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Journal of Loss Prevention in the Process Industries 12 (1999) 361–378

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Major accidents in process industries and an analysis of causes and


consequences
*
Faisal I. Khan, S.A. Abbasi
Computer Aided Environmental Management Unit, Centre for Pollution Control and Energy Technology, Pondicherry University, Kalapet,
Pondicherry-605 014, India

Abstract

This paper briefly recapitulates some of the major accidents in chemical process industries which occurred during 1926–1997.
These case studies have been analysed with a view to understand the damage potential of various types of accidents, and the
common causes or errors which have led to disasters. An analysis of different types of accidental events such as fire, explosion
and toxic release has also been done to assess the damage potential of such events. It is revealed that vapour cloud explosion
(VCE) poses the greatest risk of damage. The study highlights the need for risk assessment in chemical process industries.  1999
Elsevier Science Ltd. All rights reserved.

Keywords: Industrial hazards; Risk assessment; Explosions; Fires

1. Introduction Table 1 (Raghavan & Swaminathan, 1996). It is seen


that the states of Gujarat and Maharashtra have the lar-
To understand the mechanisms of accidents and to gest number of MAH units and also handle the largest
develop accident prevention and control strategies, it is number of hazardous chemicals. No wonder, then, that
essential to know about and learn from past accidents. the maximum number of accidents in the past occurred
However, industries are generally reluctant in revealing in these two regions.
what had happened and have a tendency to underplay
their mistakes. This aspect has been discussed by
Badoux (1983); Marshall (1987); Kletz (1989); Lees
(1996). Unfortunately the negative attitude of the indus- 2. Definition of accidents
tries to cover up the truth has caused an increase in the
frequency of accidents. Among these accidents many are According to Suchman (1961), an event can be classi-
due to the repetition of the same/similar faults (Kletz, fied as an accident if it is unexpected, unavoidable and
1991a, b). Not only for industrial accidents but even for unintended. He has proposed the following three charac-
accidents occurring during transportation there is always teristics with which to classify an event as an accident:
someone with an interest in suppressing the facts. (1) degree of expectedness, (2) degree of avoidability
In India a study funded by the International Labour and (3) degree of intention.
Office pertaining to identification of major accident haz- Secondary characteristics are: (1) degree of warning,
ards and the development of a control system was con- (2) duration of occurrence, (3) degree of negligence and
ducted (Gupta, 1990), which revealed a total of 586 (4) degree of misjudgement. An event is an accident if
major accident hazard (MAH) units and 75 hazardous it gives little warning, happens quickly, or if there is a
chemicals. The distribution of MAH units and hazardous large element of negligence and misjudgement leading
chemicals across various states of India is presented in to it.
Suchman has added that as knowledge increases an
event is more likely to be described in terms of its causal
* Corresponding author. E-mail: abbasi@giasmd01.vsnl.net.in factors and less likely as an accident.

0950–4230/99/$ - see front matter  1999 Elsevier Science Ltd. All rights reserved.
PII: S 0 9 5 0 - 4 2 3 0 ( 9 8 ) 0 0 0 6 2 - X
362 F.I. Khan, S.A. Abbasi / Journal of Loss Prevention in the Process Industries 12 (1999) 361–378

Table 1
State-wise distribution of major hazardous units (MAH) and hazard-
ous substances

State MAH units Hazardous substances

Andhra Pradesh 35 24
Bihar 12 11
Delhi 19 8
Goa 8 9
Gujarat 112 32
Karnataka 26 14
Kerala 19 19
Maharashtra 97 24
Madhya Pradesh 33 10
Tamil Nadu 41 31
Uttar Pradesh 40 14
West Bengal 40 23
Assam 7 10
Haryana 7 4
Jammu Kashmir 7 4
Nagaland 1 1
Orissa 13 10
Pondicherry 3 3
Punjab 12 6
Rajashthan 54 17

Total number of MAH factories, 586.


Total number of hazardous substances, 75.

2.1. Modelling of accident process

It is helpful to model the accident process in order to


understand more clearly the factors which contribute to
accidents and the steps which can be taken to avoid
them. One type of model, discussed by Houston (1971),
is the classical one developed by lawyers and insurers
which focuses attention on the ‘proximate cause’. It is
recognised that many factors contribute to an accident,
but for practical, and particularly for legal, purposes a Fig. 1. Fault tree accident model.
principal cause is identified. This approach has a number
of defects: there is no objective criterion for dis-
tinguishing the principal cause, the relationships between tially on the sequence of decisions and actions which
causes are not explained, and there is no way of knowing lead up to an accident, and shows against each step the
if the cause list is complete. recommendations arising from the investigation (Fig. 2).
Another type of model is the fault tree model. A sim- A model which emphasises the broader, socio-techni-
ple fault tree model of an accident is presented in Fig. cal background to accidents has been developed by
1. The initiating event which constitutes a potential acci- Geyer and Bellamy (1991) as shown in Fig. 3. It presents
dent occurs only if some enabling event occurs, or has a generic model and the application of the model to
already occurred. This part of the tree is termed a an incident.
‘demand’ tree, since it puts a demand on the protective
features. The potential accident is realised only if pre-
vention by protective equipment and human action fails. 3. Major process hazards
An accident occurs which develops into a more severe
accident only if mitigation fails. A similar model based The major hazards with which the chemical industry
on fault tree has been proposed by Wells, Phang, Ward- is concerned are fire, explosion and toxic release. Of
man and Whetton (1992). these three, fire is the most common but explosion is
Another approach to model accidents is that taken by more significant in terms of its damage potential, often
Kletz (1988), who has developed a model oriented leading to fatalities and damage to property. Toxic
toward accident investigation. The model is based essen- release has perhaps the greatest potential to kill a large
F.I. Khan, S.A. Abbasi / Journal of Loss Prevention in the Process Industries 12 (1999) 361–378 363

Fig. 2. Kletz accident model.

number of people and cause an area to be toxified for


several months to several years. Large toxic releases are
rare but, as the Bhopal tragedy indicates, may have very
high death tolls.
Often no distinction is made between fire and
explosion losses. The latter are normally included in the
overall fire statistics. In fact, it is explosions which cause
the most serious losses (Doyle, 1969, 1981; Norstrom, Fig. 3. Gayer and Bellamy model of the accident process (Geyer &
Bellamy, 1991).
1982; Davenport, 1988; Carson and Mumford, 1988). As
much as two-thirds of the losses arising from an accident
occurring in chemical process industries are attributable
to explosions (Health and Safety Executive, 1988; Lees, Table 2
1996). Over three-quarters of the explosion involve com- Main causes of large fires in the chemical and allied industries
bustion or explosive materials. Norstrom (1982) ana- (Norstrom, 1982)
lysed fire-based and explosion-based accidents separ-
ately (Tables 2 and 3). It is evident that about 18% of Causes Proportion
(%)
fires are due to release and overflow of flammable gases
and/or liquids. Fires contributed about 20% to the total Flammable liquid or gas (release, overflow) 17.8
loss. In comparison, explosions contributed about 75% Overheating, hot surfaces, etc. 15.6
to the total loss. Failure of proper reaction controls Pipe or fitting failure 11.1
seems to be the most frequent cause leading to accidents. Electrical breakdown 11.1
Cutting and welding 11.1
It contributed 35% to the total number of accidents. The Arson 4.4
processing area is the most susceptible location of the Others 28.7
accident.
Marshall (1977); Bellamy, Geyer and Astley (1989)
have reported data for various release accidents (Table
4) in which the incidents are ranked in terms of the
364 F.I. Khan, S.A. Abbasi / Journal of Loss Prevention in the Process Industries 12 (1999) 361–378

Table 3 Table 4
Information related to explosion in the chemical and allied industries Characteristics of accidental release from pipework and in-line equip-
(Lees, 1996) ment (Bellamy et al., 1989; Lees, 1996).

