[MAJOR ACCIDENTS IN OIL AND GAS, PETROCHEMICALS AND PHARMACEUTICAL]

January 2013 Semester

ABSTRACT

In this modernization era, oil and gas industry, petrochemical industry and pharmaceutical industry is among the leading industry in the world as well as the main source of economy for majority of the developing country and developed country. Thought out the years since Industrial Revolution in 1760s many major accidents were reported involving these industries. The consequences of these major accidents also giving quite a huge impact to the country, society and economy cause it not only involve property damage with billions of loss but also life of the people and the environment. Due to its importance and drastic development, significant concerns about the environmental consequences, economic consequences and safety features in these industries are being in the centre of attention. Nowadays, these industries around the globe are focusing to achieve new levels of efficiency, safety and sustainability in order to minimising the consequences hence protect worker, public and environment.

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January 2013 Semester

INTRODUCTION
Industrial development is increasing drastically especially in the field of oil and gas. High demands in the industrial have led to building many plants all over the world especially in Asian where the production can be made with lesser cost. This mini thesis was conducted in order to understand more on the causes of major accidents, its consequences and to examine lessons to be learned in order to challenge some existing paradigms and identify opportunities for the future. The National Safety Council describes an accident as an undesired event that results in personal injury and property damage. It usually implies a generally negative outcome which may have been avoided or prevented had circumstances leading up to the accident been recognized, and acted upon, prior to its occurrence. This report which focused on the major accidents that involved oil and gas industry, petrochemical industry, and pharmaceutical plant will outline the causes, relief measures, consequences and lesson learnt throughout the analysis of these catastrophic events. The information gathered were obtained through reading of past thesis on major accidents in industrial plant, report paper on the major accidents in industrial plant as well as books relating to major accidents in plant. Throughout the analysis of these three industries of major accidents, there were several causes were identified and some main phenomenathat cause the accidents will be focused and outlined in this report. The main phenomena are the loss of containment of liquid and gas vapour release, ignition source, dust explosion, reactive incidents, benzoyl peroxide explosion, and vapour cloud explosion.

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January 2013 Semester

ANALYSIS OF CASE STUDY

Loss of Containment
1.0 CAUSES

Major accidents commonly start with a loss of containment. Loss of containment ascribe as exists of material contained in an enclosed place (tank, pipe or column) to atmosphere through a hole, crack or an opening valve. The cause may start from corrosion, mechanical impact or human error.

The sequential effect of the loss depend on a series of circumstances such as the condition of material, its properties, the meteorological conditions and the measures taken to relieve the leak. Below are various loss-of-containment events with general guidelines on the causes of loss that was summarized in the Purple Book.]

I.

Loss-of-containment events in pressurized tanks and vessels Instantaneous release of the complete inventory Continuous release of the complete inventory in 10 min at a constant rate of release Continuous release from a hole with an effective diameter of 10mm

II.

Loss-of-containment events in atmospheric tanks Instantaneous release of the complete inventory (Directly into atmosphere, from the tank into an unimpaired secondary container) Continuous release of the complete inventory in 10 min at a constant rate of release (Directly into atmosphere, from the tank into an unimpaired secondary container) Continuous release from a hole with diameter of 10mm (Directly into atmosphere, from the tank into an unimpaired secondary container)

III.

Loss-of-containment events in pipes A leak with a diameter of 10% of the nominal diameter (maximum of 50mm). For fullbore rupture (outflow from both sides) in a pipe, CD=1.0. In other cases, CD=0.62. Assume that the pipe has no bend and a wall roughness of approximately 45m.

[MAJOR ACCIDENTS IN OIL AND GAS, PETROCHEMICALS AND PHARMACEUTICAL]

January 2013 Semester

IV.

Loss-of-containment events in pumps Full-bore rupture of the largest connecting pipeline.A leak with a diameter of 10% of the nominal diameter of the largest connecting pipe (maximum of 50mm). If no pump specifications are available, assumes a release rate of 1.5 times the nominal pumping rate.

V.

Loss-of-containment events in relief devices Discharge at the maximum discharge rate.

Loss-of-containment is potentially to cause major accidents in upstream oil and gas production, pharmaceutical (chemical) industries and petrochemical industries.

One of major accidents due to loss-of-containment is the petrochemical plant Flixborough 1974 accident which leaves no trace. All the staff present in the control room was reported died and destruction of all unit devices. Secretary of State for Employment was assigned to investigate the accident where 3 hypotheses were presented however not unanimously accepted. The conclusion of investigation mention of the fact that despite the forces exerted by hydraulic thrust of cyclohexane, no calculation was carried out and no concern was voiced out over the structural strength of the bellows and the bypass. Other than that, no bellows manufacturers published users guide or a standard or guidelines in effect at the time as reference and failed in employed column or other means to prevent bypass movement.

Picture visualisation on the bypass movement.

[MAJOR ACCIDENTS IN OIL AND GAS, PETROCHEMICALS AND PHARMACEUTICAL]

January 2013 Semester

The accident origin from the leaking of nitrates in the water used in the past to spray the small cyclohexane which is used to limit the risk of ignition that later cause deficiency of Reactor no.5 stemmed due to cracked corrosion. The water enters the insulation and during evaporation, deposited nitrates onto the equipment steel. The concerns over minimizing the downtime and production loses of the plant ultimately gave rise to the accident since it have to shutting down the plant for a few days to analysed the cause of leak prior to any unit reactivation and verified the other reactors with respect to degradation sustained by Reactor no.5.

