1.

0 INTRODUCTION
At Seveso near Milan in Italy, on 10 July 1976, a discharge containing highly toxic dioxin
contaminated a neighbouring village over a period of about 20 minutes. About 250 people
developed the skin disease chloracne and about 450 were burned by caustic soda. A large area of
land, about 17 km2, was contaminated and about 4 km2 was made uninhabitable. The discharge
came from a rupture disc on a batch plant for themanufacture of 2,4,5-trichlorophenol (TCP)
from 1,2,4,5-tetrachloroben-zene and caustic soda, in the presence of ethylene glycol used to
produce herbicide.

2.0 CAUSES OF THE ACCIDENT

The circumstances leading to the reactor overheating were as follows:
The reactor was shut down at the end of the reaction, but before the ethylene glycol had
been removed. (This was because an Italian law required the plant to be shut down for the
weekend) The plant was not normally shut down at this stage of the cycle.
The reactor was heated by an external steam coil which used exhaust steam, at a pressure
of 12 bar and a temperature of about 190C, from a turbine on another unit. The turbine
was on reduced load, as units were shutting down and the temperature of the
exhaust steam rose to about 300C.
The temperature of the wall of the reactor above the liquid level increased leading to
a slow exothermic reaction starting in the upper region of the liquid illustrated in by
figure 1.

Figure 1: The Seveso reactor. The hot upper portion of the reactor surface of the liquid.

The stirrer was turned off and the slow exothermic reaction started; after about seven hours a
runaway occurred.

Because the runaway reaction had raised the batch to a high temperature. the dioxin level was
verv high compared with normal level the toxic gas escape into the atmosphere as there was no
catchpot to collect the discharge from the bursting disc

3.0 MEASURES THAT COULD HAVE PREVENTED THIS ACCIDENT

The runaway would not have occurred if:
a hazard and operability study (Hazop) had been carried out on the design. This could
have predicted the rise in temperature of the steam when the turbine is running on low
load.
the batch was not stopped at an unusual stage

4.0 SUMMARY OF EVENTS AND PREVENTION

5.0 REFERENCES
Trevor Kletz., 2001. Seveso. Learning from Accidents 3rd Edition. pp.103-109
Mark Tweedale., 2003. Lessons from Incidents, Managing Risk and Reliability of Process Plants
pp.399-403

6.0 PIPER ALPHA

Rig:

Piper Alpha Platform

Date:

06 Jul 1988
3

Location: Block 15, UK Continental Shelf

Operator: Occidental
Fatalities: 167
History
The Piper Field was discovered by Occidental in January 1973, with the Piper Alpha platform
becoming operational in 1976. Located about 120 miles north-east of Aberdeen, the platform
initally produced crude oil. In late 1980, gas conversion equipment was installed allowing the
facility to produce gas as well as oil. A sub-sea pipeline, shared with the Claymore platform,
connected Piper Alpha to the Flotta oil terminal on the Orkney Islands. Piper Alpha also had gas
pipelines connecting it to both the Tartan platform and to the separate MCP-O1 gas processing
platform. In total, Piper Alpha had four main transport risers: an oil export riser, the Claymore
gas riser, the Tartan gas riser and the MCP-01 gas riser.
Explosion and Fire
On 06 July 1988, work began on one of two condensate-injection pumps, designated A and B,
which were used to compress gas on the platform prior to transport of the gas to Flotta. A
pressure safety valve was removed from compressor A for recalibration and re-certification and
two blind flanges were fitted onto the open pipework. The dayshift crew then finished for the
day.
During the evening of 06 July, pump B tripped and the nightshift crew decided that pump A
should be brought back into service. Once the pump was operational, gas condensate leaked from
the two blind flanges and, at around 2200 hours, the gas ignited and exploded, causing fires and
damage to other areas with the further release of gas and oil. Some twenty minutes later, the
Tartan gas riser failed and a second major explosion occurred followed by widespread fire. Fifty
minutes later, at around 2250 hours, the MCP-01 gas riser failed resulting in a third major
explosion. Further explosions then ensued, followed by the eventual structural collapse of a
significant proportion of the installation.
167 men died as a result of the explosions and fire on board the Piper Alpha, including two
operators of a Fast Rescue Craft. 62 men survived, mostly by jumping into the sea from the high
decks of the platform. Between 1988 and 1990, the two-part Cullen Inquiry established the
causes of the tragedy and made recommendations for future safety regimes offshore. 106
recommendations were made which were subsequently accepted and implemented by the
offshore operators.
Aftermath
A number of factors contributed to the severity of the incident:
the breakdown of the chain of command and lack of any communication to the platform's
crew;