Proportion No. of incidents


(%)
Location type
Main cause Chemical plant 278
Chemical reaction uncontrolled 20.0 Refinery 96
Chemical reaction accidental 15.0 Factory 187
Combustion explosion in equipment 13.3 Storage depot 47
Unconfined vapour cloud 10.0 Tank yard 28
Overpressure 8.3 Fuel station 15
Decomposition 5.0 Other 38
Combustion sparks 5.0 Unknown 232
Pressure vessel failure 3.3 Total 921
Improper operation 3.3
Others 16.8
Site status
Normal operations 343
Frequent location of occurrence Storage 103
Enclosed process or manufacturing buildings 46.7 Loading/unloading 33
Outdoor structures 31.7 Maintenance 146
Yard 6.7 Modification 8
Tank farm 3.3 Contractor work 18
Boiler house 3.3 Testing 5
Others 8.3 Unknown 128
Other 40
Start-up 42
Various contributing factors
Shut-down 18
Rupture of equipment 26.7
Total 884
Human element 18.3
Improper procedures 18.3
Faulty design 11.7 Materials released
Vapour-laden atmosphere 11.7 Ammonia 54
Congestion 11.7 Hydrocarbons (unspecified) 54
Flammable liquids 8.3 Chlorine 50
Long replacement time 6.7 Hydrogen 37
Inadequate combustion controls 5.0 Benzene 33
Inadequate explosion relief 5.0 Crude oil 28
Steam 25
Natural gas 24
Propane 20
amount of vapour released. Their reports suggest that Butane 18
large releases often result in explosions rather than fires. Fuel oil 18
Hydrochoric acid 16
The problem of avoiding major hazards is essentially Sulphuric acid 16
that of avoiding loss of containment. This includes not Ethylene 16
only preventing an escape of materials from leaks etc., Hydrogen sulphide 14
but also avoidance of an explosion inside the plant ves- Water 13
sels and pipe work. Some factors which determine the Nitrogen 13
Oxygen 13
scale of the hazard are: Vinyl chloride 12
1. the inventory; LEG 12
Styrene 11
2. the energy factor; Naphtha petroleum 10
3. the time factor; Total 507
4. the intensity–distance relations;
5. the exposure factor; Material phase
6. the intensity–damage and intensity–injury relation- Liquid 393
ships. Gas 260
Vapour 13
Data related to major injuries (including fatality) in Solid 9
chemical and allied industries have been plotted in Fig. Liquid ⫹ gas/vapour 120
4. It is evident from the data that, in the chemical indus- Solid ⫹ gas/vapour 3
Total 798
tries, the rate of fatal injuries is less than in mineral oil
processing industries (refineries, etc.). But during the last
F.I. Khan, S.A. Abbasi / Journal of Loss Prevention in the Process Industries 12 (1999) 361–378 365

Table 4 ance, or consistent cause–effect diagnostic system, so it


Continued. is often difficult to reconcile different analyses.
No. of incidents
3.2. Reporting of incidents and databases
Unignited material dispersion
Flammable 127 According to Lees (1980, 1994, 1996), the extent and
Toxic 123 the accuracy of the reporting of incidents and injuries
Flammable/toxic 47
Corrosive 97 are variable and this creates problems, particularly for
Irritant 1 attempts to perform statistical analysis of the data.
Unignited gas 96 For example, past incidents in the USA, the UK, and
Vapour cloud 180 some of the EU (European Union) countries have gener-
Liquid 212 ally been reported in detail and analysed critically but
Spill 186
Jet/spurt 8 comparable incidents in the erstwhile USSR, China and
Spray 10 Balkan states have received much less publicity and
Total 1087 assessment.
The problem has been discussed by Badoux (1983).
Fire or explosion event Fig. 5 shows schematically the probable extent of under-
Fire 145 reporting, curve A representing the actual reporting situ-
Flash fire 11 ation and curve B the ideal one (Lees, 1996).
Pool fire 4
Jet fire 1
There are a number of databases specifically dealing
Fireball 7 with case histories. They include the following.
BLEVEa 4
Explosion 63
쐌 Major Hazards Incident Data System (MHIDAS) and
Explosion followed by fire 77 the corresponding explosives data system EIDAS.
Explosion followed by flash fire 2 These are operated by SRD (Safety and Reliability
Total 314 Directorate, UK Atomic Energy Authority).
a
쐌 The FACTS incident database.
Boiling liquid expanding vapour explosion.
쐌 The Major Accident Reporting System (MARS),
described by Drogaris (1991, 1993).
쐌 The FIRE incident database for chemical warehouse
fires, described by Koivisto and Nielsen (1994).
쐌 The offshore Hydrocarbon Release (HCR) database
described by Bruce (1994).
In this paper a study of industrial accidents has been
conducted with a view to identify the factors which lead
to accidents and the lessons for loss prevention to be
learnt from these accidents. This study may be helpful

Fig. 4. Incidence rates of fatal and major injuries in chemical and


mineral oil processing industries (1981–1990).

few years the rates seem to have come close to each


other for the two types of industries.

3.1. General causes of accident

After an accident, various analysts and pressure


groups formulate different theories of the possible
causes. There are almost as many different diagnoses as
there are investigators. Unfortunately, there is no accept- Fig. 5. Under-reporting of accident (Lees, 1996).
366 F.I. Khan, S.A. Abbasi / Journal of Loss Prevention in the Process Industries 12 (1999) 361–378

in developing newer know-how for process safety and


accident damage control.

3.3. Classification of accidents

Accidents involving hazardous chemicals can be


broadly categorised into two major groups: fixed instal-
lation accidents and transportation accidents. The fixed
installation accidents consider all accidents occurring in
industries during different stages of operation, while
transportation accidents consider accidents occurring
during transportation, loading or unloading of chemicals.
The transportation accidents can be further categorised
according to the different mode of transportation.
A search of the literature covering the time span 1926
through to 1997 revealed reports of 3222 accidents relat-
ing to handling/transportation/processing/storage of Fig. 7. Accident cases concerning transportation.
chemicals (Nash, 1976; Lewis, 1984, 1993; Marshall,
1987; Hasstrup & Brochoff, 1990; Chowdhury & Park- tation is a matter of some controversy. We feel that the
inson, 1992; Taylor, 1993; Thomas, 1995; Lees, 1996; portion of the pipeline which falls within the confines
Khan & Abbasi, 1996, 1997). The actual number may of the industry should be treated as a fixed installation
be high as reports of all accidents are not available in the and the portion outside the industrial periphery as a
primary literature. Moreover, we have considered here transport vehicle.
accidents involving the loss of more than $1 million Of the different means of transportation, rail has
and/or fatalities. higher damage potential as larger quantities are trans-
Of the 3222 accidents, 54% are fixed installation acci- ported by this means. However, if we consider the dam-
dents, 41% are transportation accidents and 5% miscel- age it may cause to life and property, transport by road
laneous accidents (Fig. 6). The 1320 transportation acci- is more hazardous, as roads often pass through populated
dents can be further classified according to the different areas, especially in developing countries (Khan &
modes of transportation. Such classification (Fig. 7) indi- Abbasi, 1995).
cates that 37% occurred during rail transport, 29% dur- Pipeline transportation is comparatively safer, pro-
ing road transport, 6% during marine transport, 18% dur- vided that the speed and conditions of transportation
ing pipeline transport, 4% during inland waterway (temperature, phase, and pressure) as well as the route
transport, and the remaining during loading and of the pipeline are carefully managed. A summary of the
unloading of chemicals. Whether pipelines should be worst transport disasters are presented in Table 5.
considered as fixed installations or a means of transpor-