Explosion of the plant reactors

The three hypotheses from the investigation are the 8-inch pipe hypothesis, water theory and Venarts theory. In the 8-inch pipe hypothesis according Dr John Cox, the primary explosion due to 8-inch pipes cyclohexane leak was the cause for the huge explosion. The primary explosion happens due to poor clamping of both bolts on the valve flange that breaks the seal on the backflow prevention valve. The water theory defended by Ralph King stated that the cause of accident is due to azeotrope that has lower boiling point than water or cyclohexane. Azeotrope was created due to sudden presence of water inside Reactor no.4 (which was not operable due to mechanical malfunction) that interacts with cyclohexane. The explosion happens when the boiling point of the Reactor no.4 was trigger upon start up with installation temperature. Jim Venarts theory stated that it requires 2 stages for the temporary 20-inch pipe to have broken. Investigation report noted a quantity of 40 to 60 tons of cyclohexane contributing to the explosion whereas Venarts theory estimated at 10 to 15 tons of cyclohexane was freed due to the yield of bellow connected with Reactor no.4 through fatigue cause by vibrations generated from liquid flow in the installation.

[MAJOR ACCIDENTS IN OIL AND GAS, PETROCHEMICALS AND PHARMACEUTICAL]

January 2013 Semester

Montara Oil Spill Accident

Montara oil spill was considered as one of Australias worst oil disaster. This scenario took place in Montara oil field in Timor Sea off the northern coast of Western Australia. The cause of accident was an oil and gas leak and subsequently slick that took place following a blowout. According to Commissioner David Borthwicks through his final report, the cause of accident was most likely that the entering of hydrocarbon into H1 Well through its 9% cemented casing shoe and flowed up inside its casing. It was found the primary well control barrier; the 9% cemented casing shoe was a failed.Through investigation Minister Ferguson stated that the accident is due to the failure of the operator and regulator. It was the failures by PTT (Petroleum Authority of Thailand) personnel to verify and test the well integrity before BOP (blowout preventer) was removed to the next well which cause the reservoir fluids entered the well bore, eventually flowing to surface which is open to atmosphere.

In the case of explosions in pharmaceutical plant 2003 Linz, Austria from investigation it was concluded that there is leakage in pipe released methanol/peroxide into the insulation material of the column, made of polyurethane. This happen because the rise in temperature was strengthened upon contact with rusty grid that maintained the insulation material on the column which accelerating the decomposition reaction. The decomposition of peroxide had ignited fire which result in domino effect that caused the explosion of the first column followed by second column.

[MAJOR ACCIDENTS IN OIL AND GAS, PETROCHEMICALS AND PHARMACEUTICAL]

2.0 CONSEQUENCES

January 2013 Semester

In the Flixborough accident here were many victims involve in the accidents from the employees to the people surrounding the plant. During time of accident there are about 72 employees present inside the plant which 28 were killed including 19 employees in the control room and 36 others were injured badly. It was also reported that 53 injuries outside the facility and hundreds more people who bear mild injuries were not officially reported.

Besides that nearly 3000 residents from neighbouring place were evacuated to British Army shelters in order to confront with the risk from combustion fumes of the solvents and chemical substances. Other than that it was estimated about 100 million USD (in 1974 dollars) property damage was reported. All the buildings situated in the radius of 600 meters around accident scene were destroyed. It was recorded a total of 1820 house and 167 retail businesses in the vicinity were damage, about 72 out of 79 houses in Flixborough, 73 out of 77 houses in Amscott and 644 out of 756 houses in Burton. Apart from that, all the fishing activity at the River Tent whose bed flows to the Flixborough site was closed.

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January 2013 Semester

Spills of Chemical Substances.

The physical damage due to explosion.

Compared to Flixborough accident, Montara accidents did not involve any life of the employee all the 69 workers were safely evacuated with no injuries. However these accidents give a huge impact to the environment. According to the Australian Department of Resources, Energy and Tourism it was estimated around 2000 barrels per day of oil leak happened.[10] WWF-Australia and Australian Greens Senator Rachel Siewert claimed that the oil leak was far greater that what it was reported. September 3rd, 2009, it was reported by Australian Maritime Safety Authority (AMSA) that slick with evidence that oil was killing marine life was estimated at 170km from coast of Western Australia spread over 6000 km 2 and moving closer towards the shore.Montara oil spill was described may cause catastrophic for marine ecosystems even though it is a light weight crude oil it could still have toxic effects on birds, coral, marine algae and marine invertebrates.

Image of the oil spill

[MAJOR ACCIDENTS IN OIL AND GAS, PETROCHEMICALS AND PHARMACEUTICAL]

January 2013 Semester

Evidence that oil was killing marine life

In pharmaceutical plant accident Linz, Austria it was reported that 20 of the workers suffered from burns, bone fractures or bruises due to broken glass. All material within 150m radius perimeter was found damage significantly due to projections and broken glass. Other than that, offices situated closed to the explosion are destroyed. There was no environmental damage reported from the observation outside the chemical side since most of chemicals mainly methanol has burned. However the company experiences economic consequences as they lose about 20 million euros.