the presence of fire walls and the lack of blast walls - the fire walls predated the
installation of the gas conversion equipment and were not upgraded to blast walls after
the conversion;
the continued pumping of gas and oil by the Tartan and Claymore platforms, which was
not shut down due to a perceived lack of authority, even though personnel could see the
Piper burning.

7.0 CHERNOBYL
In the early morning hours of April 26, 1986, the Chernobyl nuclear power plant in Ukraine
(formerly part of the Soviet Union) exploded, creating what has been described as the worst
nuclear disaster the world has ever seen.
The day before the Chernobyl nuclear disaster, plant operators were preparing for a one-time
shutdown to perform routine maintenance on reactor number 4. In violation of safety regulations,
operators disabled plant equipment including the automatic shutdown mechanisms, according to
the U.N. Scientific Committee on the Effects of Atomic Radiation (UNSCEAR).
At 1:23 a.m. on April 26, when extremely hot nuclear fuel rods were lowered into cooling water,
an immense amount of steam was created, which because of the RBMK reactors' design flaws
created more reactivity in the nuclear core of reactor number 4. The resultant power surge
caused an immense explosion that detached the 1,000-ton plate covering the reactor core,
releasing radiation into the atmosphere and cutting off the flow of coolant into the reactor.
A few seconds later, a second explosion of even greater power than the first blew the reactor
building apart and spewed burning graphite and other parts of the reactor core around the plant,
starting a number of intense fires around the damaged reactor and reactor number 3, which was
still operating at the time of the explosions.

8.0 AMERICAN AIRLINES FALIGHT 1420

American Airlines Flight 1420 was a flight Dallas-Fort Worth International Airport to Little
Rock National Airport in the UAS. On June 1, 1999, the McDonnel Douglas MD-82 operating
for flight 1420 overran the runway upon landing in Little Rock and crashed. Of the 145 people
aboard, the captain and ten passengers were killed.
This incident was caused mainly by two factors; firstly, stress when the two pilots onboard were
confused by the sight of the runway and secondly due to the bad weather condition which kept
on worsening.

The flight was smooth until the last stage of the operation which is thlanding of thplane. The
weather conditions were ony worsenng as predicted but the pilots did nt retract from their
destination mainly due to airline pressure faced by many in th airlin industry. The plan was to
land in the bowlin alley that was formed aroud the runway. However, as the plane was
approaching, the former was more and more reducing in distance. The acceleration of the plane
did nothing but make the landing more difficult in additions to the crosswids. The pilots then
dicided to make a change in the direction and thn task was to inlocate the storm which was
intensifying. The mission was then to land the plane as fast as possible before the situation
becomes completely out of control. The rise in stress level also contributed in the confusion of
the flight deck as they decided to abandon their direct visual approach and requested help from
Little Rocks instrument landing sytem. This delayed the landing further more and also meant
that the storm was more and mo inensifying. The heavy rain caused by the latter cut the visibility
even more. Low visibility and hih winds made the final approach more dangerous.
According to the National Transportation Safety Board (NTSB) report on the crash, the probable
causes of this accident were the flights crews failure to discontinue the approach when severe
thunderstorms and their associated hazards to flight operations had moved into the airport area
and the crews failure to ensure that the spoilers had extended after touchdown which should
have automatically been done.

From the above writen paragraphs, it is seen that appart from the bad weather conditions, this
incident also occurred due to the omission of the extension of the spoilers after touchdown which
plays an important role in the slowing process of th airplain. This implies that there were soe
problems that caused thespoilers not to deploy automatically hence questioning its reliability.
It can therefore be concluded that the system was not effective and a combination of technical
performance, human factor and environmental conditions led to the crash.
The crash of the flight 1420 was caused by the overgrowing stress among the crew. This
produced a sequence of events that led to the verification of the deployment of the spoilers.