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Chemical Process Safety: Learning from Case Histories
Chemical Process Safety: Learning from Case Histories
Chemical Process Safety: Learning from Case Histories
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Chemical Process Safety: Learning from Case Histories

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Chemical Process Safety: Learning from Case Histories, Fourth Edition gives insight into eliminating specific classes of hazards while also providing real case histories with valuable lessons to be learned. This edition also includes practical sections on mechanical integrity, management of change, and incident investigation programs, along with a list of helpful resources.

The information contained in this book will help users stay up-to-date on all the latest OSHA requirements, including the OSHA-required Management of Change, Mechanical Integrity, and Incident Investigation regulations. Learn how to eliminate hazards in the design, operation, and maintenance of chemical process plants and petroleum refineries.

World-renowned expert in process safety, Roy Sanders, shows how to reduce risks in plants and refineries, including a summary of case histories from high profile disasters and recommendations for how to avoid repeating the same mistakes. Following the principles outlined in this text will help save lives and reduce loss.

  • Features additional new chapters covering safety culture, maintaining a sense of vulnerability, and additional learning opportunities from recent incidents and near misses
  • Contains updated information from the US Bureau of Labor Statistics and the National Safety Council, with concise summaries of some of the most important case histories of the twenty-first century
  • Includes significantly expanded information from the US Chemical Safety Board, US OSHA, American Institute of Chemical Engineers, and the UK Health and Safety Executive (HSE)
  • Provides a completely updated chapter to guide readers to a wealth of reference material available on the web and elsewhere
Release dateJul 22, 2015
Chemical Process Safety: Learning from Case Histories
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Roy E. Sanders

Sanders recently retired from PPG Industries in Lake Charles, LA. Roy worked for PPG for 42 years and specialized in Process Safety fundamentals since 1974. He is associated with the Mary Kay O’Connor Process Safety Center at Texas A&M, McNeese State University, Lake Charles, and is a member of the editorial boards of both the AIChE’s Process Safety Progress and Putman’s Chemical Processing. He has taught brief process safety courses across the USA, as well as, Bahrain, Canada, India, the Netherlands Saudi Arabia and Taiwan.

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    Chemical Process Safety - Roy E. Sanders

    Chemical Process Safety

    Learning from Case Histories

    Fourth Edition

    Roy E. Sanders

    Table of Contents


    Title page




    1: Perspective, perspective, perspective



    The media rarely focuses on the benefits of the chemical industry

    A glance at the history of chemical manufacturing before the industrial revolution

    The modern industrial chemical industry modifies our way of living

    Risks are not necessarily how they are perceived

    Natural pesticides

    Plant employee safety versus life-style choices

    The chemical industry’s excellent safety record

    Who has the most dangerous jobs?

    What events resulted in fatal occupational injuries in 2012?

    Just how dangerous is it to work in a US chemical plant?

    How are the chemical and refinery industries doing today when it comes to major losses? And what should we do in the future?

    Process safety culture

    2: Good intentions


    Modifications made with good intentions

    A tank truck catastrophically fails

    Siphoning destroys a tender tank

    Tank roof splits from overfilling

    A well-intended change yields a storage tank collapse

    A water drain line is altered and a reactor explodes

    An air system is improved and a vessel blows up

    A new air system improved economics, but jeopardized safety

    Another incident with nitrogen backup for a compressed air supply

    The hazards of nitrogen asphyxiation

    Concerns for safety on a refrigerated ethylene tank

    Beware of impurities, stabilizers, or substitute chemicals

    Good intentions on certain new protection systems lead to troubles

    A gas compressor is protected from dirt, but the plant catches fire

    A replacement check valve installed – one detail overlooked

    What was one of the immediate causes of the fire?

    What did investigators recommend?

    Another good intentions project: new tanks are destroyed and the neighborhood is disrupted

    Another tragic incident involving hydrogen sulfide takes the lives of two workers

    Closing thoughts on sewers

    Carbon absorption incidents show history repeats

    The lighter side

    A review of good intentions

    3: Focusing on water and steam: the ever-present and sometimes evil twins


    Hydro-test goes awry

    A flooded column collapses as water is being drained from the system

    Water reacting with strong chemicals

    Easy-to-use steam heat can push equipment beyond safe design limits

    Heating water in a confined system

    Steam condenses and a mega-vessel is destroyed during commissioning

    A tragedy develops when hot oil is pumped upon a layer of water

    Discussion and recommendations

    4: Major US incidents in the twenty-first century: Some folks thirst for recent case histories


    Unfortunately – there is often a certain sameness in process incidents

    Delaware City, Delaware, incident

    Rouseville, Pennsylvania, incident

    Buffalo, New York, incident

    Learning opportunities from major incidents in the twenty-first century

    President Obama signs an Executive Order relating to process safety management

    An explosion in a plastics manufacturing facility in Illinois results in five deaths, plant closure and eventual tear down of the facility

    A glimpse of the PVC plastic facility, the loss of life and property

    PVC reactor layout and most likely incident scenario

    Not learning from incidents

    Key findings on the Illiopolis PVC plant incident

    The CSB recommendations submitted to Formosa Plastics USA [8]

    The March 2005 Texas City, Texas, refinery incident – the most tragic US refinery accident of the decade

    Besides poor safety culture – what happened prior to the release?

    What happened immediately after the release?

    Besides poor safety culture – what are some key technical findings of the Chemical Safety Board?

    Besides poor safety culture – what are some key organizational findings of the Chemical Safety Board?