[MAJOR ACCIDENTS IN OIL AND GAS, PETROCHEMICALS AND PHARMACEUTICAL]

3.0 RELIEF MEASURES

January 2013 Semester

17th July, 1974, Secretary of State for employment has ordered a committee of experts to advise the government on relief measures to control the operations of chemical pants. A draft law entitled Health and Safety at Work was issued and discussed in the House of Commons. In the draft law, it was stated that the operator must adopt all reasonable measures to ensure human health and safety. In effort to improvise industrial risk management, The Flixborough accident as well as Seveso (ARIA 5620) needs to take as lesson to build awareness among industrial to strengthen public authority control over industrial activities presenting major technological risks. This awareness resulted in the adopting of the now wellrenowned Seveso directive by European Council on June 24, 1982. From the accidents, Flixborough rebuilt plant with paying strict attention from what they gained through the accident such as replacing the process involving cyclohexane oxidation with the use of phenol hydrogenation which considered being safer. November 3rd, 2009 the slick from Montara accident was stopped by pumping about 3400 barrels of mud by PTTEPAA into the well and capping the blowout through the wellbore cemented.Other than that, in order to recover the environment the Australian Marine Oil Spill Centre began sprayed 10 000 litres of chemical dispersant onto parts of the slick by mobilising Hercules aircraft.Besides that, environmental monitoring program was executed by Australian Government in assisting the spill response. The environmental monitoring program compromises a series of operational studies, including a wildlife monitoring program.[20] The objective of the wildlife monitoring program is to locate, assess and treat oil affected wildlife. With a lead about managerial oversight issue from PTTEP AA Chief Operations Officer testimony in Montara accidents 2009 recent development in process safety indicators was created.[21] PTTEP AA develops a system upon principles of Swiss Cheese Model by Professor James Reason. The essence of the system is from the status of people involve critically to preventing major accidents events, barriers were identified covering from the front line personnel to senior management drawing on the formal safety analyses and Bow-Ties the safety cases. It is also extremely useful to have records kept of all accidents to plant etc which might have resulted in personal injuries. A careful analysis of these records and a proper study of them will indicate the location and causes of various accident risks the UK safety regulator, 1932. It shows not only we need to know what

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had happened but also what could happen; therefore it is vital to understand the critical measure to indicate performance. LINE OF SIGHT TOOLS

Following explosions in pharmaceutical plant 2003 Linz, Austria there are no change in process made by the company, however the ozonolysis columns was installed in separate cold box at -20oC in different building with video control installed. The ozonolysis columns are also installed with leakage indicator system and the columns are not isolated anymore. Additional safety measure such as pressure and temperature measurements is added as well as building the reactor to resist an explosion and pressure relief valve is installed. In 2004, more than 50 experts from different countries were involved for analysis by company and about 400.000 were spend. The measure taken by company was to modify the process in order to implement a reaction with air and inert gases replacing ozone. All ozonolysis plants with flammable dilution were closed by the local government except for laboratories until the causes of accident are distinguished.

[MAJOR ACCIDENTS IN OIL AND GAS, PETROCHEMICALS AND PHARMACEUTICAL] Ignition Source, Dust explosion and vapour cloud explosion 1.0 CAUSES

January 2013 Semester

Ignition sources are defined as any process or event capable of causing a fire or explosion. Accidents caused by ignition happened whenever flammable or combustible materials or substance involved in a process. As a result, fire and explosions could happened and this can lead to losses of human lives, catastrophic disaster, huge loss for the company and nation and also release of thermal radiation to the environment. There are around 19 possible ignition identified by Health and Safety Executives (Hazardous Area Classification and Control of Ignition Sources, 2004)

Flames; Direct fired space and process heating; Use of cigarettes/matches etc; Cutting and welding flames; Hot surfaces; Heated process vessels such as dryers and furnaces; Hot process vessels; Space heating equipment; Mechanical machinery; Electrical equipment and lights Spontaneous heating; Friction heating or sparks; Impact sparks; Sparks from electrical equipment; Stray currents from electrical equipment Electrostatic discharge sparks: Lightning strikes. Electromagnetic radiation of different wavelengths Vehicles, unless specially designed or modified are likely to contain a range of potential ignition sources

There are two major effects that are led by ignition which are dust explosion and vapor cloud explosion.

[MAJOR ACCIDENTS IN OIL AND GAS, PETROCHEMICALS AND PHARMACEUTICAL] 2.0 CONSEQUENCES

January 2013 Semester

Dust explosion similar to combustible liquids, combustible or flammable powder could be ignited whenever they are dispersed or finely divided into specific concentration and make contact with an ignition source. They undergo rapid burning and releases gaseous products which contribute to significant pressure rise of explosive force. Dust explosion can be divided into two types, primary and secondary. Primary explosion take place in a confined space or atmosphere such as vessel and chamber, part of manufacturing plant and equipment. The result of these explosions would cause shockwave which will rupture and damage the plant. Due to this event, the disturbed settled dust around the area will goes into suspension. Secondary type which is suspended combustible dusts formed dust clouds which consist of flammable dust, finely distributed, and mixed with the oxygen in the atmosphere. When the clouds make contact with ignition sources large explosions occur. In most cases, primary explosion is the ignition source. Secondary dust explosion is more severe since it propagates through the dusts clouds and caused damages to buildings and surrounding people.

Kinston Accidents (2003) West Pharmaceutical Services plant was destroyed by an explosion and fire on January 29 causing six deaths, dozens injuries and hundreds losses their job. The explosion was due to fine plastic powder which accumulated above a suspended ceiling over the manufacturing area which ignited. The investigators classified this accident as Combustible Dust Explosions and Fire type. Masterton Dust Explosion (1965) A devastating explosion took place in the factory of general Plastics (NZ) Ltd, Masterton. The blast burst floor upwards, demolished a locker room and hurled 300kg machine to the roof. Four people died and six were injured in the incident. The casualties could have been higher as the explosion took place during afternoon tea break, and most staff was away. A short circuit of an under floor electrical socket was identified as the source of ignition for plastic dusts which has accumulated under the floor of the button ornamenting room and initiated a primary dust explosion in the floor cavity. The force of this primary explosion burst the floor upwards taking the un-burnt dust, gasses and flame into both ornamenting and locker room which than leads to secondary explosion. These further explosions caused large-scale damage to the factory.