4. Fixed installation accidents

Our survey reveals that 1744 significant accidents


have occurred during the period 1928–1997. A study of
major factors (vessels, chemicals, process conditions)
leading to accidents is summarised in Table 6. It reveals
that chemical process plants are most prone to accidents.
Ammonia is the chemical most often involved. Of the
1744 accidents (up to November 1997), 441 (25%) have
involved fires and explosions, and 1247 (71%) have
involved toxic release. The remaining accidents (4%)
featured a combination of fire, explosion and toxic
release. In terms of harmful consequences, toxic release
covers wider areas than fires/explosions. Also if the tox-
icity of the released chemical is high, as was the case
with the MIC (methyl iso-cynate) leak during the Bhopal
disaster, the damage may be very severe.
The destructive impact of an explosion generally
Fig. 6. Accident classification. covers a wider area than the region-of-impact of a fire.
F.I. Khan, S.A. Abbasi / Journal of Loss Prevention in the Process Industries 12 (1999) 361–378 367

Table 5
The most gruesome transportation accidents dealing with hazardous chemicals

Year Location Chemical Incident Fatality/injury

Pipeline transport
1981 S. Raface, Venezuela LPG Explosion 18/35
1984 Cubato, Brazil Gasoline Fire and explosion 508/31
1984 Ghari Dhoda, Pakistan LNG Explosion 60/11
1988 Mexico City, Mexico Crude oil Fire and explosion 12/80
1989 Nizhnevartovsk, Russia LPG Explosion and fire 462/290

Road transport
1975 Texas, USA LPG Explosion 16/35
1978 Los Afaques, Spain Propylene Explosion and fire 216/400
1978 Xilotopee, Mexico Butane Explosion 100/200
1987 Preston, UK Diesel oil Fire 12/16
1988 Karo, Nigeria Petrol Explosion and fire 15/35
1995 Madras, India Benzene Explosion and fire 115/10

Rail transport
1974 Decatur, USA Isobutane Explosion 7/152
1978 Tennessee, USA Propane Explosion 25/50
1981 Potosi, Mexico Chlorine Toxic release 29/1000
1983 Pojuca, Brazil Gasoline Fire 10/40
1983 Dhurabai, India Kerosine Explosion 47/15
1988 Arzanas, Russia Explosive Explosion 73/230

Table 6 Marshall, 1977, 1987; Kletz, 1988, 1991a; Lees & Ang,
Major factors leading to accident in the chemical industries (Lees, 1984; Kharbanda & Stallworthy, 1988; Hasstrup & Bro-
1996)
choff, 1990; Palmer, 1983; Prugh, 1991; Amendola,
No. of times Proportion Contini & Nichele, 1988; TPL, 1992; Khan & Abbasi,
(%) 1996, 1997; Koivisto, Vaija & Dohnal, 1989; Koivisto &
Nielsen, 1994; Chemical Industrial Digest, 1995; Loss
Equipment failure 223 29.2 Prevention bulletins, 1980, 1981, 1982, 1983, 1984,
Operational failure 160 20.9
Inadequate material evaluation 120 15.7 1986).
Chemical process problems 83 10.9 The worst ever accident in the chemical process indus-
Material movement problems 69 9.0 tries involving toxic release occurred at Bhopal in 1984.
Ineffective loss prevention program 47 6.2 The worst ever fire-cum-explosion accident (on shore)
Plant site problems 27 3.5 occurred in Mexico in the same year. The worst ever
Inadequate plant layout 18 2.4
Structures not in conformity with use 17 2.2 off-shore accident occurred on Piper Alpha in 1988.
requirement

5. Case studies
Secondly, except in certain cases when ambient con- We present below brief case-histories of typical acci-
ditions conspire to enable very rapid spread of a fire, dents.
most fires take time to consolidate. If emergency pre-
paredness measures are in place, this time proves crucial 5.1. Accidents in refineries
in enabling control of the fire. On the other hand, when
an explosion takes place it does so instantly, giving no At a refinery in France, a spillage occurred on 4 Janu-
time for escape. ary 1966 when an operator was draining water from a
In a very large number of situations, explosions in 1200 m pressurised propane sphere. The propane vapour
chemical process industries are either caused by fire, or spread over a radius of 150 m and was ignited by a car
lead to a fire. A summary of major catastrophic accidents on the road. The pool of propane below the sphere
for the period 1928–1997 is presented in Tables 7–9. engulfed the vessel in flames. The resultant boiling-
This information was collected by various literature liquid-expanding-vapour explosion (BLEVE) killed the
sources (Nash, 1976; Gugan, 1979; Amesz, Francocci, fireman and 17 others. The conflagration took 48 hours
Primavera & Van der Pas, 1983; Lees, 1980, 1994, 1996; to control and caused extensive damage to the refinery.
368 F.I. Khan, S.A. Abbasi / Journal of Loss Prevention in the Process Industries 12 (1999) 361–378

Table 7
List of major accidents in chemical process industries, 1926–1969

Year Location Chemical Event Deaths/injured

1926 St. Auban, France Chlorine Toxic release 19/105


1928 Homburg, Germany Phosgene Toxic release 10/50
1929 Syracause, New York Chlorine Toxic release 1/100
1939 Zarnesti, Romania Chlorine Toxic release 60/?
1940 Mjodelana, Norway Chlorine Toxic release 3/34
1942 Tessenderloo, Belgium Ammonium nitrate Explosion > 100
1943 Ludigshafen, Germany Butadiene Explosion 57/37
1943 Los Angeles, CA Butane Fire 5/ > 25
1944 Cleveland, OH LNG Fire and explosion 128/300
1944 Denison, TX Butane Fire 10/45
1947 Brest, France Ammonium nitrate Explosion 21/?
1947 Rauma, Finland Chlorine Toxic release 19/200
1947 Texas City, TX Ammonium nitrate Explosion 552/3000
1948 Ludigshafen, Germany Dimethyl ether Explosion 245/2500
1949 Perth, NJ Hydrocarbons Fire 4/26
1950 Poza Rica, Mexico Hydrogen sulphide Toxic release 22/320
1952 Walsum, Germany Chlorine Toxic release 7/56
1954 Bitburg, Germany Kerosine Fire 32/16
1955 Whiting, IN Naptha Explosion 2/30
1958 Niagara Falls, NY Nitromethane Explosion ?/ > 200i
1958 Signal Hills, CA Oil forth Fire 2/34
1959 Meldrin, GA LPG Explosion 23/78
1959 Kansas City, MO Gasoline Fire 5/?
1959 Phillipsburg, NJ Seal oil Explosion 6/6
1959 Roseberg, OR Ammonium nitrate Explosion 13/74
1959 Ube, Japan Ammonia plant Explosion 11/40
1960 Forepart, TX Allyl chloride Explosion 6/14
1960 Kingsport, TN Aniline plant Explosion 15/55
1961 La Barre, LA Chlorine Toxic release 1/114
1962 Doe Run, Key Ethylene oxide Explosion 2/19
1962 New Belin, NY LPG Explosion 10/75
1962 Ras Taruna, Saudi Arabia Propane Fire 1/111
1962 Toledo Acrylic polyamide Explosion 10/46
1964 Mebronville, MA PVC Explosion 7/27
1964 Texas, USA Ethylene Explosion 2/34
1965 Louisville, KY Mono. acetylene Explosion 12/60
1965 Natchitoches, LA Natural gas Explosion 17/56
1966 Freyzin, France Propane Fire and explosion 18/83
1966 Larsoe, LA NGL Fire 7/20
1966 LaSallie, Quebec Styrene Explosion 11/10
1966 West Germany Methane Explosion 3/83
1967 Antwerp, Belgium VCM Explosion 4/33
1967 Hawthorn, NJ ? Explosion 2/16
1967 Lake Charles, LA Isobutane Explosion 7/14
1968 East Germany VCM Explosion 24
1968 Hull, UK Acetic acid Explosion 2/13
1968 Lievin, France Ammonia Toxic release 5/35
1968 Pernis, Netherlands Oil (compr.) Explosion 2/85
1969 Basel, Switzerland Nitro liquid Explosion 3/28
1969 Repcelak, Hungary Carbon dioxide Explosion 9/23
1969 Crete, NB Ammonia Toxic release 8/20
1969 Escombreaes Petroleum Explosion 4/3
1969 Laurel, MS LPG Explosion 2/976
1969 Puerto la Cruz Light hydro. Explosion 5/23
1969 Teeside, UK Cyclohexane Fire 2/23