    BP shares their investigation findings on key issues

    BP Texas City violations and settlement agreements

    An independent blue ribbon panel investigates BP’s North American operations

    A foreword on the findings published by the Baker Panel – broadens the impact

    The summary of the Baker Panel findings

    Corporate safety culture

    Refinery tragedy in Anacortes, Washington

    Introduction to the Anacortes refinery incident

    Details on the Tesoro refinery incident

    Why the catastrophic rupture? The technical focus

    Other Chemical Safety Board findings

    The CSB video Tesoro Tragedy – Behind the Curve

    CSB sweeping game changing recommendations for the US environmental agency

    CSB recommendations for the State of Washington

    CSB recommendations for the American Petroleum Institute

    The Washington Department of Labor and Industries issues citations

    Ammonium nitrate catastrophe in West, Texas April 17, 2013 – fifteen perish

    Major incidents in the twenty-first century

    5: Two highly destructive twenty-first century vapor cloud explosions: one in the United Kingdom and the other in Venezuela: Two massive explosion incidents with some significant similarities


    Buncefield UK fuel storage and transfer depot explosion and fires 2005

    Introduction to the Buncefield incident and impact in the area

    A look at some details prior to the explosion and massive fire

    The economic costs of the Buncefield incident

    Fuel concerns after the explosion and fires

    Instrumentation and control systems

    Buncefield report recommendations

    Recommendations for design and operation of fuel storage sites

    Summary comments on the Buncefield incident

    A catastrophic explosion at Amuay refinery in Venezuela

    Immediate events leading up to the explosion

    A closer look a details at the Amuay refinery incident

    Petroleos de Venezuela (or PDVSA) leak source study

    RMG presented their view promptly after the incident

    The Economist speaks to some underlying issues

    The Manufacturing Center in Energy orientation (COENER) report

    One strongly critical media report speaks about the Amuay refinery operations

    The Amuay refinery based upon an insurance report

    Blunt recommendations by the Manufacturing Center in Energy

    Conclusions and recommendations for the Amuay disaster

    Vapor cloud explosions – closing comments

    When it comes to vapor clouds what can you do?

    6: Preparation for maintenance


    Some problems when preparing for maintenance

    A tank vent is routed to a water-filled drum to Avoid problems

    Preparing to paint large tanks

    Preparing a brine sludge dissolving system for maintenance

    What happened in the brine system?

    A violent eruption from a tank being prepared for maintenance

    An explosion while preparing to replace a valve in an ice cream plant

    A chemical cleaning operation kills sparrows, but improves procedures

    Other cleaning, washing, steaming, and purging operations

    A tragedy when preparing for valve maintenance

    A review of changes made to prepare for maintenance

    7: Maintenance-induced accidents and process piping problems


    Planning and communication

    Repaired reboiler passes the hydro-test and later creates a fire

    A tank explodes during welding repairs after passing a flammable gas test

    A phenol tank’s roof lifts as repairs are made

    Catastrophic failures of storage tanks as reported by the Environmental Protection Agency

    Hot work on tank catwalk results in a contractor’s death, injuries, and a costly off-site environmental insult

    Sulfuric acid tank background basics

    Unsafe condition report and hot work permit shortcomings

    The management of change shortcomings in sulfuric acid tank incident

    Root causes as defined by the CSB

    Similar tragic incidents involving hot work to tanks provided within the CSB full report Delaware City

    The Chemical Safety Board offers safety advice on Hot Work within a 14 min video

    Another tank explosion during maintenance hot work

    Repair activity to a piping spool results in a massive leak from a sphere

    The Phillips 66 incident: tragedy in Pasadena, Texas

    A massive fire, BLEVEs, and $5 million damages after a mechanic improperly removes a valve actuator

    Misdirected precautions on a reactor system isolation plug valve result in a vapor cloud explosion

    A hidden blind surprises the operators

    Poor judgment by mechanics allowed a bad steam leak to result in a minor explosion

    The Flixborough disaster and the lessons we should never forget

    Do piping systems contribute to major accidents?

    Beware of other piping issues

    Specific piping system problems reported as major incidents

    Four case histories of catastrophic pipe failures

    An 8-in. pipeline ruptures and an explosion occurs – December 24, 1989

    Piping problems review

    Concluding thoughts on maintenance – induced accidents and process piping problems

    8: One-minute modifications: small, quick changes in a plant can create bad memories


    Explosion occurs after an analyzer is repaired

    When cooling methods were changed, a tragedy occurred

    Instrument air backup is disconnected

    A furnace temperature safeguard is altered

    It appeared to be icicles hanging in a small plant

    Another costly gasket error

    While compressed asbestos gaskets are phased out, other leaks will occur

    Other piping gasket substitution problems

    New stud bolts fail unexpectedly

    A Repaired hose fails triggering a major fire

    Hurricane procedures are improperly applied to a tank conservation vent lid

    Painters create troubles

    Pipefitters can create troubles when reinstalling relief valves

    Another pipefitter’s error

    Lack of respect for an open vent as a vacuum-relief device results in a partial tank collapse

    Just a bucket of water destroys a tank

    Lack of respect for an open vent as a pressure-relief device costs two lives

    One-minute modifications review

    9: Accidents involving compressors, hoses, and pumps


    Reciprocating compressors

    A piece of compressor water jacket is launched

    The misuse of hoses can quickly create problems

    The Chemical Safety Board investigates a chlorine unloading hose failure

    The Chemical Safety Board investigated a phosgene hose failure with a fatality

    Fatality from a ruptured hose in HF service

    Hose mishaps frequently lead to loss of containment – maybe more than we think

    The water hose at the Flixborough disaster

    Hoses used to warm equipment

    Three-Mile Island Incident involved a hose

    The Bhopal Tragedy was initiated by use of a hose

    Improper purge hose set up for maintenance creates major problems

    High-pressure hydrogen inadvertently backs into the nitrogen system and an explosion occurs

    A nitric acid delivery to the wrong tank makes front-page news

    How do you prevent such an incident?

    Other truck delivery incidents

    An operator averts a sulfuric acid unloading tragedy

    Hoses cannot take excessive abuse

    What is the advice from practitioners?