[MAJOR ACCIDENTS IN OIL AND GAS, PETROCHEMICALS AND PHARMACEUTICAL]

January 2013 Semester

Vapour cloud explosion is very similar to dust explosion except the consequences are more catastrophic. VCE occur when combustible substance such as gasses which is highly flammable exposed to ignition source. In many cases, these gasses escaped to the atmosphere due to rupture or crack in vessel and pipes. The accumulations of these gasses are highly dangerous. Vapour cloud does not require certain concentration to explode however the magnitude of explosion increased due to higher concentration of gas in the vapour clouds. Gas explosion can generate pressure without the presence of confining walls thus makes them more dangerous. During VCE, ignited flames travel quickly through the gases and air mixture inside the cloud. The rapid fire spread faster than the gasses expansion to the atmosphere, thus pressure waves are formed ahead of the flame front. This causes congestion or turbulence within the flow field of gasses which enhance the burning velocity. The faster the flame travels, the higher the pressure generated ahead of it. Thus, transition from deflagration to detonation (DDT) occurs. The detonation is selfsustaining as long as the concentration of gas is at certain limits, which means it will not stop until all the gases are burned. Flixborough Accidents - 1974 Large explosions occurred at Nypro (UK) site in Flixborough which caused severe damaged. Twenty eight workers were killed in the accident and thirty six workers suffered injuries. The probable cause of this incident was identified on the same year before the explosions. They discovered a vertical crack on the reactor which caused a leak of a flammable substance, cyclohexane. A bypass system was installed to make sure other reactor can keep going. On June 1974, the system ruptured which causes a huge amount of cyclohexene escaped. The substance found a source of ignition thus caused the explosion. Buncefield, UK 2005 On 11 December 2005, Buncefield storage depot started to receive excess amount of unleaded petrol leading to overflow. The failure of automatic safety switch alarm causes the tank to fill twice its maximum capacity. The overpressure of liquid contributes to high magnitude concentration of vapor cloud under stable wind conditions. The diameter of the cloud was estimated to be 391m. High speed rotating machine in the pump house is identified as the source of ignition. The effect of overpressure could be felt as far as 2km from the centre explosion.

[MAJOR ACCIDENTS IN OIL AND GAS, PETROCHEMICALS AND PHARMACEUTICAL]

3.0 RELIEF MEASURES

January 2013 Semester

Sources of ignition should be controlled effectively in all hazardous area using proper design measures and systems. Procedure - A thorough safety and inspection should be conducted when handling any equipment possible of causing ignition especially welding and cutting machines. Permit - Clearance permit should be considered wisely before being released. Every aspects of the working area should be inspected before executing the process. Area/Zoning - United Kingdoms Dangerous Substances and Explosive Atmospheres Regulations of 2002 (DSEAR) classified zones to ensure proper tools, activities and equipment are used in the area based on flammable substance concentration in the atmosphere. They are: Zone 0: An area in which an explosive gas atmosphere is present continuously or for long periods; Zone 1: An area in which an explosive gas atmosphere is likely to occur in normal operation; Zone 2: An area in which an explosive gas atmosphere is not likely to occur in normal operation and, if it occurs, will only exist for a short time.

Selection of Equipment - DSEAR also provide a guideline about proper equipment to be used inside the zone which applied on newly installed and newly modified installation. The categories are defined by ATEX equipment directive, from UK law as the Equipment and Protective Systems for Use in Potentially Explosive Atmospheres Regulations 1996. Standards were set out to this equipment to ensure safety of workers and working activity inside the zones.

Lightning Protection - Surge protection device should be installed to protect the structure and work sites against lightning. Ignitions caused by lightning cannot be eliminated entirely but the risk can be minimized. Thus, precautions and emergency action plans should be prepared for worst case scenario.

Vehicles - Normal vehicle has wide range of ignition sources such as electrical circuits, inlet exhaust of combustion engine, electrostatic, overheating on breaks, engines, and other moving parts. A set of rules should be taken where these vehicles may be used and excluded. Vehicles certified to ATEX are highly encouraged to be used in any facilities, power plants, and other hazardous sites.

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Specialist vehicles such as cranes and trucks are used in some cases such as repairs, maintenance and construction. Thus, as specified by DSEAR, these vehicles needs written instruction or permits before entering the sites.

[MAJOR ACCIDENTS IN OIL AND GAS, PETROCHEMICALS AND PHARMACEUTICAL] Reactive Incidents 1.0 CAUSES

January 2013 Semester

Hazard is defined as a situation in the workplace whether chemical or physical condition that has potential to cause harm to human life, environment or property. Reactive hazard is a substance that have potential to initiate a reactive incident by changes its chemical structure which lead to rapid release of energy, heat and gaseous products that will cause severe consequences such as fire, explosion or toxic release. Reactive incident could be describes as a sudden event involving an uncontrolled chemical reaction.

Reactive hazard may undergoes chemical reaction which is runaway reactions, chemical incompatibility between two or more substances, impact or thermal sensitive self-reactive that involve rapid

decompose process producing a potential explosive release of energy. The ability of chemical substances to react when exposed to certain physical conditions or other chemicals, might results in injury of people, death, property damage and negative effects towards the environment if it is not properly manage. Examples of uncontrolled chemical reactions that are considered as reactive hazard in industry are polymerisation, acid-base, oxidation reduction, decomposition and reaction with water. The level of severity effect for reactive hazards depends on various parameters such as temperature, pressure, chemicals concentration, catalytic effects, impurity and many more.