?, information not available.


F.I. Khan, S.A. Abbasi / Journal of Loss Prevention in the Process Industries 12 (1999) 361–378 369

Table 8
List of major accidents in chemical process industries, 1970–1979

Year Location Chemical Event Deaths/injured

1970 Philadelphia, Panama Catl. cracker Explosion 7/42


1971 Emmerich, Germany Ammonia Toxic release 4/53
1971 Houston, TX VCM Explosion 1/50
1971 Longview, TX Ethylene Explosion 4/60
1971 Netherlands Butadiene Explosion 8/21
1972 Rio de Janerio, Brazil Butane Explosion 37/53
1972 Lynchburg, VA Propane Fire 2/3
1972 Netherlands Hydrogen Explosion 4/40
1972 Weirton, WV Coke plant Explosion 10/10
1972 West Virginia, USA Gas Explosion 21/20
1973 Kingman, AZ Propane Fire 13/89
1973 Austin, TX NGL Fire 6/21
1973 Japan VCM Explosion 1/16
1973 Potchefstroom Ammonia Toxic release 18/34
1973 St. Amand L’Eaux, France Propane Explosion 5/45
1973 Sheffield, UK Gas works Explosion 4/24
1973 Staten Island, NY LNG Fire 40
1974 Beaumont, TX Isoprene Explosion 2/10
1974 Czechoslovakia Ethylene Explosion 14/79
1974 Decatur, IL Propane Explosion 7/152
1974 Flixborough, UK Cyclohexane Explosion 28/76
1974 Houston, TX Butadiene Explosion 1/235
1974 Madras, India Potassium sol. Hot release 9/15
1974 Wenatchee, WA MENiterate Explosion 2/66
1975 Antwerp, Belgium Ethylene Explosion 6
1975 Beek, Netherlands Propylene Explosion 14/108
1975 Eagle Pass, TX Propane Fire 16/7
1975 Philadelphia, Panama Oil vapours Explosion 8/20
1975 Scunthorpe, UK Water-methyl Explosion 11/15
1975 South Africa Methane Explosion 7/7
1976 Chalmette, LA Ethyl benzene Explosion 13/?
1976 Houston, TX Ammonia Toxic release 6/200
1976 Los Angles, CA Gasoline Fire 6/35
1976 Gadsden, AL Gasoline Fire 3/24
1976 Sandefijord, Norway Flamm. liquid Explosion 6/?
1976 Seveso, Italy TCDD Toxic release ?/300
1977 Colombia, USA Ammonia Toxic release 30/22
1977 Gela, Italy Ethylene oxide Explosion 1/25
1977 Gujarat, India Hydrogen Explosion 5/35
1977 Mexico Ammonia Toxic release 2/102
1977 Umm Said, Qatar LPG Fire 7/87
1977 Westwego, LA Explosive dust Explosion 35/5
1978 Chicago, IL Hydrogen sulphate Toxic release 8/29
1978 Santa Cruz, Mexico Propylene Fire 52/88
1978 St. Marys, WV Cooling water ? 51/26
1978 San Carlos, Spain Propylene Explosion 211
1978 Texas City, TX Butane Fire 7/11
1978 Waverly, TN Propane Explosion 12/21
1978 Youngestown, FL Chlorine Toxic release 8/50
1979 Banter Bay, Eire Oil Explosion 50

?, information not available.

At a refinery at Pernis (Netherlands) in 1968, an over- At Texas city, USA (on 30 May 1978), one of the
flow of hydrocarbon caused a small explosion. This trig- LPG storage vessels in a petrochemical factory
gered another small explosion which in turn led to a (Mahoney, 1990) suffered overpressure while it was
major explosion with fire, extensively damaging an area being filled, due to failure of a pressure gauge and also
of about 300 m. Two people were killed and 85 injured of a relief valve. It cracked and leaked LPG. The leak
(Lees, 1996). ignited into a massive fire ball, which shattered the ves-
370 F.I. Khan, S.A. Abbasi / Journal of Loss Prevention in the Process Industries 12 (1999) 361–378

Table 9
List of major accidents in chemical process industries, 1981–1997

Year Location Chemical Event Deaths/injured

1981 Montanas, Mexico Chlorine Toxic release 29/50


1982 Spencer, OK Heated water Burning 7/12
1983 Reserve, LA Chlorobutadine Fire and toxic release 3/12
1983 Houston, TX Methyl bromide Toxic release 2/11
1984 Brazil Gasoline Fire and toxic release 508/221
1984 Roeoville, IL Propane Explosion 15/76
1984 Mexico City, Mexico LPG Fire and explosion 550/23
1985 Clinton, USA Ammonia Toxic release 5/8
1985 Breed Ford, UK Ammonia Toxic release 2/13
1985 Brazil Ammonia Toxic release > 5000 evacuated
1985 Illinois, USA Naptha Explosion 7/12
1985 Priola, Italy Ethylene Explosion 23/11
1985 Algerais, Spain Naptha Explosion and fire 18/56
1985 Mont Belyieu, TX Propane Fire 4/13
1986 Basel, Switzerland Fungicide Toxic release ?/severe damage to
ecosystem
1986 Ohio, USA HCL Toxic release 3/26
1986 Kennedy Space Center, FL Hydrogen Explosion 7/119
1986 Pascagoula, MS Aniline Fire 3/76
1987 Grangemouth, UK Hydrocarbon Explosion and fire 67/21
1987 Piper Alpha Hydrogen Explosion 167/55
1987 Antwerp, Belgium Ethylene oxide Explosion 5/20
1987 Pampa, TX Acetic acid Explosion 3/43
1987 Louisiana, TX Hydrocarbon Fire and explosion 15/21
1988 Maharastra, India Naptha Fire 25/23
1988 Rafnes, Norway Vinyl cloride Explosion 7/13
1988 Narco, LA Propane Explosion 7/48
1989 Antwerp, Belgium Aldehyde Explosion 32/11
1989 USSR Ammonia Explosion and toxic release 7/57
1989 Baker, Gulf of Mexico Natural gas Explosion 2/24
1989 Worms, Germany Carbon dioxide Explosion 3/25
1989 Pasadena, TX Ethylene Explosion 23/314
1989 Boston Rouge, LA Ethane Explosion 4/12
1989 Phillips, USA Ethylene Explosion 23/130
1990 Channeiview, TX Waste oil Fire 5/13
1990 Rio de Janerio, Brazil Hydrocarbon Fire 3/?
1990 Czechoslovakia Hydrogen Explosion 15/26
1990 Fagaras, Romania Explosives Explosion 21/34
1990 Thane, India Hydrocarbon Fire and explosion 35/10
1990 Porto de Leixoes, Portugal Propane Fire and explosion 14/76
1992 Sodegraura, Japan Hydrogen Explosion 10/7
1993 Panipat, India Ammonia Explosion and toxic release 3/25
1994 Dronka, Egypt Fuel Fire 410/?
1995 Gujrat, India Natural gas Fire ?/?
1995 Ukhta, Russia Gas Fire 12/?
1996 Bombay, India Hydrocarbon Fire 2/45
1997 Chennai, India LPG Fire 3/4
1997 Chennai, India Molten metal Explosion 2/5
1997 Gujart, India Hydrocarbon Explosion 3/11
1997 Visag, India LPG Fire and explosion 60/30