    Centrifugal pumps

    River water pump piping explodes

    Severe pump explosions surprise employees

    A large condensate pump explodes

    Closing thoughts on pump explosions. Courtesy of the Beacon


    10: Failure to use, consult, or understand specifications


    Lack of well-defined, rigid operating instructions cost $100,000 in property damages

    Other thoughts on fired heaters

    Low-pressure tank fabrication specifications were not followed

    Explosion relief for low-pressure tanks

    Tinkering with pressured vessel-closure bolts ends with a harmless bang

    Piping specifications were not utilized

    Pump repairs potentially endanger the plant, but are corrected in time to prevent newspaper headlines

    Plastic pumps installed to pump flammable liquids

    Weak walls wanted – but alternate attachments contributed to the damage

    11: Imagine If modifications and practical problem solving


    Imagine If modifications – let us not exaggerate the dangers as we perform safety studies

    New fire-fighting agent meets opposition – Could Kill Men as Well as Fires

    A process safety management quiz

    New fiber production methods questioned

    Practical problem solving

    The physics student and his mischievous methods

    12: The role of mechanical integrity in chemical process safety


    Mechanical integrity in a chemical plant

    A regulatory view of mechanical integrity

    Mechanical integrity programs must be tailored to the specific site

    Mechanical integrity in design and installation

    Equipment covered by mechanical integrity

    Regulatory enforcement of mechanical integrity

    What is all this about RAGAGEP?

    Struggling with mechanical integrity

    Written procedures and training

    Classification of equipment by hazard potential

    Mechanical integrity programs for pumps/compressors

    Mechanical integrity programs for piping, pressure vessels, storage tanks, and process piping

    Inspecting pressure vessels, storage tanks, and piping

    Inspection of pressure vessels and storage tanks

    Mechanical programs for safety-critical instruments and safety relief valves

    The critical role of safety relief valves

    In-house testing safety relief valves

    Mechanical integrity program for process safety interlocks and alarms

    Protective process safety interlocks at a DuPont plant

    Another company – a different emphasis on safety critical instrument systems

    Another approach – prooftesting at a Louisiana plant

    Additional information on mechanical integrity

    13: Effectively managing change within the chemical industry



    Preliminary thoughts on managing change

    Are management of change systems like snowflakes?

    A reality check provided by previous chapters

    Keeping MOC systems simple

    Losing tribal knowledge

    Some historical approaches to plant changes

    The US OSHA PSM Standard addresses management of change

    Principles of an effective management of change system that prevents uncontrolled change and satisfies OSHA

    An overall process description to create or improve a management of change system

    Clear definitions are imperative

    Key steps for an effective management of change system for a medium or large organization

    Key steps for an effective management of change system for a small company

    Multidisciplined committee can provide an in-depth look when identifying hazards

    Operational variances for maintenance need a close examination too

    Variances, exceptions, and special cases of change

    Should the MOC system be paperless?

    Over two dozen plants share their MOC practices

    Management of change approvals, documentation, and auditing

    Closing thoughts on management of change policy

    The Center for Chemical Process Safety

    Recommendations and regulations after 1988

    14: Investigating and sharing near misses and unfortunate accidents



    What does the regulation say about incident investigations?

    Plant cultures can affect investigations

    More guidelines on the culture of incident reporting

    An OSHA program coordinator’s view

    Layers of incident causes

    A furnace tube failure case history is revisited

    Process safety incident investigation techniques

    Applying root cause analysis

    Some chemical manufacturers’ approaches to incident investigation

    What is a root cause?

    STAMP – a new accident causality model

    Some thoughts on process safety incident investigation techniques

    Complying with the OSHA element on incident investigation

    Report approval, report distribution, sharing the findings, corrective action tracking, and report retention


    15: Keep a sense of vulnerability for safety sake: seven recommendations for keeping a sense of vulnerability at your chemical processing or refining site


    Opening thoughts on unease and who should it impact

    How do you create a sense of unease or vulnerability?

    A focused effort is essential

    Success can blind us of reality

    Seven recommendations to reduce your vulnerability

    Why not step back in time?

    16: A strong safety culture is essential: it is essential to develop a strong safety culture


    Process safety culture has been recognized and accepted in recent years

    Foundation for development of safety culture

    About 65 companies shared to shape the earlier definition of Safety Culture in 2003

    What is process safety culture? Perhaps – it is the root cause of the decade!

    A dozen features essential to developing a durable safety culture within PSM

    API RP 754 describes the Purpose of Indicators as [17]

    Is safety culture really important?

    17: Sources of helpful information for practicing chemical process safety


    Key cost free process safety resources at your finger tips

    Process safety resources via consultants, professional associations and trade associations via the web

    Excellent books addressing chemical process safety – from a process engineer’s viewpoint

    Two of the best process safety videos which focus on learning from case histories



    Butterworth-Heinemann is an imprint of Elsevier

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    Copyright © 2015, 2004, 1999, 1993 Elsevier Inc. All rights reserved.

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    This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).


    Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

    Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

    To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

    ISBN: 978-0-12-801425-7

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    Look around the bookshelves for technical books. There are many good books and articles on Chemical Process Safety theory and procedures. These texts offer sound advice on identifying chemical process hazard analysis, management of change, operating procedures, training, audits, and guidelines books addressing the elements of US Department of Labor’s Occupation Safety and Health Administration’s (OSHA’s) Process Safety Management Law. However, only a few people, such as Trevor A. Kletz, offer many authentic case histories that provide opportunities to learn fundamentals in process safety.

    Trevor Kletz encouraged me to write a book on plant modifications in 1989. At that time, we were working together teaching an American Institute of Chemical Engineers Continuing Education Course entitled Chemical Plant Accidents – A Workshop on Causes and Preventions. I hope that my books in some way mimic Trevor Kletz’s style of presenting clear, interesting anecdotes that illustrate process safety concepts. Hopefully, my recorded case histories can be shared with chemical process operators, operations supervisors, university professors studying chemical process safety, chemical plant pipefitters, welders, and maintenance supervisors.

