5. State the root and immediate cause.

From the industrial plant past accident at Flixborough, the root cause which lead to
this catastrophic accident are management systems deficiencies which results in a lack of
experienced and qualified people. According to the Flixborough Report, There was no
mechanical engineer on site of sufficient qualification, status or authority to deal with the
necessary measures being taken. Beside that, the plant did not have a sufficient complement
of experienced people to be overworked and liable to error. There was also inadequate
procedures involving plant modifications. Hazardous material also did not adequately address
on pressure vessels which mainly dealt with steam and air. Next root cause was the area that
could exposed many people to severe hazard should not installed with a process with a very
large amount of hot hydrocarbons under pressure and well above its flash point.
As for immediate cause, the pipe replacing a failed reactor failed which then releasing
large quantities of hot cyclohexane forming vapor cloud and ignited. The incorrect
installation of bellows which used dog-leg at the end of each pipe without adequate support
was contrary with manufacture recommendation. The reactor that failed showed stress crack
corrosion. Beside that, the use of oxidation chemistry which due to potential for operating in
explosive region can lead to uncontrolled reaction. Subsequent to the reaction, the product
mix is quenched with water and produced energi intensive process from cyclohexane which
caused explosion.