?, information not available.

sel, propelling its fragments as missiles. During the next tower and other facilities. Later investigations revealed
20 minutes five horizontal bullets and four vertical ones many shortcomings in the plant layout.
were damaged by missiles. The other two vessels were On 12 December 1987 a crude oil storage tank in a
also damaged in this way. refinery at Maharashtra, India, started boiling over, spill-
On 8 March 1984 an explosion in a refinery at Kerala ing its contents on the dike around it. The emergency
destroyed a fire tender along with the shed in which it services were alerted and tried to evacuate the contents.
was housed, besides a chemical warehouse, cooling After 4 hours of pumping out, the tank caught fire and
F.I. Khan, S.A. Abbasi / Journal of Loss Prevention in the Process Industries 12 (1999) 361–378 371

exploded, spilling the contents. Eight hours of vigorous near the main gate of the HPCL refinery, caught fire at
fire fighting had to be carried out before the fire could 06:40 h and exploded, rocking Visakhapatnam city. The
be controlled. There was extensive damage to the pro- storage tanks were all full, with crude imports unloaded
perty. A liberal sizing of the dike and providing a separ- at the HPCL berth just a few days previously. The
ate dike for a large tank like this would have helped to second sphere exploded 15 minutes later and before
prevent the spread of fire to other tanks. noon, the others also caught fire. The blaze spread. Huge
An accident took place on 18 April 1989 in a 14 inch tongues of flame and thick black smoke billowed into
natural gas pipeline owned by a gas company in India. the sky and joined the hovering monsoon clouds. There
The pipeline was carrying compressed natural gas at a was a sharp shower in the morning and people wearing
pressure of about 295–298 psig from the compressor white shirts saw them turn black with soot. The rain
station to various consumers. The accident occurred water flooding the road also turned black and murky.
about 730 ft. from the compressor station. Security per- With both the entrances to the refinery blocked by
sonnel heard a loud sound at about 09:50 h and saw a burning tanks, neither the fire tenders nor the officials
huge cloud of black smoke emanating from the ruptured could enter the premises for several hours. Only when
pipeline which caught fire immediately. The flame rose the contents in the tanks were burnt out could they ven-
as high as 150 ft. during the initial stage. ture in. The death toll could have been higher had the
The fire damaged buildings consisting of the general fire started half-an-hour later when the first shift staff
stores and the office of the materials department. Two would have been present.
employees died and six others received burn injuries. Even more significant, as the accident occurred on a
Investigations revealed that the portion of the pipeline Sunday, the administrative personnel, who number over
which had blown off was extensively corroded compared 200, were not on duty. There were some contract labour-
with other portions of the pipeline. The underground ers along with the HPCL personnel in the Crude Distil-
pipeline was close to the materials department where old ling Unit which was shut down for routine maintenance
lead cells were stored. The corrosion could be due to the work. The shock of the initial explosion made people
leakage of spent weak acid which seeped through the think an earthquake had occurred. They ran helter-
ground and corroded the buried pipeline. skelter, leaving their belongings behind.

5.1.1. Maharashtra accident 5.2. Accidents in chemical/petrochemical industries


On 5 November 1990 an explosion at the offside bat-
tery of compressors at a gas cracking plant in Maharash- On the evening of 21 September 1921, two explosions
tra, India, killed 35 people, as well as causing heavy occurred at the Oppau works of Badische Aniline and
damage to property and business interruption losses. Sodafabrik (BASF) in a span of 3 seconds. The
Among the deficiencies in the layout, identified after the explosions created a mammoth crater of 80 m diameter,
disaster, was the location of a contractor’s shed danger- destroyed the plant, and 700 of the 1000 houses nearby.
ously close to the gas compressors. Less publicised, but The explosion was caused by the detonation of some
perhaps of greater consequence, was the lack of a facility 4500 t of a 50:50 mixture of ammonium sulphate and
to shut down the flow of hydrocarbon at the site itself. ammonium nitrate. It was set off by blasting powder,
The plant personnel had to run to the control room faster which was being used to break up storage piles of
than the vapour that followed them to close the feed material which had become caked. Exactly the same pro-
valve. cedure had been carried out without any mishap some
16 000 times previously!
5.1.2. Visakhapatnam disaster Even houses in the adjacent city of Ludwigshafen and
On 14 September 1997, a huge fire and explosions in the Mannheim area were damaged. Walls were dislo-
devastated the terminals and storage tanks at the refinery cated and windows broken. At these places and at Heid-
of HPCL (Hindustan Petroleum Corporation Limited) at elberg, which is about 14 miles from Oppau, the effect
Visakhapatnam unit in India. More than 55 people were of the explosion was first felt by two very heavy earth-
killed and dozens of others seriously injured (The quake-like shocks. In Mannheim some seconds later, and
Hindu, 1997a). in Heidelberg 82 seconds after the shocks, there came
Two bodies were found on the upper storey of the an enormous rush of air which broke windows and doors
administrative block which had collapsed while three and caused damage to gas holders, oil tanks, and many
more were seen in the debris underneath by a team of river barges. The sound of the explosion and the earth
reporters who ventured in later in the evening. The build- shocks reached as far as Bayreuth, a distance of 145
ing, housing, the recreation club and canteen were also miles, and the air pressure wave caused considerable
destroyed. damage in Frankfurt, which is about 53 miles from the
One of the eight Horton spheres or globe tanks, which scene of the explosion. The explosion killed 430 people,
contained LPG, crude and kerosene tanks separately, including 50 people in the village.
372 F.I. Khan, S.A. Abbasi / Journal of Loss Prevention in the Process Industries 12 (1999) 361–378