    The first book was a moderate success. The sequel received a new title, Chemical Process Safety: Learning from Case Histories. The second edition includes the best parts of the first book, two new chapters, new incidents, and plenty of additional vivid photos.

    This third book offers major improvements. There are up-to-date statistics in chapter one. There is more on nitrogen asphyxiation and new case histories. There is also a completely new chapter on accidents involving compressors, hoses, and pumps. This book provides many new, useful references and many that can be found on websites.

    This fourth edition was developed after my retirement from industry and into the part-time consultant business. Today there are so many additional resources. The introductory chapter has been rejuvenated and reinforced with today’s statistics. There are four new chapters. I was able to get help from the Mary Kay O’Connor Process Safety Center (College Station, Texas), supporters of the Lake Area Industries/McNeese University Engineering (Lake Charles, Louisiana) Partnership, the US Chemical Safety Board case studies, and the Buncefield Investigation reports. There was also some excellent additions of material from the Beacon – a monthly feature of the Center for Chemical Process Safety.

    As I look back, I think all refinery and chemical plant should keep a sense of vulnerability toward present day and historical industrial events and provided a chapter on that topic. In my opinion, at times, too much of today’s effort is compliance to a law without much attention to avoidance of something that has previously happened. I, as one of a chorus, recommend basic review of real incidents such as the simple misuse of hoses and have added some of those case histories.

    As I developed the fourth edition, I realized that over the years many of us, initially focused on the technical solutions to the various incidents that occurred, but maybe we should all be thinking more broadly on the Process Safety Culture as the BP Baker Panel did. The fourth edition has a chapter on Process Safety Culture. Finally the last chapter is completely revised and chock full of references and excellent sources of process safety related information.

    The reader should be aware that much of my experiences were within a major chemical plant with about $2 billion replacement cost, 1500 employees, and over 600 acres of chemical plant. There are toxic gases, flammable gases, flashing flammable liquids, combustible liquids, and caustic materials, but there were no significant problems with combustible dusts and no significant problems with static electricity.

    The information in this book came from a number of sources, including stories from my experiences in the now defunct Louisiana Loss Prevention Association; students in the AIChE’s Chemical Plant Accidents course; members of the Lake Area Industries – McNeese State University Engineering Department’s OSHA Support meetings; coworkers, process safety clients, friends, the written literature and the world wide web. I believe the case history stories are true, but some are hearsay and are not supported with any significant documentation. The approaches and recommendations made on each case seemed appropriate. However, the author, editor, and publisher specifically disclaim that compliance with any advice contained herein will make any premises or operations safe or healthful or in compliance with any law, rule, or regulation.


    Fourth Edition

    I am delighted with all of the support I was given for the fourth edition. First, I am grateful that my family and friends understood I had to make some sacrifices and had to neglect somethings in order to get this edition to the publisher, even if it arrived a little tardy.

    Equally important, I want to thank the late Trevor A. Kletz for encouraging me to attempt to write a book, decades ago, and always helping me along the way by sharing his knowledge. Furthermore, I appreciate the encouragement from Dr M. Sam Mannan at the Mary Kay O’Connor Process Safety Center and the generous help from numerous presenters at the Lake Area Industries/McNeese Engineering Partnership. A special thanks to Manuel David – a talented draftsman. Manuel continued to provide new crisp concise sketches to support the words in several chapters of the fourth edition.

    Second, I appreciate the guidance support of Natasha Welford, Fiona Geraghty and Nicky Carter of Elsevier. They did all they could to promptly and professionally assist in all the things must be done to improve my drafts in to well-formatted book.

    Finally, I want to thank the individuals and groups for technical and interpersonal support to make this edition a reality. For lack of a better method, I will acknowledge their support by chapters.

    Received help from the Mary Kay O’Connor Process Safety Center for Chapter 1, Perspective, Perspective, Perspective. Sonny Sachdeva and Jiaqi Zhang, two very bright, energetic Texas A&M folks helped find data on Risks and proof read major portions of this chapter.

    In Chapter 3 Focusing on Water and Steam; The Ever-Present and Sometimes Evil Twins, I appreciate John R. Lockwood’s case history on a tragic silo washing incident.

    Received lots of help for Chapter 4 Major US Incidents in the twenty-first century. Dr Vic Edwards was kind enough to review this chapter as it was being developed and his input was appreciated and useful.

    Chapter 5 Addressed two powerful unconfined vapor cloud explosions. One incident occurred in the United Kingdom and one happened in Venezuela. Natasha Welford worked hard to obtain two excellent aerial photos of Buncefield. Olga Reyes Valdes a PhD Candidate Mary Kay O’Connor Process Safety Center had developed a research presentation on the Amuay Refinery incident in Venezuela and generously shared her work. I am grateful that Dr Steven D. Emerson critically reviewed my first draft of this chapter to help shape it.

    The portion of Chapter 9 focused on hoses also benefitted from the help of John R. Lockwood.

    Chapter 13 focusing on Management of Change benefitted from Michael Bearrow’s and Jack Chosnek’s recent articles.

    While updating Chapter 14, on incident investigation, I received excellent professional guidance from Jack Philley. Philley has had extensive incident investigation experience and was the principal author of the text CCPS Guidelines for Incident Investigation.

    Chapter 15 is entitled Keep a Sense of Vulnerability for Safety Safe. I appreciate the input from two masters. I thank Joseph Louvar for encouraging me to write the topic as an AIChE Process Safety Progress article and to help shape it. I am grateful for Mark Rosenzweig, Editor-in-Chief, of Putman’s Chemical Processing magazine for his skillful enhancements to polish the chapter.