From CSB investigations the common factors contributing to the reactive incident are as follows [5]: 1. Lack of management of change. 2. Lack of awareness of reactive hazards. 3. Ineffective employee training. 4. Inadequate emergency preparedness and community notification. 5. Ineffective plant design and maintenance. 6. Lack of root cause incident investigations and communication of lessons learned.

One of example reactive incident is the major accident at the Catalyst System Inc. Facility in Gnadenhutten, Ohio. This incident happened at 11.55am on 2nd of January. The employees were drying 75 percentage of granular BPO to 98 percentage BPO when the material exploded and decomposed. At

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that time, 25 people were employed in the area and were having their lunch break. Two buildings are located there with building number 1 contains all the paperwork and building two is solely for BPO manufacturing. There are many types of BPO substance. There are the dry BPO which contains less than 5 percentage of water. Then there is the wet BPO which contains 66 to 85 percentage of BPO and 34 to 15 percentage of water. The common PO comes in the form of paste where the BPO and water quantity is almost exactly half. The 98 percentage of BPO is a Class I organic peroxide which can easily explode due to extreme heat, sudden shock or friction. Since it is a strong oxidizer it can easily explode compared to the 50 percentage of BPO paste which is Class IV organic peroxide. The characteristic of a 98 percent Granular BPO is a white rhombic crystalline solid. It is unstable and decomposes at prolong period of exposed temperature between 75 to 80 degree Celcius. Its by product due to decomposition is a white smoke of benzoic acid, phenyl benzoate, biphenyls, benzene, terphenyls and carbon dioxide. This type of BPO cannot detonate but is capable of deflagration. Deflagration is a reaction that moves at less than the speed of sound and is unable to explode without a confinement area compared to detonation which means the exact opposite of deflagration. It has lower potential energy than other conventional explosive but when stored, the explosion can be destructive. Its destructiveness can be reduced by diluting it with water or other proper solvent. At Catalyst System, BPO is manufactured by reacting benzoyl chloride, hydrogen peroxide and sodium hydroxide and since the reaction is exothermic, crushed ice is added for cooling. The many uses of BPO is for dental resin cement, automobile body putty, mine roof bolt, cheese and flour bleaches, silicone rubber and polyvinyl chloride manufacturing. The methods to obtain a 98percentage BPO is by first manufacturing and adding raw material to produce 20 percentage BPO. Water is removed from the centrifuge to produce 78 percentage BPO. A spherical rotating vacuum dryer is used to dry the BPO to produce a 98 percent concentrated.

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The potential causes or probable initiating scenarios of the thermal decomposition are 1) Failure of the temperature probe 2) Contamination in the dryer from exposure to metal surface 3) Hot spot in the dryer 4) Contamination in the dryer from exposure to metal surface 5) BPO remaining in the dryer too long 6) Generation of heat energy from friction 7) Failure of the vacuum pump causing loss of evaporative cooling 8) Generation of a spark due to static electricity

200 pounds of benzoyl peroxide exploded at the Catalyst System Inc. Facility in Ohio

9) Violation of good practise in terms of equipment handling and safety measures to be taken

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2.0 CONSEQUENCES

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One employee received small puncture on his shoulder from flying debris and other were safe since they were having their lunch break at the time. Besides that, there is a small fire in the southwest corner of the building. Runoff water from the building was also tested in several locations to see if they were hazardous. The dryer propelled through the steel dividing wall and landed 35 feet from the initial location. Extensive damaged from the support at the south side of the building can be seen. The roof was also badly damaged.

3.0 RELIEF MEASURES Instantly after the explosion, the automatic building sprinkler activated and the employees went to the designated evacuation area. The quick response from the Gnadenhutten Police and Fire Departments helped in preventing a bigger consequence of the incident. The fire brigade extinguished the fire and several other fire departments were called to assist. Based on the advice on the safety data sheet of the material, water was continuously showered into the building and its contents. The runoff water was tested for its hazard and is concluded not to be hazardous. Occupational Safety and Health Administration (OSHA) investigated the incident and deduced not good practise by Catalyst System. If good engineering practise, flowed industry standards and guidance documents, this incident would not likely happen.

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LESSON LEARNT THROUGHOUT CASE STUDYS ANALYSIS

Flixborough, UK 1974 Incidents
The main reason for the accident to happen was due to failure happened in the management of safety systems at the Houston Chemical Complex. According to healthandsafetyatwork, the FBI had investigated that the unclosed valve during the release was due to the wrong way of air hoses connected. The air hoses were required as they supplied pressure to open and close the valve. Hence, the valves were not closed properly. Indeed, Philips 99 blasts destroyed the control room. As such, a sufficient amount of technical organizational lessons could be learned from this disaster:Errors in the incident: Company safety procedures were not obeyed Absence of process hazard analysis on the polyethylene plant. This in fact has caused serious safety issues to be ignored and overlooked. Absence of permanent combustible gas detection and alarm system Ineffective permit-to-work system for line operating, vehicle access, hot work at hazardous area. Inefficient and ineffective design of the valve Inadequate fire-fighting capability Ignition sources sited near or downwind from large hydrocarbon stores. Ignition sources were introduced into high hazard area without testing. Irrelevant control rooms locations (i.e very near to hazardous operation)

Solutions: 1. Instillation Design It is indeed very important to design the layout and the location room carefully. This is to avoid the risks borne by personnel inside the facility. In this Flixborough accident, the control room was located too near to hazardous operation. In addition to that, the location of onsite occupied premises such as labs and administrative buildings must be analysed and studied properly in order to isolate the most

