,