    Chapter 16 addressed Safety Culture now recognized as one of the most important parts of a process safety. Steve Arendt (of ABS Consulting) provided various presentations at McNeese State University, which were the main ingredients of this chapter. This chapter was also shaped by input from Jiaqi Zhang and Sonny Sachdeva of The Mary Kay O’Connor Process Safety Center at Texas A&M.

    Chapter 17 was also reviewed and enhanced by Sonny Sachdeva and Jiaqi Zhang from the Mary kay O’Connor Process Safety Center.

    There are a few photos of pressure vessel and piping fabrication, which are courtesy of Custom Metal Fabricators of Lake Charles, Louisiana.

    Finally, I am grateful for the assistance of Delma Porter of Superior Writing, LLC, for her professional skills to clarify some of my ramblings.

    Third Edition

    I am appreciative of all the support I received to make this third edition a reality. I am grateful that my family and close friends understood that I had to make a few sacrifices and miss some activities to get this third edition completed.

    Without the editor’s support by Christine Kloiber and Phil Carmical of Elsevier Science, no words would have been written. But, once the words are written I continue to rely on the guidance and keenly developed proofreading skills, and candid critiques of Selina Cascio to convert my blemished sentences into free flowing, easily understood thoughts. Selina has helped me with nearly all of my technical writings over the past 20 years, and her input has really made a positive impact.

    I am grateful for the additional material that appears in this third edition courtesy of David Chung of the US Environmental Protection Agency, from Douglas S. Giles and Peter N. Lodal of Eastman Chemical Company, from Dr Trevor A. Kletz, from Nir Keren of the Mary Kay O’Connor Process Safety Center, from Catherine Vickers of PPG, and countless others who are referenced throughout the text. I was also lucky to get talented drafting help from Manuel David. Manuel created easy-to-understand illustrations to support the narratives of the incidents.

    I would be also be remiss if I did not thank the PPG Professionals in Monroeville, Pennsylvania for their technical and legal review. The Monroeville supporters include Jeff Solomon, David McKeough, and Maria Revetta.

    Second Edition

    I am grateful for Michael Forster of Butterworth–Heinemann for encouraging a second edition of this book. He has been a steady support for this challenge for several years. Without his energy and support this second edition would not have happened.

    The professional proofreading skills of my daughter Laura Sanders and her husband Morgan Grether have be instrumental in adding life and clarity to about one half of the chapters. And the project could not be finished without the guidance, keenly developed proofreading skills, and candid critiques of Selina Cascio. I would be also be remiss if I did not thank the PPG Professionals in Monroeville, Pennsylvania for their technical review. The Monroeville supporters include David McKeough, Maria Revetta, and Irwin Stein.

    I am grateful to Dr Mark Smith, of the Institution of Chemical Engineers, for extending the permission granted in the first edition to use a few sketches and photos to enhance several case histories.

    Also a note of thanks to Manuel David and Warren Schindler, talented drafters, who provided several excellent sketches to add visual images to clarify important concepts. Naturally, I am very grateful and appreciate the continuing support of Dr Trevor A. Kletz. He has never been too busy to provide guidance.

    To my wife, Jill, and to Julie and Lisa, my two daughters who live with me, thanks for understanding. When you have a full-time job, a project like this requires sacrifice. I appreciate their patience as I had to avoid some family activities for over a year while I whittled away on this project.

    First Edition

    A number of people deserve thanks for encouraging me and helping me with this challenge. As an engineer within a chemical manufacturing facility, opportunities to write articles did not seem realistic to me. In the early 1980s after submitting a rather primitive proposed technical paper, Bill Bradford encouraged me to draft a manuscript. My first technical paper was on the subject of Plant Modifications and it was presented to the AIChE in 1982.

    In 1983, Trevor A. Kletz asked me to help him teach an American Institute of Chemical Engineers Continuing Education Course. I was shocked and elated to be considered. It was such a great opportunity to learn from this living legend in Loss Prevention. It has been educational and enjoyable ever since; he has become my teacher, my coach, and my friend.

    I assisted Trevor Kletz in teaching a two-day course entitled Chemical Plant Accidents – A Workshop on Causes and Preventions. We periodically taught the course for six years, and then he encouraged me to consider writing this book on Plant Modifications. Jayne Holder, formerly of Butterworth, was extremely supportive with all my concerns and questions.

    Before I got started, I was searching for help and William E. Cleary, Jack M. Jarnagin, Selina C. Cascio, and Trevor A. Kletz volunteered to support the project. Then the hard part came. Again, Trevor Kletz and Jayne Holder encouraged me to get started.

    I am grateful to Bill Cleary for his technical and grammatical critique, and to Selina Cascio for her skill in manuscript preparation including endless suggestions on style and punctuation. Jack Jarnagin’s drafting assistance provided the clear illustrations throughout the text, and to Trevor for his continuous support.

    Also, thanks to my wife, Jill, for both her patience and her clerical help, to my daughter Laura for proofreading, and to Warren H. Woolfolk for his help on Chapter 8. Thanks to Bernard Hancock, of the Institution of Chemical Engineers (UK) for his generous permission to use a number of photos to enhance the text. I also thank the management of PPG Industries – Chemicals Group, my employer, for their support. Finally, I appreciate the many contributors of incidents and photographs who, because of the situation, wanted to remain anonymous.