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hazardous units and limit their access to just authorized staff. Also, the hazard potential present onsite must be limited by reducing the stored hazardous materials. 2. Management of facility modification, personnel interventions and maintenance. Any modification done to the plants or system can lead to risk. Thus, it is essential to use the same and official standard requirements as the original facilities (i.e undergo construction inspection) on the design, constructions and modification for hazardous installations. Also, a systematic maintenance programme is always advisable to ensure the smooth flow of any emergency intervention. Furthermore, the continuity installation operation after an incident required a thorough analysis of the reasons may lead to shut down. As such, an imperfect managing feedback is portrayed due to the ignored and escaped investigations especially in the Reactor 5, even though cracks were already appeared. The crack presence in Reactor 5 that was the source of the accidental sequence, stemmed from corrosion due to drinking water (high nitrates content) sprayed to dilute cyclohexane discharge and minimize the ignition risk. Such human error would not be disastrous if the safety system and corporate safety produces have been followed. 3. Mechanical Lessons Most of the pipes involved in the accident were because of the losing strength. This hence led to formation of liquid zinc. Liquid zinc could increase below temperature 800C - 900C, with 5.8kg/mm2 tension within a few seconds. When zinc is in contact with steel equipment under pressure, the slightest amount of fire would decrease the strength and the reliability of the equipment to the point of failure. In addition to that, the presence of nitrates in the drinking water due to crack of Reactor 5 caused corrosion. Hence, it is necessary to verify the structural reliability for nitrate-induced corrosion to happen. 4. Human Factor Small amount of right personnel was one of the main reasons for the accident to happen. In future, it is hoped that well trained and competent staff be hired and safety programme for hazardous installations are compulsory for everyone in the organizations. A proper recruitment must be done, as this organization and plant require high-competent skilled employees. After all, the key is not only

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productivity, but productivity at the safest conditions. In this case, rushing to restart operation by having incompetent workers to work under economic pressure would worsen the accident.

Montara Oil Spill

Errors of the accident: Failure to maintain well barriers Inefficient management of change control Failure to verify barriers Insufficient amount of personnel competence, hence leading to deficient decision-making.

Solutions 1. Responsibility for Environmental Issues. Employees and organization will definitely ensure the responsibility of operating machinery in the plant if they have been told about the importance of environmental issues related to the energy production. There are many ways a company can do as such (i.e created environmental programme for the employees). Things which are advisable to be included are: Waste disposal advice and management Weather monitoring, anticipation, and spill monitoring activities Oil spill fate, chemistry and computer trajectory modelling Dispersant use and toxicity advice Shoreline contamination assessment Environmental problem solving Environmental priorities and preferred response action.

By having such programmes, it will not only enhance the capabilities of employees, but also creating a huge responsibility to every individual to work effectively and efficiently to protect the environment and to produce maximum energy production. 2. Technical System

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January 2013 Semester

In order to overcome this accident from occurring again, a good governance on technical system is highly required. In this Montara spill, a drilling management system has to be developed to achieve industry best practice. Firstly, carefully defined barrier philosophy must be done to avoid unmaintained well barrier. Also a revamped well operations management must be practiced Verification hold points have to be introduced as a key work steps too. 3. Human Factor Highly competent technical workers are very vital to company especially doing jobs offshore. This is because; a slight change would cause a major disaster. Therefore, to have such kind of employees, a company must ensure to retain its high standard of hiring workers, and also cater proper training for the new workers to fully utilise the technical knowledge. 4. HSE culture and system. HSE managers should always do frequent reports to the CEO. Safety culture must be embedded to everyone in the organization especially on functional HSE staff in drilling.

Linz, Austria Plants Explosion

Errors of the Accident: There was a leakage in a pipe released methanol / peroxide into the insulation material which was made from polyurethene. This has lengthened the rise of temperature especially during summer. The methanol evaporated, leading to an increase in the peroxide concentration. Eventually, the material involved were burned and decomposed and explosion occurred as the domino effect Solutions: 1. Technical System There are many lessons can be learnt due to this incident. One of them is the importance of technical system in the pharmaceutical plants. According to impel, the process did not go through a full safety analysis with determination of physico-chemical and toxicological characteristics of the substance. This aspect is high ignored by companies. Therefore, technical knowledge with correct people to handle them are highly required to prevent such incident from happening again.

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2. Flammable Solvents

January 2013 Semester

Many chemical reactions involved big amount of hazardous and flammable solvents. Hence, thorough studies on cases related to hazardous chemicals must be embedded in the specific organization. One of the ways to overcome this problem is by having cold box, efficient safety devices and pressure-proof reactor.

West Pharmaceutical Rubber Explosion

The dust explosion that has been discussed previously was due to rubber strips that were moisturized by dust, in this case, polyethylene powder. This powder can be as tiny as talcum powder and has the ability to form explosive mixtures when it is exposed to the air. Solutions: 1. Technical Aspects Uncovered and unsealed ceilings are highly not advisable especially the area of which contain explosive dust. On top of that, hazardous and explosive dusts must be made sure not to accumulate until it reaches the explosive environment. Such event may be possible to occur especially with the presence of ignition, confined area, oxygen and dispersion. Also, any possible explosive dust may be accumulated at a place which have not been occupied or used for such a long time. In order to overcome any accident from happening, personnel must make sure to remove the explosive dust carefully before entering the area affected. 2. Dust Control Many prevention methods can be done to prevent this incident from reoccurring: Utilise dust collection system and filtration Utilize vacuum cleaners approved to collect the accumulated dust Minimize the release of dust from process equipment or ventilation system Monitor dust residue in unconfined and confined areas at regular time frames Utilize cleaning methods which inhibit the generation of dust clouds. Locate relief valves further away from hazardous area

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3. Training

January 2013 Semester

Effective and efficient trainings must be implemented to employees and management teams. All employees should be trained to work in an environment that prioritize safety and environment. In this case, workers are expected to have an ample knowledge on overall plant programs for dust control and ignition source control. In fact, it is advisable for them to be trained before starting the work, during the work and when hazards occur. In addition to that, workers who deal with flammable chemicals in the workplaces are required to follow established regulations (i.e. 29 CFR 1910.1200). Such regulations standardize the labels on containers of dangerous chemical substances, catering workers training, and utilizing material safety data sheets.