On 3 July 1987 an explosion occurred inside an ethyl- cyclohexane was oxidised to cyclohexanone and
ene oxide purification column at a chemical factory at cyclohexanol by air injection in the presence of a cata-
Antwerp, Belgium (Lees, 1996). The explosion was due lyst.
to decomposition of ethylene oxide. It was accompanied On the evening of 27 March 1974, it was discovered
by a fire ball, which started a number of secondary fires. that reactor number 5 was leaking cyclohexane. The fol-
These, together with blasts and missiles, caused exten- lowing morning an inspection revealed that the leak had
sive damage. Fourteen people were injured. extended by some 6 ft. This was a serious state of affairs
Faulty operations at the Tomsk-7 fuels reprocessing and a meeting was called to decide a course of action.
facility in Russia are believed to have resulted in the A decision was taken to remove reactor 5 and to install
‘running away’ of a solution of 500 litres of tributyl a bypass assembly to connect reactor 4 directly to reactor
phosphate (TBP) saturated with strong nitric acid, 6 so that the plant operation could continue.
resulting in explosive failure of the storage vessel and The openings to be connected on these reactors were
subsequently blowing out a wall of the reprocessing of 28 inch diameter, but the largest pipe which was avail-
building. TBP is an important organic solvent used in able on site and which might be suitable for the by-pass
acidic extraction steps in separation processes at fuel was of 20 inch diameter. The two flanges were at differ-
reprocessing facilities. Solutions of TBP, hydrocarbon ent heights so that the connection had to take the form
diluent, and HNO3 (known as ‘red oil’ because of the of a dogleg of three lengths. Calculations were done to
colour of nitrated hydrocarbons) undergo exothermic check that (a) the pipe had a large enough cross-sectional
reactions that can thermally ‘run away’ if heated to a area for the required flow, and (b) that it was capable of
temperature where the heat of reaction exceeds heat loss- withstanding the pressure as a straight pipe.
es. But no calculations were done which took into
A recent accident (14 May 1997) at Hanford was the account the forces arising from the dog-leg shape of the
result of a spontaneous (autocatalytic) chemical reaction pipe; no drawing of the by-pass pipe was made other
of the solution stored in a tank (Tank A-109) located in than in chalk on the workshop floor; and no pressure
the plutonium reclamation facility. This 1500 litre tank testing was carried out either on the pipe or on the com-
initially contained a solution of 0.35 M hydroxylamine plete assembly before it was fitted. A pressure test was
(OHNH2HNO3) and 0.25 M nitric acid called CCX sol- performed on the plant after the installation of the by-
ution. The unused solution in the tank had been slowly pass, but the equipment was tested to a pressure of 9
evaporating. The loss of water concentrated the solution kg/cm2. Further, the test was pneumatic not hydraulic
until conditions were reached that caused a spontaneous (Lees, 1996).
chemical decomposition reaction. The reaction created a The plant was restarted. Initially the by-pass assembly
rapid release of gases, which built up pressure inside the gave no trouble. On 29 May 1974 the bottom valve on
tank. The pressure blew the lid off the tank and severely one of the vessels was found to be leaking. The plant
damaged the room. No casualties were reported as no- was again shut down for repairs, and restarted on June
one was near at the time of the accident. 1. A sudden rise in pressure up to 8.5 kg/cm2 occurred
On 25 November 1997 explosion occurred in a chemi- early in the morning when the temperature in Reactor 1
cal factory manufacturing rubber products at Halol in was only 110°C and less in the other reactors. Later that
Panchmahal district of Gujrat state. Three persons were morning, the pressure reached 9.1–9.2 kg/cm2.
killed and 11 others injured (The Hindu, 1997b). The During the late afternoon an event occurred which
explosion occurred in one of the reactors. Detailed infor- resulted in the escape of large quantities of cyclohexane.
mation is awaited. This event was the rupture of the dog-leg shaped by-
pass system. It was perhaps aided by a fire on a nearby
5.2.1. The Flixborough disaster 8 inch pipe. The escaped cyclohexane soon caught a
The Flixborough plant of Nypro Limited, UK, was spark, and there was a massive unconfined vapour cloud
built for the production of caprolactum which is the basic explosion. The blast and the fire destroyed the cyclohex-
raw material for the production of Nylon 6. Cyclohex- ane plant as well as several other plants in the vicinity.
anol necessary for the production of caprolactum was Of those working on the site at the time, 28 were
produced by oxidation of cyclohexane. The latter chemi- killed and 36 others suffered injuries. Outside the plant,
cal, which in many of its properties is comparable with injuries and damage were widespread but no-one was
petrol, had to be stored. More importantly, large quan- killed. Of the 28 people who died 18 were in the control
tities of cyclohexane had to be circulated through the room. Some of the bodies had suffered severe damage
reactors under a working pressure of about 8.8 kg/cm2 from flying glass. The main office of the factory was
and a temperature of 155°C. The reaction is exothermic; demolished by the blast of the explosion. Mercifully, the
any escape of cyclohexane from the plant was therefore accident had occurred on a Saturday afternoon when the
dangerous. The cyclohexane plant at Flixborough con- offices were not occupied. If they had been, the death
sists of a stream of six reactors in series in which toll would have been much higher.
F.I. Khan, S.A. Abbasi / Journal of Loss Prevention in the Process Industries 12 (1999) 361–378 373

Property damage extended over a wide area, and a skin troubles. The plant was sealed for 10 years and then
preliminary survey showed that 184 houses and 167 dismantled from the inside brick by brick, the rubble was
shops and factories had suffered to a greater or a embedded in concrete, and the concrete blocks were
lesser degree. sunk in the Atlantic. Five years later yet another accident
involving TCDD release occurred at Bolsover. It
5.2.2. Seveso disaster involved a runaway reaction in a trichlorophenol reactor,
On the morning of Saturday, 10 July 1976, a safety similar to the one that later occurred at Seveso. The reac-
valve vented on a reactor at the Icmesa Chemical Com- tion reached 250°C, the reactor exploded and the super-
pany at Seveso, a town of about 17 000 inhabitants some vising chemist was killed. The plant was closed down,
15 miles from Milan (Italy). A white cloud drifted over and then reopened after 2 weeks when it appeared that
part of the town, heavy rainfall brought the cloud to workers exposed had suffered no ill effects. But within
earth. The release occurred from a reactor producing 7 months, 79 persons complained of TCDD symptoms.
trichlorophenol, which is used to make a bactericide hex- The plant was dismantled and buried in a deep hole. But
achlorophenol and the herbicide 2,4,5 trichloro phenoxy the story did not end there; 3 years later contractors on
acetic acid. The reactor also contained the chemical gen- the site developed TCDD symptoms. The only apparent
erally referred to as TCDD (2,3,7,8-tetrachloro dibenzo possible source of contamination was a metal vessel
paradioxin). This substance was not an intended reaction which had been thoroughly cleaned and subjected to
product but an undesired by-product. An estimated 2 kg sensitive testing.
of TCDD were released, although this estimate is neces- The lesson that emerged from Seveso was that press-
sarily approximate. ure relief valves on plants handling highly toxic sub-
In normal operations the amount of TCDD made in stances should not discharge to the atmosphere but to a
the reactor was small, but on this occasion the reactor closed system.
had got out of control. The contents had got overheated
and the safety valve had vented. The higher temperature 5.2.4. The Bhopal disaster
in the reactor favoured the production of an abnormal The worst ever disaster in the history of the chemical
quantity of TCDD. industry occurred in Bhopal, India, on 3 December 1984.
In the immediate area of the release the vegetation A leak of methyl isocyanate from a chemical plant,
was contaminated and animals began to die. On the where it was used as an intermediate in the manufacture
fourth day a child fell ill and on the 5th day civil auth- of a pesticide, spread beyond the plant boundary and
orities declared a state of emergency in Seveso. An area caused death by poisoning of over 2500 people—injur-
of some 2 square miles was declared contaminated and ing about 10 times as many.
people were asked to avoid contact with the vegetation Methyl isocyanate boils at about 40°C at atmospheric
or eating anything from this area. The contaminated area pressure. According to press reports, the contents of the
was later sought to be closed completely. On 27 July the storage tank became overheated and boiled, causing the
first evacuation of some 250 people took place. By the relief valves to lift. The discharge of vapour—about 25
end of July, 250 cases of skin infection had been diag- t—was too great for the capacity of the scrubbing sys-
nosed. Some 100 people had been told to evacuate their tem. The escaping vapour spread beyond the plant
homes and some 2000 people had been given blood tests. boundary where a shanty town had sprung up. The cause
In early August it was found that the area contaminated of the overheating was contamination of the methyl iso-
was about five times larger than originally thought cyanate, by water or other materials, and several possible
(Lees, 1996). mechanisms were suggested. According to some reports,
cyanide was produced. Had Union Carbide conducted
5.2.3. Other accidents involving TCDD risk analysis (specifically maximum credible accident
There have been accidents involving TCDD release analysis) during the design of the MIC system or even
prior to the Seveso disaster. At Ludwigshafen, 55 people later, it would have learnt that in the event of a MIC
were exposed when there was accidental TCDD release leak the scrubbing system would be inadequate. This
in 1953, and many developed severe symptoms of would have enabled the industry to install better emerg-
TCDD poisoning. Various measures were taken to ency handling systems, thereby saving thousands of lives
decontaminate the plant building, including the use of (Abbasi, Krishnakumari & Khan, 1997).
detergents, the burning off of the surfaces, the removal
of insulating material and so on, but these were not 5.2.5. The Worms Explosion
effective and eventually the whole building had to be On 21 November 1988 an explosion occurred in a
destroyed. In another accident at Duphar in 1963, a leak liquid storage vessel of Proctor Gamble, Worms, Ger-
of 0.03–0.2 kg of TCDD occurred. Some 50 persons many. The explosion was supposed to be the worst
were involved in cleaning up the leakage, of whom four among ever explosion in cryogenic storage of liquefied
subsequently died, and about a dozen suffered occasional carbon dioxide. The storage tank was a horizontal-high-
374 F.I. Khan, S.A. Abbasi / Journal of Loss Prevention in the Process Industries 12 (1999) 361–378