    Perspective, perspective, perspective


    This chapter is completely rejuvenated with today’s data and recent facts. It presents an accurate representation of the US chemical industry, including its value to humanity, its history, and its high degree of safety. This chapter provides a brief review of the countless benefits of the chemical industries and gives a glimpse of the history of the vital chemical manufacturing industry. However, the concept of comparative risks is the main focus of this chapter. The perceived risks of the chemical industry and its occupations are often misunderstood. Many individuals who depend on television and radio for information probably believe that working in a chemical plant is a hazardous occupation. This myth is exposed by the fact that chemical-plant employees enjoy one of the safest occupations. This chapter stresses on the general safety and low risk rates of employees in the chemical and petroleum refining industries. Despite excellent efforts in the field of process safety, there are some serious questions challenging whether enough is being done to reduce major losses.



    perception of risks

    good safety performance in chemical plants

    dangerous jobs

    fatalities by occupation

    fatal occupational injuries by event


    Perspective, perspective, perspective – Chemical manufacturing industries are often the targets of misperceptions. This opening chapter shows a more accurate representation of today’s US chemical manufacturing and the petroleum refining industries, including chemistry’s value to humanity, its history, and its high degree of safety. The first section is a brief review of the countless benefits of the chemical industries that surround us, that increase our life span, and that enhance our enjoyment of life. The second section is a glimpse of the history of the vital chemical manufacturing industry; however, the concept of comparative risks is the main emphasis of this chapter. The perceived risks of the chemical industry and its occupations are often misunderstood.

    Working in the chemical industry is safer than most individuals realize. We shall provide a perspective of the risks of working within this industry by comparing that risk with actual statistical dangers encountered with other well-understood occupations, commonplace activities, and life-styles. Later chapters will focus on costly errors in the chemical industry along with practices and procedures to reduce the occurrence and severity of such incidents. Viewed in isolation, case histories alone could easily lead to the inaccurate picture that the chemical industry is dangerous. In fact, the chemical industry has an impressive safety record that is considerably better than most occupations. Fatal accident rates reported by the Bureau of Statistics demonstrate that working in the chemical industry is statistically safer than working in a grocery store. The news media does not often speak of the safety of the chemical plants because these statistics lack news-selling sizzle.

    The media rarely focuses on the benefits of the chemical industry

    Chemical manufacturing and petroleum refining have enriched our lives. Few individuals in the developed world realize how the chemical industry has improved every minute of their day. The benefits of the industries are apparent from the time our cell phone (or our plastic alarm clock) tells us to wake up from a pleasant sleep on our polyester sheets and our polyurethane foam mattresses. As our feet touch the man-made laminate floor (or nylon carpet), we walk a few steps to turn on a phenolic light switch that allows electrical current to pass safely through polyvinyl chloride insulated wires. At the bathroom sink, we wash our faces in chemically sanitized water using a chemically produced soap.

    We enter the kitchen and open the plastic-lined refrigerator cooled by fluorochlorohydrocarbon chemicals and reach for the orange juice, which came from chemically fertilized orange groves. Many of us bring in the morning newspaper and take a quick look at the news without thinking that the printing inks and the paper itself are chemical products. Likewise, other individuals choose to turn on the morning television news or weather and do not think twice that practically every component within the television or radio was made of products produced by the chemical industry. In short, we are not very aware that we are surrounded by the benefits created from chemicals and fail to recognize how the industries have enriched our lives.

    An American Chemical Society publication once stated:

    The chemical industry is more diverse than virtually any other U.S. industry. Its products are omnipresent. Chemicals are the building blocks for products that meet our most fundamental needs for food, shelter, and health, as well as products vital to the high technology world of computing, telecommunications, and biotechnology. Chemicals are a keystone of U.S. manufacturing, essential to the entire range of industries, such as pharmaceuticals, automobiles, textiles, furniture, paint, paper, electronics, agriculture, construction, appliances and services. It is difficult to fully enumerate the uses of chemical products and processes… . A world without the chemical industry would lack modern medicine, transportation, communications, and consumer products [1].

    A glance at the history of chemical manufacturing before the industrial revolution

    Humanity has always devised ways of trying to make life a little better or easier. In the broad sense, prehistoric people practiced chemistry beginning with the use of fire to produce chemical changes like burning wood, cooking food, and firing pottery and bricks. Clay was shaped into useful utensils and baked to form water-resistive hard forms as crude jars, pitchers, and pots as far back as 5000 bc [2].

    The oldest of the major industrial chemicals in use today is soda ash. It seems to date back to 3000–4000 bc because beads and other ornaments of glass, presumably made with soda ash and sand, were found in Egyptian tombs. It seems a natural soda ash was used as an article of trade in ancient Lower Egypt [3].

    Other chemical processes can also be dated back thousands of years. From what we know today, even the earliest civilized man was aware of the practical use of alcoholic fermentation. The Egyptians and Sumerians made a type of ale before 3000 bc, and the practice may have originated much earlier. Wine was also made in ancient Egypt before 3000 bc by treading the grapes, squeezing the juice of the crushed grapes, and allowing the juice to ferment in jars. In addition to the ale and grape wine, the ancients drank date wine, palm wine, and cider [4].

    The Romans and Greeks before the Christian era seem to have been without soap as we know it, and to some of us today their cleaning methods seem unrefined. The Greeks used oil for cleansing the skin and supplemented it with abrasives such as bran, sand, ashes, and pumice-stone. Clothes and woolen textiles were cleaned by treading the material or beating the fabric with stones or a wooden mallet in the presence of fuller’s earth together with alkali, lye, or ammonia, usually in the form of stale urine. Roman fullers put out pitchers at street corners to collect urine. As repugnant as it may seems to many people, it should be noted that stale urine was used for cleaning clothes from Roman times up to the nineteenth century when it was still in use on sailing ships [5].

    During the 900s, Europeans only lived for about 30 years, and life was a matter of much toil for very little rewards. Food was scarce, monotonous, often stale, or spoiled. Homes offered minimal protection from the elements and clothing was coarse and rough. War, disease, famine, and a low birth rate were ever present. Fewer than 20% of the Europeans during the Middle Ages ever traveled more than 10 miles (16 km) from the place they were born. The age that followed these bleak years brought forth a burst of inventiveness as mankind began to understand how science could take over some of their burdens [6,7].

