THE SEVESO DISASTER

Group CC

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Table of Contents
The Unwanted Event ................................................................................................................. 1
Controls and Defences ............................................................................................................. 2
Why Did it Happen? .................................................................................................................. 3
Lessons Learnt ......................................................................................................................... 3
References ................................................................................................................................ 4

The Unwanted Event

On Saturday 10th of July 1976, the Seveso disaster occurred leading to the worst known industrial
release of the highly toxic chemical 2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD). The plant,
owned by ICMESA (Industrie Chimiche Meda Societ Azionaria), produced trichlorophenol from
1,2,4,5 tetrachlorobenzene by reaction with sodium hydroxide. The trichlorophenol was in turn
used as an intermediate in hexachlorophene production.[1]
The reaction of tetrachlorobenzene to trichlorophenol was thought to be carried out at
temperatures below 230C to prevent the side reaction producing TCDD. However, it was found
that the side reaction actually began at 180 C. A decision was made to use exhaust steam from
the electricity generating turbines at the plant to drive the reaction. This exhaust steam was
available at 12 bar and 190C at normal operating conditions and would heat the reaction mixture
to 158C. [1][3]
Due to legislation that stated that plants shut down during weekends, a shutdown was initiated
which stopped a batch process one step before the final ethylene glycol removal stage.
Concurrently, other sections of the plant were shut down, reducing power demand as well as load
on the turbine thus leading to an increase in temperature of exhaust steam from the normal 190C
to 300C. This steam went on to heat up the reactor after shutdown, exceeding temperatures of
180C thus initiating the TCDD producing side reaction. Plant operators unaware of this
temperature increase continued with the shutdown process. As a result, heat was isolated in the
reactor upper portion, 7 hours later, the side reaction critical temperature was exceeded leading
to a runaway reaction. As a result of the runaway reaction, a reactor pressure relief rupture disc
opened and released a cloud of 6 tonnes of chemicals containing 1kg of TCDD into the
environment. The cloud dispersed to nearby residential areas killing thousands of animals and
causing serious harm to several people. A large amount of TCDD was washed into the soil by
rainfall contaminating 1800 hectares of land. The release was noticed by maintenance workers
approximately 20 minutes after it had begun. Following the release, a large number of animals
were slaughtered to prevent TCDD from entering the food chain, children were hospitalised with
chloracne and evacuation of the hardest hit zone was ordered. Several pregnant women opted to
abort fearing birth defects. Various inefficiencies slowed down the response time to this disaster,
mainly non-disclosure to the local government by the company and a delay in realizing that TCDD
had been released. [1][3]

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Controls and Defences[3]
FAILED CONTROLS

HUMAN ERRORS

WORKPLACE FACTOR

1. Rupture disk incorrectly calibrated. Slip - A 3.5 bar set disk was used instead of a disk with a lower FFPE: Poor design allowed for disc to rupture and release hazardous
pressure setting. The venting would have happened at a lower materials at high temperatures.
temperature.
2. Abrupt stop to batch process
before completion of production
cycle. Residence time of batch
increased.

Cultural violation - although by law no plant operation should occur

over the weekend, they should have followed correct shutdown
procedures. Cooling and agitation should have continued until they
were sure the reactor was at a safe temperature.

CWE: The operation of the plant as a whole was not considered i.e. how each
step affects the next. As a result of shutting down other parts of the plant, the
reactor system was unknowingly no longer receiving exhaust steam at 12 bar
and 190C but steam at 300C.
CP: Operator did not check that the reactor had cooled sufficiently.

3. Failure to adhere to distillation Cultural Violation - The plant operated in a reverse order to that SWP: The operators did not follow the distillation patent.
patent.
stated by the distillation patent.
4. No temperature gauges on the Slip - Unable to see the increase in steam temperature from 190C CWE: Critical controls were not monitored.
steam line (latent pathway).
to 300C. Unfortunately, the critical temperature turned out to be
180C, which was 50C lower than what the company believed. The
mild exothermic reaction that started led to a runaway reaction
when the temperature reached 230C.

