Subsequent to a tube break inside a refinery, fire ignited on a furnace. The emergency shutoff system was tripped and the unit became depressurised via the tube that broke inside the furnace. During this incident, the unit was on a return path to its nominal flow rate. Roughly 24 hours prior to the break, following another incident, the reforming unit was operating at an extremely low flow rate over a 3-hour period. The low flow rate safety system had been bypassed without implementing any compensatory measures. The next day, this information was not even relayed to the daytime shift, with the abnormal situation leading to the quick coking of the tubes and accelerating their creep. The fire had originated from overheated tubes tied to an internal coking operation, caused by operating at an insufficient flow rate (in a breach of safety rules). In underestimating the incident occurring the previous day, the subsequent shift had not been properly informed. The environmental agency requested strengthening the refinery’s safety management rules and verifying their strict implementation, in addition to installing an alarm management system. The agency also requested: formalising both the resources to be notified in the event of a process-related incident outside of plant operating hours and the rules for overseeing unplanned shutdowns and corresponding start-ups; revising the periodic safety test acceptance protocol; and expanding training and recycling programmes thanks to the Company’s new tools, in emphasising furnaces and incident management.