    In Europe, the harvesting and burning of various seaweeds and vegetation along the seashore to create a type of soda ash product is one of the earliest examples of recorded industrial chemical manufacturing. No one is sure when this type of chemical processing began, but it was fairly widespread before modern recorded history. In fact, the Arabic name for soda, al kali, comes from the word kali, which is one of the types of plants harvested for this early industrial chemical producing activity. The desired product of this burned vegetation was extracted with hot water to form brown-colored lye. The process yielded primarily sodium carbonate (or by its common name, soda ash), which was used to manufacture soap and glass. Soda ash is by far the oldest of the major industrial chemicals used today [3].

    During the 1600s and 1700s, scientists laid the foundations for the modern chemical industry. Germany, France, and England initially manufactured inorganic chemicals to preserve meat and other foods, make gunpowder, dye fabrics, and produce soap. In 1635, the first American chemical plant started up in Boston to make saltpeter for gunpowder and for the tanning of hides [8].

    The chemical industry was being formed as the Industrial Revolution began, but as late as 1700, only 14 elements had been identified. The early chemical manufacturing process development can be accredited to Nicolas LeBlanc, a physician to the Duke of Orleans, who outlined a method of making soda ash starting with common table salt. The Duke of Orleans gave Dr LeBlanc sufficient funds to build such a plant not far from Paris in the 1790s [9]. Other soda plants sprang up in France, England, Scotland, Austria, and Germany [10].

    The LeBlanc process was the first large-scale industrial chemical process. The process produced large quantities of gaseous hydrochloric acid as a by-product that released into the air and caused what was probably the first large-scale industrial pollution. It was later found that this waste gas could be captured and reacted with manganese dioxide to produce gaseous chlorine. The LeBlanc process was used until about 1861, after which it began to be replaced by the more efficient Solvay process [7].

    The modern industrial chemical industry modifies our way of living

    During the 1800s, chemists discovered about half of the 100 known elements. After 1850, organic chemicals, such as coal-tar dyes, drugs, nitroglycerin explosives, and celluloid -plastics were developed and manufactured. The two World Wars created needs for new and improved chemical processes for munitions, fiber, light-weight metals, synthetic rubber, and fuels [8]. The 1930s witnessed the production of neoprene (1930), polyethylene (1933), nylon (1937), and fiberglass (1938), which signaled the beginning of an era that would see plastics replace natural materials. These plastics would radically influence how things were designed, constructed, and packaged [11].

    After the Second World War, the expansion of the petroleum refining and chemical process industries far outstripped that of the rest of the manufacturing industries. The chemical industry also was different than the older established industries due to the nature of toxic and flammable liquids and gases [12]. Naturally, the handling and storage of hazardous materials presented a potential peril that was often far greater than those posed by the traditional industries.

    By the 1950s and 1960s chemical processing became more and more sophisticated, with larger inventories of corrosive, toxic, and flammable chemicals, higher temperatures, and higher pressures. A series of fires, explosions, toxic releases, and other tragic events in the 1970s, 1980s, and 1990s resulted in public outcry. Federal regulations and process safety focused conscientious management have resulted in much better performance. Chemical manufacturing and petroleum refineries continue to strive to improve their process safety performance.

    The United States is expected to see a real surge of growth in chemical manufacturing and petroleum refining in the second decade of the twenty-first century. It is up to the companies to effectively convey all the lessons of the case history lessons to the new employees.

    A recent 2013 business publication stated:

    Manufacturing is coming back to America. The numbers are quite stunning, . . .

    The single reason why manufacturing is coming back to America is because fracking has unlocked so much low-cost natural gas. . . .

    From plastics to fertilizer plants, the manufacturing boom features several projects that are only possible with low-cost natural-gas supplies. That’s because natural gas is an important feedstock used by these manufacturers to create the products we need for our everyday lives [13].

    This book will focus on a large number of near misses, damaging fires, explosions, leaks, physical injuries, and bruised egos. A flawed plant modification, improper maintenance, poor operating practice, or failure to follow procedures was determined to be at least a contributory cause in many case histories cited in the chapters that follow. We will also look at some of the underlying causes such as Safety Culture and Operating Discipline. These two system influences have been revealed and highlighted in a number of the more recent incidents. Addressing Safety Culture and Operating Discipline and may be equal or more significant than just addressing the technical causes.

    Strangers to the chemical industry might be tempted to think that it is one of the most hazardous of industries; the opposite is true. The US Chemical Industries (and most other chemical industries) are among the safest of all industries. Facts show that it requires a high degree of training and discipline to handle large quantities of flammable, combustible, toxic, or otherwise hazardous materials (Fig. 1.1).

    Figure 1.1   It is safer to work in a US chemical plant than at a grocery store according to the United States Department of Labor – Bureau of Labor Statistics.

    Many of the featured case histories in this book occurred over 20 years ago; however, the lessons that can be learned will be appropriate into the twenty-first century. Tanks can fail from the effects of overpressure and underpressure in 2025 just as well as they failed in the 1980s. Incompatible chemicals are incompatible in any decade and humans can be forgetful at any time. Before we review a single case history, it is time to boast about the safety record of the chemical industry.

    Risks are not necessarily how they are perceived

    True risks differ from perceived risks. Due to human curiosity, the desire to sell news, 24-h-a-day news blitz, and current trends, some folks have a distorted sense of risks. Most often, people fear the lesser or trivial risks and fail to respect the significant dangers faced every day.

    Two directors with the Harvard Center of Risk published (2002) a family reference to help the reader understand worrisome risks, how to stay safe, and how to keep the risk in perspective. This fascinating book filled with facts and figures is entitled Risk – A Practical Guide for Deciding What’s Really Safe and What’s Really Dangerous in the World Around You [14].

