Causes

Basic causes:
1. Personal factors:
Skills and training

The workers were lack in skills and

training in order to work safely with
the hazardous chemicals.

2. Job factors:
Task

No process hazard analysis were carried

out in the polyethylene plant.

Equipment

The single-block (DEMCO) valve on the

settling leg was opened during the
maintenance.
No blind flange insert was used as a
backup.
The valve lockout system for the
maintenance operation was inadequate.

 Procedures:

The standard operating procedures were not

appropriately followed.

Controls:

The audible level of the emergency alarm was not

high enough. No permanent combustible gas
detection and alarm system located in the region
of the reactors.
Did not have a dedicated water system for
fighting fires.

Environment:
Proximity of high-occupancy structures (control
rooms) to hazardous operation.
Inadequate separation between buildings.
Crowded process equipment.

3. Organization factors:
Communications
The organization failed to inform and train
the maintenance employees to work safely
with hazardous chemicals.

Work pattern
No provision was made for the development,
implementation and enforcement of
effective permit systems.

Causes
Root causes
Explosion occurred because of the
released of 85,000 pounds of a
flammable mixture containing ethylene,
isobutane, hexane and hydrogen.
Formation of a large gas cloud due to
high pressure and temperature.

Poor management
Personal factors (workers)
Job factors

Unsafe
Act

Indirect

Unsafe
Conditio
n

Unplanned releases
of highly flammable
gases

EXPLOSION
People died
Property
damage

Basic
Causes

Direct
Cause