pressure vessel having a nominal capacity of 30 t of car- The following were the tell-tale conditions in and
bon oxide and was well connected to a relief and around PEPCON:
safety system.
쐌 lack of proper storage;
The main reasons for the explosion were identified as:
쐌 combustible fibre glass insulation and sources of fire;
(a) overheating causing excessive pressure and failure of
쐌 glass panel walls in the batch house;
the relief valve; (b) brittle failure of a tank at or near
쐌 inadequate spacing between adjacent process vessels
normal operation; (c) a combination of the above. A
and product storage tanks;
detailed investigation has been carried out by the Federal
쐌 no alarm to warn plant personnel, fire departments or
Government as well as Proctor Gamble to find the real
Henderson’s other citizens;
causes of the failure. It was found that tank was brittle
쐌 no dependable fire-fighting arrangement with sprink-
failure from two position (non uniform—faulty design).
lers and deluge system;
Due to excessive pressure, liquid carbon dioxide escap-
쐌 no modern, dependable, radio system to back-up dam-
ing from the relief valve reached a critical point and
aged telephone lines needed to call for help, co-ordi-
sealed the relief valve by forming dry ice. This prevented
nate response teams and warn the community;
the gas from escaping and hence an explosion took
쐌 lack of an effective emergency response plan at PEP-
place.
CON, within the surrounding industrial complex and
The explosion intensity was so great that it destroyed
within the town of Henderson.
two neighbouring units. An excess of pressure of more
than 1 atm was reported over a radius of 1000 m. The The explosion caused about $100 million in damage
shock wave velocity also exceeded 500 m/s. Fragments to the surrounding community and completely destroyed
of vessel of more than 100 kg were found more than a neighbouring marshmallow plant. About 350 persons
500 m from the site of the accident. Good planning of were injured. Two persons died—the plant manager and
the unit’s location ensured that no hazardous chemicals the controller.
were stored nearby, so only mechanical damage took
place. 5.2.7. The Phillips explosion
The consequences of explosion were three fatalities at The explosion at the Phillips petrochemical (similar
the site, more than 10 people hospitalised and an esti- to the present case study) plant in Pasadena, Texas, on
mated damage of $20 million with 3 months of pro- 23 October 1989 is one of the worst industrial accidents
duction lost. of the last 10 years.
The immediate cause was simple: a length of pipe was
5.2.6. Pepcon explosion opened up to clear a choke without bothering to see that
On 4 May 1988 a massive explosion destroyed a the isolation valve (which was operated by compressed
Pacific Engineering and Production Company air) had not been closed. The air hoses which supplied
(PEPCON) plant near Henderson, about 12 miles south power to the valve were connected up the wrong way
of Las Vegas, USA. around so the valve was open when its actuator was in
PEPCON was one of only two plants in the USA that the closed position. Identical couplings were used for the
produced ammonium perchlorate (AP); the other was the two connections so it was easy to reverse them. Accord-
Kerr-McGee plant, also located in Henderson about 2 ing to company procedure they should have been discon-
miles from the PEPCON plant. PEPCON reportedly pro- nected during maintenance but they were not. The valve
duced about one-third of the AP used as an oxidiser and could be locked open or closed but this hardly mattered
propellant in solid, composite rocket fuels for NASA’s as the lock was missing. The explosion occurred less
space shuttle and missiles. than 2 minutes after the leak started and two iso-butane
Although a fire started the PEPCON explosion, the tanks exploded 15 minutes later. The explosive force
cause of the fire was not easy to explain. After the was equivalent to 2.4 t of TNT; 23 people—all
explosion, PEPCON blamed the fire on a leaking under- employees—were killed and over 130 injured. Nearly 40
ground pipeline of Southwest Gas Company that tra- t of ethylene gas leaked and exploded.
versed PEPCON’S property. But the natural gas pipeline
had been installed about 10 years before the PEPCON 5.2.8. Panipat explosion
plant had been built, and although ruptured, it only con- One evening during August 1993 there was an
tributed to the fire and heat required to detonate the explosion at the National Fertiliser Limited (NFL) ferti-
second and the largest explosion. liser plant near Panipat, which later followed by toxic
The fire was also attributed to a welder’s torch but release and dispersion of the deadly gas, ammonia. An
one of the reports absolved the welder of any blame. accurate official report on what happened and how, has
Some blamed the batch dryer’s fibre glass insulation not as yet been made available. However, some reliable
which had a history of AP spills into the combustible sources reported that one evening an operator observed
insulation. a leak in one of the vessels, which he reported to the
F.I. Khan, S.A. Abbasi / Journal of Loss Prevention in the Process Industries 12 (1999) 361–378 375

supervisor. To rectify the problem the vessel was iso- train from Nizhnevartovsk destined for the Red Sea
lated and repaired. After repair, the vessel was brought resort of Alder was approaching the leakage area when
back into operation without checking whether the iso- the driver noticed a fog in the area that had a strong
lation (slip plate) device had been removed. Pressure smell. The driver of another train approaching from the
gradually built up inside the vessel and after a few hours opposite direction (Alder to Nizhnevartovsk) saw much
an explosion (BLEVE) occurred, spreading the contents the same as he approached the west-bound train. Both
of the vessel over the area. As the plant was situated far trains were full, with a total of 1168 people on board,
from a populated area and the quantity was not too great, and as they approached the area, the turbulence caused
the consequences were not severe. by them mixed up LPG mist and vapour with the overly-
Four members of the operating team and two shift ing air to form a flammable cloud. One of the trains
engineers died, more than 25 people were injured and ignited the cloud. Several explosions took place in quick
more than 1000 people were adversely affected. The succession, followed by a ball of fire that was about 1
presence of proper safety arrangements prevented the mile wide and which raced down the railway track in
death toll and damage from being much greater. Severe both directions. Trees were flattened within a radius of
damage was inflicted on an area of around 2 km2 and 2.5 miles of the epicentre of the explosions and windows
the cost of the damage has been estimated to be around were broken up to 8 miles away. The accident left 462
$20 million. dead and 796 hospitalised with 70–80% burn injuries.

