ACCIDENT ANALYSIS ASSIGNMENT – KQD 7006

HAZARD ID AND EVAL

THE FEYZIN DISASTER, FRANCE
DONE BY:
1) KRYSTLE JAMEELA BT MATHEW SAN (KQD
190009)
2) NAVEEN JAYAKUMAR (KQD 190010)
3) ABDULRAHMAN ALGARNAS (KQD 190024)
4) ANANDA NAIR (KQD 190020)

FOR: PROF DR. CHE ROSMANI

ROOT CAUSES OF THE FEYZIN DISASTER ACCORDING TO THE SUBSYSTEM
WITHIN SOCIOTECHNICAL SYSTEM

1. External systems
● The eight LPG storage spheres were located about 300 meters from the
nearest village of Feyzin.
● The main storage areas were located adjacent to a motorway.
● The short distances from the dense residential, commercial areas and public
roadways to the refinery considered unsafe as evacuation of up to 0.5km will
usually ensure the safety of the people surrounding any refinery.

2. System climate
● The fire services who attended the blaze were not trained in controlling the
type of BLEVE fire.
● The operator who was part of the team who was in charge of taking a sample
from each of the LPG storage spheres during the day of the tragedy carried
out the task in the incorrect order which led to a very powerful jet of propane
to rush out.

3. Organization & management

● Emergency Response Plan was not prepared properly.
● An incident controller who supposed to take charge of the scene in which the
incident occurring was not assigned during the shift of sample taking for the
LPG.
● A site main controller who supposed to arrange backup support for the
incident controller and advising the emergency services about the way the
incident is likely to develop also was not assigned.
● The time delayed before the first BLEVE explosion of the sphere.
● There was no expertise in handling the sampling taking task.
● The management of the refinery was supposed to inform the local authorities
(outside or nearby the refinery who were likely to be affected by the major
accident) about the activity and associated hazards so they were aware of the
advance warning and precautionary action they should take in case of any
emergency.

4. Site & plant facilities

● The eight LPG storage spheres were located about 450 meters away from the
nearest refinery unit.
● The spacing between individual spheres varied from 11.3 meters to 17.2
meters had shown that those spheres were placed close to each other.
● During the fire of sphere no. 1 occurred, not only the water spray for that
particular sphere was turned on but also for the whole area. This was why
 there was insufficient water to feed the whole system and water had to be
pumped from the canal.
● The refinery roadway was adjoined with the public’s road. There was no
dedicated road for the plant use only.
● The discharge from the drain line was directed downwards in the vicinity of &
under the valve, instead of the side.
● The improper design of the valve placement on the sphere which caused
limited access for the operator.
● Darkness and poor lighting added to the difficulties.

5. Management control
● Operator was not used to the new instruction on sampling procedures that
was issued recently (a few months) before the Fenzin disaster occurred.
● There was no proper or expertise to conduct the Emergency Response Plan
during the time of the incident.
● There was no Emergency Team to support the operation team during the time
of the incident.
● Inadequate skilled training to measure the competency of the operator prior to
handle a particular assigned task.

6. Working environment
● Operator was supposed to be aware of the compliance of safe work
procedures so there would not be any potential hazard which could lead to
major accidents.
● Poor knowledge on new instruction on sampling procedures.
● Poor response, skills & knowledge on emergency event or major incident.
● The primary cause of the propane leak was the operational fault of the plant
operator. This fault was exaggerated because of poor access to the valves &
the lack of permanent valve spanner.

7. Communication & information

● Information on new instruction on sampling procedures was not shared fully
among operators.
● There was neither clear communications nor exchange of information
between the Feyzin refinery management and the local authority about the
advance warning & precautionary actions the public should take in case of
emergency. This was why the public did not evacuate during the incident
stage of the fire.
● Automated gas leak indicator was not installed on the storage spheres.
● Report concerning the refinery information (such as CIMAH report or HAZOP
table) was not prepared prior to start up the refinery. Therefore, operators
were not aware of the characteristics and the danger of the chemical
substance they were working with.
 ● With the presence of the Emergency team at the refinery, the impact of the
accident could be lessen as there were experts who were trained, skilled and
knowledgeable of how to handle emergency.

8. Procedure & practices

● The operator did not comply with the sampling instruction or the standard
operating procedures.
● The operator had gone through training but it did not measure the operator’s
understanding towards the assigned work procedures.
● The Emergency Response Team who supposed to handle emergency was
not assigned in the refinery.

9. Operator performance
● There was no special training in between the issuing date of the new
sampling procedure till the day of the tragedy to update the operator of any
new changes made to the previous instruction to avoid incorrect order.
● The operator was not aware of the risk of working against the safe work
procedure.
● Training was held for operator prior to carry out assigned task but his
understanding or competency was not measured as there was no scoring test
conducted for each operator.
● The team who was in charge of the sample taking started their shift at about 6
am in the morning. Therefore, the operator could be sleepy which led him to
incorrect order of conducting work according to the sample instruction.

10. Equipment integrity

● The discharge from the drain line was directed downwards in the vicinity of &
under the valve, instead of the side.
● The placement of the valve was designed wrongly which led to poor access to
the valves for the operator to take sampling.
● Insufficient fire fighting system to control the fire or blaze at the refinery. (Eg:
Insufficient water supply to support the whole system, insufficient dry
chemical readily supplied in-house to handle fire or blaze)