    The Introduction to Risk – A Practical Guide … starts with these words:

    We live in a dangerous world. Yet it is also a world safer in many ways than it has ever been. Life expectancy is up. Infant mortality is down. Diseases that only recently were mass killers have been all but eradicated. Advances in public health, medicine, environmental regulation, food safety, and worker protection have dramatically reduced many of the major risks we faced just a few decades ago [14].

    The introduction continues with this powerful paragraph:

    Risk issues are often emotional. They are contentious. Disagreement is often deep and fierce. This is not surprising, given that how we perceive and respond to risk is, at its core, nothing less than survival. The perception of and response to danger is a powerful and fundamental driver of human behavior, thought, and emotion [14].

    A number of thoughts on risk and the perception of risk are provided by a variety of authors in subsequent sections.

    Splashy and dreadful versus the ordinary

    In his article, John F. Ross states the public tends to overestimate the probability of splashy and dreadful deaths and underestimates common but far more deadly risks [15].

    The Smithsonian article says that individuals tend to overestimate the risk of death by tornado but underestimate the much more widespread probability of stroke and heart attack. Ross further states that the general public ranks disease and accidents on an equal footing, although disease takes about 15 times more lives. About 400,000 individuals perish each year from smoking-related health issues. Another 40,000 people per year die on American highways, yet a single airline crash with 300 deaths draws far more attention over a long period of time. Spectacular deaths make the front page; many ordinary deaths are mentioned only on the obituary page [15].

    The authors of Risk A Practical Guide for Deciding What’s Really Safe and What’s Really Dangerous in the World Around You reinforce that fear pattern with this quote in the introduction, Most people are more afraid of risks that can kill them in particularly awful ways, like being eaten by a shark, than they are of the risk of dying in less awful ways, like heart disease – the leading killer in America [14]. The appendix of this guide contains lots of supporting data. It reads that in 2001, two US citizens died from shark attacks, and 934,110 citizens (1999) died of heart disease. Which one generally appears as a headline news article?

    A tragic story of a 3-year-old boy in Florida (1997) illustrates this point. This young boy was in knee-deep water picking water lilies when he was attacked and killed by an 11-ft. alligator. The heart-wrenching story was covered on television and in many newspapers around the nation. The Florida Game Commission has kept records of alligator attacks since 1948, and this was the seventh fatality.

    Many loving parents probably instantly felt that alligators are a major concern. However, it could be that the real hazard was minimum supervision and shallow water. The CDC reports that countless young children drown every day. An article entitled Unintentional Drowning: Get the Facts [16] from the United States the Centers for Disease Control and Prevention (CDC) reported the following:

    Every day, about ten people die from unintentional drowning. Of these, two are children aged 14 or younger. Drowning ranks fifth among the leading causes of unintentional injury death in the United States.

    From 2005-2009, there were an average of 3,533 fatal unintentional drownings (non-boating related) annually in the United States — about ten deaths per day. . . .

    Who is most likely to drown according to the CDC [16]?

    • Males: Nearly 80% of people who die from drowning are male.

    • Children: Children ages 1 to 4 have the highest drowning rates. In 2009, among children 1 to 4 years old who died from an unintentional injury, more than 30% died from drowning. Among children ages 1 to 4, most drownings occur in home swimming pools. Drowning is responsible for more deaths among children 1-4 than any other cause except congenital anomalies (birth defects) [16].

    A specific example of splashy and dreadful versus the ordinary

    Which creature is a threat to man? Is it a prehistoric looking alligator in the wild or that attractive deer on the edge of a forest? Which is perceived to be a serious threat to man? And which one has statistically caused significant loss of life?

    Many individuals perceive that alligators are deadly menaces to people. I live in the state of Louisiana. Louisiana and her southern marshes are home to a large share of the wild alligator population in the United States. Every time someone is attacked by an alligator the story becomes the lead local TV news article. If a gator wanders into a business or is found in a subdivision, it becomes the lead news story. The media implies that in the states where alligators are commonplace, they are an ever-present life-threatening hazard. However, according to the Shreveport Times newspaper report in June 2007, There’s also never been a recorded death of a human by an alligator in Louisiana. Florida has recorded 18 since 1948 [17].

    A more scholarly medical research article in 2005 offered similar data but implies that there has not been any death from alligators in Louisiana since 1948. The research article notes that, "The alligator is one of the few nonvenomous reptiles that can cause serious or fatal injuries to humans." Later in his article, Dr R. Langley acknowledges One problem with attempting to obtain information on alligator attacks is there is no uniform for collecting information and no mandatory reporting [18].

    The 2013 annual report by the Louisiana Department of Wildlife and Fisheries, said "The Louisiana Department of Wildlife and Fisheries (Department) manages the American alligator (Alligator mississippiensis) as a commercial, renewable natural resource. The Department’s sustained use program is one of the world’s most recognizable examples of a wildlife conservation success story. . . . Since the inception of the Department’s program in 1972, over 904,000 wild alligators have been harvested, over 7.5 million alligator eggs have been collected, and over 4.8 million farm raised alligators have been sold" [19].

    There is no doubt that alligators are dangerous, but their encounters are usually not deadly. It is estimated that there are nearly two million wild alligators in Louisiana. Furthermore there is a history of over 40 years of regulated hunting and harvesting 900,000 wild alligators and harvesting millions of alligator eggs. Despite the large numbers of alligators that inhabit Louisiana, the threat seems smaller than the typical news media’s perception.

    Unfortunately some large alligators wander into subdivisions looking for a mate or worse yet are regularly fed in parks and wildlife refuges and gradually lose all fear of humans. These alligators are considered nuisance gators and must be removed by a licensed nuisance gator hunter for the good of the public (Fig. 1.2).

    Figure 1.2   Roy Sanders and an unfortunate 10 ft. 4 in. or 3.1 m nuisance alligator in Southwest Louisiana.

    While we tend to fear the possibility of meeting an alligator, a greater threat is the innocuous wild

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