5.3. Accidents at other facilities 5.3.2. Sao Paulo accident


On 25 February 1984, at least 508 people, most of
On 22 June 1974 a 16 inch elbow of a pipe carrying them young children, were killed in Sao Paulo (Brazil)
potassium carbonate solution in a fertiliser plant at Tam- when a gasoline pipe 2 ft. in diameter ruptured and 700
ilnadu, India, ruptured suddenly, splashing the hot sol- t of gasoline spread across a strip of swamp. The cause
ution into the nearby control room. The toughened glass of the pipe rupture was not reported, though it was said
panes shattered; eight people died in the control room to have been brought to a pressure above the safety
instantaneously, one died in the hospital and others sus- threshold. It was also stated that there was no way of
tained grievous injuries. monitoring the pressure in the pipeline.
On 31 August 1997 a blast occurred at Sterlite copper
smelter plant at Tuticorin, Tamilnadu state. Two people 5.3.3. The Basel disaster
were killed and two were seriously injured. According On 1 November 1986, a warehouse at Sandoz near
to the management report, four strong blasts occurred in Basel caught fire and burned. The warehouse contained
a rotary holding furnace in a period of 30 seconds (The ten types of pesticide, totalling about 1200 t, and 12 t
Hindu, 1997c). The blasts were so intense they were of mercuric fungicide. Most of these chemicals are toxic
audible even 10 km from the site of the accident. Due to both humans and animals. Around 70 to 80% of the
to the blast molten copper and slag at a temperature of stored chemicals have been drained out in different
1200°C spilled out over the whole area. forms due to fire. Although an alarm was given, the citi-
zens of Basel received no relevant information and were
5.3.1. The Siberian accident in a state of disquiet for several hours. The health of the
Perhaps the most macabre accident—next only to the River Rhine nearby was seriously endangered. Several
Bhopal gas tragedy in its severity—occurred on 3 June miles of the river turned a red colour and all aquatic life
1989, near Nizhnevartovsk in western Siberia. Engineers was destroyed. Nearby vegetation was also adversely
noticed a sudden drop in pressure at the pumping end affected.
of an LPG pipeline. The pipeline was commissioned in In total, 50 000 people were affected, and approxi-
1985 to carry mixed LPG to feed the industrial city of mately 5 km2 of river, ground water and 2 km2 of soil
Ufa. Instead of investigating the trouble, the engineers were contaminated. The total damage was estimated as
responded by increasing the pumping rate in order to $SFR 100 million.
maintain the required pressure in the pipeline. The actual
leakage point was about 890 miles downstream between
the towns of Asma and Ufa, where the pipeline was 6. Accident analysis
installed about 1/2 mile away from the Trans-Siberian
Railway. The smell of escaping gas was reported from 6.1. Fatality–frequency (FN) analysis
the valley settlements in the area but no-one did anything
about it. The escaping liquefied gas formed two large FN curves, also known as social risk plots, represent
pockets in the low lying areas along the railway line. the probability of fatalities as a function of the number
The gas cloud then drifted for a distance of 5 miles. of fatalities. Maximum fatalities have been observed in
Some hours later, after the main leakage had started, a fixed installation accidents (47%) followed by transpor-
376 F.I. Khan, S.A. Abbasi / Journal of Loss Prevention in the Process Industries 12 (1999) 361–378

Fig. 8. FN curves for transportation and fixed installation accidents.


Fig. 10. Trend of vapour cloud explosions.

tation accidents (34%). However, the FN curve for trans-


portation accidents (Fig. 8) is more flat than the curve accidents, about 49% have been attributed to fires and
pertaining to fixed installation accidents, indicating that explosions, 38% to toxic release and 13% to combi-
the probability of fatality is higher in transportation acci- nations of these effects. The average fatality per accident
dents than in fixed installation accidents. In other words, in fixed installations is 2.32; it is 3.27 for fire and
fatalities per accident are higher during transportation explosion, and 2.49 for toxic release. The FN curve for
than in a fixed installation. This is apparently due to the fire and explosion includes fire, vapour cloud explosion
additional risks a hazardous unit faces when it is in tran- (VCE), confined vapour cloud explosion (CVCE) and
sit compared to when it is fixed. Further, if an industry boiling liquid expanding vapour cloud explosion
where a fixed installation accident takes place has an (BLEVE). The number of explosions (either type) has
efficient emergency preparedness programme in place, been plotted as a function of a 5 year moving average
the damage may be contained. Such damage control is in Fig. 10. It is evident from the figure that during 1975–
rarely possible if a vessel fails due to a transportation 1979 a large number of explosions were reported, while
accident, or during transit. subsequently there was a sharp decrease. To study the
The FN curves also reveal that fires and explosions damage consequence of each accidental event, FN
cause more fatalities per accident compared with toxic curves for various accidental events (explosions, fires,
release (Fig. 9). The possible reason may be that only and toxic release) are presented in Fig. 11. It can be
deaths occurring immediately after the toxic release are observed that the curve for VCE is the flattest, while that
reported in the literature. Long-term chronic impacts— for fire is the steepest, indicating that VCE has the high-
which could be very significant—do not normally come est risk of fatalities while fire has the least.
to light. Of the total fatalities due to fixed installation

Fig. 9. FN curves for fire and explosion, and toxic release accidents. Fig. 11. FN curves for various accidental events.
F.I. Khan, S.A. Abbasi / Journal of Loss Prevention in the Process Industries 12 (1999) 361–378 377

An illustrative table of fatality rates due to accidents 쐌 Pipeline transport of chemicals is comparatively safe,
in different countries is presented in Table 10. The provided that the line is carefully maintained and its
Netherlands has the lowest fatality rate per accident route does not pass through populated areas.
while Austria and Belgium have the highest. 쐌 With an increase in density of industries in a complex,
the probability of accidents as well as that of the dom-
ino effect increase sharply.
7. Conclusion
The study highlights the need for accident forecasting,
consequence assessment, and development of up-to-date
From a study of the available models of accidents and
emergency preparedness and disaster management plans
case studies, the following conclusions can be drawn.
in the chemical process industries.
쐌 Most of accidents take place due to malfunctioning of
a component of equipment and/or minor negligence
of personnel during operation or maintenance. References
쐌 Although the number of accidents per year has
declined through the 1980s, the extent of damage per Abbasi, S. A., Krishnakumari, P., & Khan, F. I. (1997). HOT topics:
global warming, ozone hole, diversity, acid rain, industrial haz-
accident has increased substantially. This is parti- ards, and disinfection. Chennai, India: Oxford Press.
cularly true in developing countries such as India. Amendola, A., Contini, S., & Nichele, P. (1988). MARS; the major
쐌 The damage potential of an accident depends upon the accident reporting system. Preventing Major Chemical and Related
chemical in use, causative factors, operating con- Process Accidents, 445, 1121–1141.
ditions and site characteristics. Amesz, J., Francocci, G., Primavera, R., & VanderPas, T. (1983). The
European abnormal occurrences reporting system. Euredata, 4, 6.2.
쐌 The damage potential in terms of the area affected is Badoux, R. A. J. (1983). Some experience of a consulting statistician
a maximum for toxic release and depends upon the in industrial safety and reliability. Third National Reliability Con-
type of chemical, meteorological conditions and site ference. See also Reliability Engineering (1985), 10, 219–228.
characteristics. Bellamy, I. J., Geyer, T. A. W., & Astley, J. A. (1989). Evaluation of
쐌 The impacts of fires and explosions extend over much the human contribution to pipework and in-line equipment failures
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