5. Delayed emergency response by Mistake - when the leakage occurred, the company had no idea CP: The company did not know that TCDD was released in large amounts
the company.
that TCDD was released along with TCP
and therefore did not realise that local authorities would need to be informed
immediately in order to initiate community evacuation.
SWP: The company should have ran tests immediately to establish exactly
which chemical had been released without making any assumptions

6. Failure to install emergency Deviant violation - The company ignored a recommendation from FFPE: No containment unit was in place to deal with released toxins
containment unit (latent pathway).
the manufacturer to install a containment unit to capture toxic
material that may have been released by the rupture disc.
SWP: There was no legislation in place at the time that required the company
to have an emergency containment unit and without which the firm could not
do business.
7. Inadequate control measures Slip - the company had no automated control systems in place FFPE: Reactor heat exchange system had no thermometer to monitor
installed (latent pathway).
(automation technology may not yet have been available). There temperature of steam.
were no alarms installed as well.
CWE: Critical controls were not monitored.
SWP: No alarms were installed to alert the operators of any dangerous
situations.

Why Did it Happen?

Failures in Management Systems [2][3]
The following are the management systems failures:
The company failed to inform local authorities and government immediately after the
incident occurred. This would have enabled swift evacuation of civilians and livestock,
preventing the exposure to TCDD. This would have also provided ample time for the
preparation of medical facilities.
Faults associated with the plant design, as a result of cost cutting, include the absence of
containment vessels to collect or destroy toxins, a second receiver to replace the damaged
disc, temperature gauges and emergency alarms to warn against hazardous materials.
Violation of the distillation patent resulted in the plant procedure being incorrectly applied.
Risk Management Failure [2][3]
Several accidents had occurred in similar TCP manufacturing plants before the Seveso
incident. The company did not take into consideration any additional safety precautions
and design modifications.
Adequate knowledge of the process would have prevented the side reaction occurring at
low temperatures.
Failure to immediately test the released chemicals to ensure no TCDD had been released
to the environment
Lessons Learnt
One of the lessons we learnt from this disaster was that the operation of a chemical process
should not be carried out without completely understanding the process or how each stage affects
the next. A complete HAZOP study is very important because when this disaster happened, very
little if any information was known about the chemicals that were released. A HAZOP was
developed in the 1960s, but only fully established in 1977 - the year after this incident [4]. This
shows the importance of considering every angle of an operation. During the design phase of a
project, it is equally essential to investigate and learn from previous similar processes. As in the
case with the Seveso disaster, five accidents had occurred using similar reactants and if the
design team had studied these, this accident could have been avoided.
It is important to take responsibility when something goes wrong, regardless of the magnitude of
the incident. Had the company spoken up sooner, damage and injury to people, animals and land
could have been minimised. It is important for companies to have clear lines of communication
with government to prevent disasters such as these as well as to manage the effects should an
accident occur.
The Seveso disaster case study shows the importance of a proper shutdown procedure. The
abrupt stop to the production cycle in order to conform to the law did not give the firm the excuse
to overlook a prudent shut down procedure.

References
1. https://en.wikipedia.org/wiki/Seveso_disaster
2. http://www.informit.com/articles/article.aspx?p=1717264&seqNum=8
3. http://www.hse.gov.uk/comah/sragtech/caseseveso76.htm
4. http://www.sozogaku.com/fkd/en/cfen/CC1300002.html accessed on 22/03/2016
5. https://www.google.co.za/url?sa=t&rct=j&q=&esrc=s&source=web&cd=9&cad=rja&uact=
8&ved=0ahUKEwiYqvjltTLAhWGvRoKHT1lCx4QFghRMAg&url=http%3A%2F%2Fwww.cheme.utm.my%2Fst
aff%2Farshad%2Fimages%2Flecture%2FSafety%2Fhazop_method.ppt&usg=AFQjCNF
QdYisw5pH2DQpo5ue1WkVM0GiIw&sig2=FXAFFUAswZQ5r0xF9yDsg&bvm=bv.117218890,d.ZWU