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WEST FERTILIZER

COMPANY (WFC)
MOHAMAD AZRUL BIN SUHAIMI 18317
MUHAMMAD FARHAN BIN MOHD YUNUS 18446
MUHAMAD HAZIQ BIN HALMI 18202
MOHD SHAFIK BIN SANUSI 18444

Presentation Outline

Introduction about PSM

Discussion on why disasters continue to occurs

Case Study

The process involved and its related hazards

What caused the disasters?

PSM Failings

Recommendations

INTRODUCTION
About PSM

What is PSM?
A HOLISTIC management of process safety to
prevent process incidents and mitigate their
consequences

OSHA Proposed PSM

PSM Effective

ELIMINATION
(or significant reduction)
of process-related
incidents.

14 Elements of PSM

Process safety information (PSI)

Mechanical integrity

Process hazard analysis (PHA)

Hot work permit

Operating procedures

Management of change

Employee participation

Incident Investigation

Training

Contractors

Emergency planning and


response

Compliance audits

Trade secrets

Pre-startup safety review (PSSR)

DISASTERS CONTINUE
TO OCCURS
WHY?

The reasons why disaster continue to occur even PSM has been introduced are:

Lack of understanding about PSM


Implementation of PSM
Technology Transfer

Operators Characteristics

DETAILS OF THE PROCESS &


ITS RELATED HAZARDS
TO AVOID SIMILAR INCIDENTS

Details of the Process


The West Fertilizer Company (WFC) stored and distributed:
Fertilizers
Chemicals
Grains
Various other farming supplies
Stockpiles of about 40 60 tons of fertilizer grade ammonium nitrate
were estimated to be on site and about 30 tons detonated.

Details of the Process


Fertilizer Name
Fertilizer grade ammonium

Amount (in tons)


40 to 60

nitrate (fertilizer building)


Fertilizer grade ammonium

100

nitrate (railcar)
Anhydrous ammonia

17

Potash

45

Diammonium phosphate

70

Diammonium phosphate and

25

potash
Ammonium sulfate
Zinc sulfate

60 to 70
17.5

Table 1: WFC Fertilizer Inventory in April 2013

Ammonium Nitrate Hazards


Stable material under normal condition.
Not sensitive to mild shock or other typical sources of detonation (such
as ignition).
When it comes to fire situation, it posses 3 main hazards:
Uncontrollable fire
Decomposition with the formation of toxic gases
Explosion
Ammonium nitrate is classified as explosive when the prills are
produced with more than 0.2% carbonaceous material.
As an oxidizer, it can increase flammability or explosibility of other
combustible substances when it decomposes after exposure to heat.

WHAT CAUSED THE


DISASTER?
TO AVOID SIMILAR INCIDENTS

What Caused the Disaster?


The warehouse store which stores 30 tons of ammonium nitrate is
made up from woods.
The wooden bins also stored significant amount of combustible seeds.
On April 17th 2013, a fire started in the fertilizer building.
Source of ignition remain unknown.
Smoke and soot from the fire accumulated on the pile of
ammonium nitrate stored in the bins.

What Caused the Disaster?


The fire burns through door.
More outside oxygen rushed in which increased the amount of
radiant heat.
Heat absorbed by the layer of soot on top of the pile of
ammonium nitrate.
Rapidly heating the surface of the fertilizer thus making it
sensitive to detonation.
20 minutes after the first fire reported, 30 tons of ammonium nitrate
detonated.

PSM FAILINGS
TO AVOID SIMILAR INCIDENTS

PSM FAILING
Process
Hazard
Analysis

Training

Emergency
Response and
Plan

Process Hazard Analysis


The warehouse storing 40 tons of ammonium nitrate is made
up from woods.
The wooden bins also stored significant amount of
combustible seeds.

No fire alarm available.


No sprinkler system installed.
In term of siting, the anhydrous ammonia tank is too near to

from the combustible warehouse and no safeguards is


available.
The company location very near to the schools and

residential area.

Training
Employees at
WFC had limited
training on
FGAN hazards CSB

Employees were
unaware that
the FGAN
fertilizer on site
could explode.

WFC employee
training was
hands on and
job specific.

CSB concluded
that FGAN
safety training
was inconsistent
and no formal
training
addressing
FGAN hazards.

Training
The volunteers who responded to the WFC facility fire did not
have sufficient HAZMAT training.

There is very little emphasis on how to effectively


respond to fire incidents involving FGAN

Only two of the deceased firefighters had taken the HAZMAT


awareness course, but only the introductory basic level.

Emergency response and planning


There is no or lack of emergency planning provided by
WFC to its employees.

CSB found there is no evidence of pre-incident planning


that address the likelihood of a fire involving FGAN at
the WFC facility.
The emergency response personnel also made a
mistake by not properly evacuate the nearby residents
due to unavailability of emergency response plan.
Emergency alert systems for the public were not
activated before the explosion, although McLennan
County had such systems in place.

CSB found that no immediate evacuation at the first


sign of fire occurred.

RECOMMENDATIONS
TO AVOID SIMILAR INCIDENTS

FOR OSHA:
To

add fertilizer grade ammonium nitrate (FGAN) to the

PSM Highly Hazardous Chemicals, Toxics and Reactives.


To

update the Explosives and Blasting Agents Standard to

ensure safer handling of the chemicals

FOR EPA:
To

revise its Risk Management Program rule to include

FGAN on its list of regulated substances.

FOR LOCAL AUTHORITIES:


To implement zoning restrictions that prevented residences,

schools, and business from being built so close to highly


hazardous chemical facilities.

Map for West Fertilizer Company

1961

2013 (Before Explosion)

2013 (After Explosion)


Source: Google

FOR EMERGENCY RESPONDERS:


Improve

the training quality for all emergency responder

such as firefighters (e.g. receive minimum level of training


on responding to fires involving hazardous chemicals).

FOR FERTILIZER FACILITIES:


To

modify or construct the storage facilities using non-combustible

materials such as concrete which can significantly reduce the risk.


Improve

the training quality for all the employees to ensure they

understand the hazards that FGAN posed.


To develop or improve the emergency action plan.
Source: CSB Report

To properly conduct Process Hazard Analysis (PHA).

CONCLUSION

Conclusion
The West Fertilizer Company (WFC) explosion occurs when the fertilizer grade

ammonium nitrate (FGAN) that were stored in a wooden storage facilities


combusted and exploded.
1. Impact :
i.

15 Death (12 emergency responders and 3 members of the public),

ii.

More than 260 victims injured,

iii.

Damage to more than 150 offsite buildings

Conclusion
2. Factors that causes the explosion:
i.

Lack of awareness from the employees and community on the hazards posed from
FGAN

ii.

Nearby homes and business were built near the West Fertilizer Company over the years
prior to the accident

iii.

the failure of the facilities to comply with several PSM elements; Training, Emergency
Planning and Response, and Process Hazards Analysis (PHA).

Several recommendations have been made to ensure similar incident can be avoided in the
future.

THANK YOU
WE ARE READY FOR YOUR QUESTION.