Pitkin, Louisiana
As pointed out earlier, many reasons have caused the accident happened at Pitkin, Louisiana temple 221 Common Point Separation Facility. This may include: insufficient amount of awareness towards reactive hazards, management of change, health and safety environment and inefficient plant design and maintenance.

Solutions:

1. Health, and Safety Awareness to the workers

In future, it is hoped that well trained and competent staff be hired and safety programme for hazardous especially towards reactive substances are compulsory for everyone in the organizations. This may require a big cost, but benefits in a long term. Eventually, the key is not only productivity, but productivity at the safest conditions.

2. Proper plant design & Monitoring

In this case, engineers, architects, contracts are responsible in designing a separation facility properly. Highly hazardous areas must be isolated away from the public. In addition, the control of temperature and pressure of control room is essential in preventing this accident from happening again. In order to

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January 2013 Semester

achieve this, highly skilled teams must be formed so that a proper plant design can be reached with no technical error Also, regular monitoring sites at regular and frequent interval is vital too.

Catalyst System Inc. Facility in Gnadenhutten, Ohio 1. Proper Cleanouts This is essential especially at areas that contain hazardous chemical substances. Highly skilled workers are required to remove unwanted chemicals from the work area with the correct methods to maintain the safety environment of the work place. Typically, such areas aforementioned must always practice proper documentations to keep track with the disposal of chemical substances. 2. Importance of the Waste Generator Waste generator is reliable and credible methods used by highly knowledgeable workers on waste constituents, and how waste was created. To achieve this awareness, proper training must be done to the workers and only workers who have completed such trainings are allowed to work in such fragile, highly chemical-contained areas. Normally Satellite Accumulation Area (SAA) is applicable at area nearby the point of waster generation. The trained workers must then always coordinate use of the SAA when dealing with reactive substances. It involves safe handling, compliance with land-disposal restrictions and acceptance of the waste by appropriate recycling or disposable facilities. 3. Hazardous Waste Characterization It is important to always maintain records of accumulations of waste. Every time chemical is being placed in confined container (i.e vacuum), one must always keep track of the temperature and the time period of the storage. The record must be timely and accurate reflection of what has been added into the container. Then, when the container is no longer needed, the record eventually will become the basis to be developed and summarise which will be monitored by related personnel.

Create a standard safety board for Chemical and Dust Explosions

Since dust explosions have become a serious problem in American oil and gas industry, many negative outcomes have been developed to such issues. Hence, by having a standardized regulations by established organization, it is hoped that many companies will be aware the importance of safety of environment. On top of that, this regulation is hoped to be address in their workplace too.

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Health and Safety Awareness

January 2013 Semester

Goals; identify the elements necessary for dust to explode, describe difference between primary and secondary dust explosion, and explain the importance of preventing dust from reaching combustible levels. This method is a long-term benefit method as it is for future investment. As people often say, such event is a rare event, but catastrophic when it happens.

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January 2013 Semester

REFERENCES
J.Casal, Evaluations of the Effects and Consequences of Major Accidents in Industrial Plants. Elsevier B.V., Oxford, 2008. Committee for the Prevention of Disasters.Guidelines for Quantitative Risk Analysis (the Purple Book). The Hague, SDU, 1999. "Flixborough (Nypro UK) Explosion 1st June 1974: Accident summary". Health and Safety Executive.Retrieved 2011-09-28. Chartres, John; Kershaw, Ronald; Osman, Arthur (3 June 1974). "Fire rages on after one of the worst disasters in world chemical industry". The Times (London) (59105): p. 1. Parker, R. J. (Chairman), The Flixborough Disaster: Report of the Court of Inquiry, Her Majestys Stationery Office, London, 1975. Gold, Russell; Casselman, Ben (30 April 2010). "Drilling Process Attracts Scrutiny in Rig Explosion". The Wall Street Journal. ABC News. (November 3, 2009). West Atlas oil leak stopped. ABC News.Retrieved February 19, 2013 from http://www.abc.net.au/news/2009-11-03/west-atlas-oil-leak-stopped/1127990. PTTEP Australasia. (November 3, 2009). PTTEP Australasia Timor Sea Operations Incident Information #87.Web Citation. Retrieved February 19, 2013, from http://www.webcitation.org/5l3PRe8Lj. DSM Corporate Communications. (June 4, 2003). Investigations into Causes of Explosion at DSM Plant.DSM Press Release.Retrieved February 16, 2013, from http://www.dsm.com/content/dam/dsm/cworld/en_US/documents/17e-03-melamine.pdf. ABC News. (October 22, 2009).Oil leaking 'five times faster' than thought.ABC News.Retrieved February 16, 2013, from http://www.abc.net.au/news/2009-10-22/oil-leaking-five-times-faster-thanthought/1113420. Siewert, Rachel . (August 29, 2009). WA oil spill much worse than thought. Rachel Siewert.Retrieved February 19, 2013, from http://rachel-siewert.greensmps.org.au/content/news-stories/wa-oil-spillmuch-worse-thought. ABC News. (October 23, 2009). Oil leak worse than feared. ABC News.Retrieved February 19, 2013, from http://www.abc.net.au/news/2009-10-23/oil-leak-worse-than-feared/1114430. ABC News. (September 4, 2009).Oil slick moving closer to coast.ABC News.Retrieved February 20, 2013, from http://www.abc.net.au/news/2009-09-04/oil-slick-moving-closer-to-coast/1417966.

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January 2013 Semester

Buckeridge, John (August 24, 2009). Expert comment on West Atlas oil spill.RMIT Newsroom.Retrieved February 16, 2013, from http://www.webcitation.org/5l3T7EeGp. Neil Sinclair. (August 13, 2003). Explosion injures 18 at DSM Fine Chems plant in Linz, Austria. ICIS News.Retrieved February 23, 2013, from http://www.icis.com/Articles/2003/08/13/511874/explosioninjures-18-at-dsm-fine-chems-plant-in-linz-austria.html. Kletz, T. A., What Went Wrong? Case Histories of Process Plant Disasters, 4th edition, Gulf, Houston, Texas, 1998, Sections 9.1.1, 12.2 and 12.4.5. Teng-yang, R., Sollows, K. F. and Venart, J. E. S., Flow in a scale model of the Flixborough by-pass pipe, Hazards XV The Process, its Safety and the Environment: Getting it Right, Symposium Series No. 147, Institution of Chemical Engineers, Rugby, UK, 2000. Sonti, Chalpat. (November 3, 2009). Oil spill finally stopped: company. WANews.Retrieved February 21, 2013, from http://www.watoday.com.au/wa-news/oil-spill-finally-stopped-company-20091103hv56.html. ABC News. (August 24, 2009). Oil leak could continue for 8 weeks. ABC News.Retrieved February 19, 2013, from http://www.abc.net.au/news/2009-08-23/oil-leak-could-continue-for-8-weeks/1401608. Department of Sustainability, Environment, Water, Population and Communities.(n.d.)."Montara oil spill".Australian Government.Retrieved February 20, 2013, from http://www.environment.gov.au/coasts/oilspill.html. Jacob Andy. (April 9, 2010). Evidence to the Montara Inquiry pages 1784/5.Australian Government: Department of Resources, Energy and Tourism. Retrieved February 18, 2013, from http://www.ret.gov.au.Home Office Safety Organisation in Factories, published by HMSO 1932. R.K. Eckhoff, Dust Explosions in the Process Industries, 3rd ed., Gulf Professional Publishing, USA, 2003. K.L. Cashdollar, Overview of dust explosibility characteristics, J. Loss Prevent. Process Ind. 13 (2000) 183199. U.S. Chemical Safety Board.(n.d.).Combustible Dust Explosion and accidents.Completedinvestigations.Retrieved February 24, 2013, http://www.csb.gov/investigations/investigations.aspx?Type=2&F_All=y. Fire from

OSH Answers.(n.d). Hazard and Risk.Canadian Centre of Occupational Health and Safety.Retrieved February 27, 2013, from http://www.ccohs.ca/oshanswers/hsprograms/hazard_risk.html. Occupational Safety & Health Administration (OSHA).(n.d). Chemical Reactivity Hazards.United States Department of Labor.Retrieved March 1, 2013, from http://www.osha.gov/SLTC/reactivechemicals/.

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January 2013 Semester

Fire from

U.S. Chemical Safety Board.(n.d.).Combustible Dust Explosion and accidents.Completedinvestigations.Retrieved February 24, 2013, http://www.csb.gov/investigations/investigations.aspx?Type=2&F_All=y.

A.Kenchenpur, July 2012, GAS AND VAPOR EXPLOSION HAZARDS Basis of Safety (Control of Ignition Sources), Chilworth Technology Inc, http://www.hse.gov.uk/comah/sragtech/techmeasareaclas.htm McGraw-Hill Dictionary of Scientific & Technical Terms, 6E, Copyright 2003 by The McGraw-Hill Companies, Inc. CSB U.S. Chemical Safety Board, http://www.csb.gov/investigations/detail.aspx?SID=36 Dangerous Substance and Explosive Atmosphere Regulations 2002 (DSEAR,2002) Picture The Chemical Engineering. (January, 2005).Flixborough revisited. Business Virgin.Retrieved February 19, 2013, from http://business.virgin.net/olwen.cox/pubs/FlixRevisit.htm American Institute of Chemical Engineers.(n.d.).Elements of Process Safety.Centre for Chemical Process Safety. Retrieved February 19, 2013, from www.aiche.org Hull Daily Mail. (August 12, 2011). The biggest story we ever covered. Hull and East Riding.Retrieved February 24, 2013, from http://www.thisishullandeastriding.co.uk Perth Now. (March 5, 2013). Oil Spill report: Montara owner PTTEP must prove it is fits to operate. Business.Retrieved February 22, 2013, from www.perthnow.com.au Feww. (October 14, 2009). Australia Fails to Plug Oil in Timor Sea.Fire Earth.Retrieved February 22, 2013, from https://feww.wordpress.com Gulf of Mexico Oil Spill Blog. (November 26, 2010). Montara Oil Spill Whales Not Monitored. Gulf of Mexico Oil Spill.Retrieved February 24, 2013, from http://gulfofmexicooilspillblog.com Informationssur les accidents technologiques. (June, 2009). Explosions in pharmaceutical plant, Linz Austria.Fine chemicals manufacture. Retrieved February 20, 2013, fromwww.aria.developpementdurable.gouv.fr