Journal of Loss Prevention in the Process Industries 70 (2021) 104404

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Journal of Loss Prevention in the Process Industries

journal homepage: http://www.elsevier.com/locate/jlp

Incident analysis of the “Pajaritos” petrochemical complex

Henry M. Aquino-Gaspar a, Christian O. Díaz-Ovalle b, **, Antioco López-Molina a, *,
Carolina Conde-Mejía a, Luis M. Valenzuela-Gómez a
a
Departamento de Ingeniería Petroquímica, Universidad Juárez Autónoma de Tabasco, Carr. Libre Villahermosa –Comalcalco Km 27, Jalpa de Méndez, Tab., 86205,
Mexico
b
Departamento de Ingenierías, Tecnológico Nacional de México/I. T. Roque, Km 8.0 Carretera Celaya-Juventino Rosas, Gto, 38110, Mexico

A R T I C L E I N F O A B S T R A C T

Keywords: On April 20th, 2016, an explosion occurred in the “Pajaritos” petrochemical plant, in Coatzacoalcos, México. The
Polyvinyl chloride accident caused 32 deaths and almost 100 workers were seriously injured. At present, there is no official in­
Process stream index formation about the cause of the accident and the existent reports are confidential. This paper proposes an
CFD
explanation of what happened at the petrochemical plant facilities by considering the testimony of several
ASPEN PLUS ®
witnesses and the process simulation. The strategy includes three steps: 1) the process simulation via Aspen
Analysis of consequences
Plus® software; 2) The hazardous process streams identification through the process stream index (PSI); and 3)
The consequences description using the TNT method, ALOHA® and ANSYS FLUENT. The results agreed with the
testimony of witnesses and indicated the level of environmental damage and the unavailable prioritization of
process safety over the production and management systems. This indicates that these accidents are recurrent as
a consequence of a low safety culture in developing countries.

1. Introduction • On April 28th of 1973, in Jouetsu, Niigata, Japan, a production plant

In the last decades, the high demand of petrochemical products has
forced the process facilities to expand (Hassani et al., 2017). Unfortu­
nately, these significant changes in the industry have increased the
process risk and have caused industrial accidents, which have released
many chemicals into the environment affecting the population (He et al.,
2011). The polymer industry is one example, where the production of
polyvinyl c
hloride (PVC) was 44.4 Mt in 2018 (Business Wire, 2018). This
process requires hazardous raw materials and extreme operating con­
ditions (Gaur and Wunderlich, 1983; Wang et al., 2009). Furthermore,
the process plants in developing countries disregard the safety measures
to achieve highly reliable production (de Souza Porto and de Freitas,
1996). This problem can be observed in the poor safety culture of
workers, which added to the extreme conditions in the production
processes generates conditions of high risk catastrophic events.
The PVC process has experimented serious accidents. Two of the
most transcendental events are:
the “Pajaritos” petrochemical complex in Coatzacoalcos, Veracruz,
México (N:18◦ 06′ 47′′ , W:94◦ 23′ 17.5′′ ). This case is analyzed here to
of PVC suffered a VCM leak that yielded an explosion with partial
destruction of the chemical plant. The VCM leak was located in the
feed stream in the refining tower and came from a storage tank. The
source of the problem was the sudden opening of a control valve due
to maintenance service by corrosion. The released gas reached
enough temperature to explode and damage 2.2 km around. The
incident investigations found a release of around 4 t of VCM (Koseki
and Tamura, 1973).
• On April 23rd, 2004, in Illipolis, IL, U.S., a production plant of PVC,
owned by Formosa Plastics Corp., exploded and caused the death of
five workers and considerable damages. The U.S. Chemical Safety
Board (CSB) investigated the incident. It concluded that: a) causes:
human error, wrong interpretation of the safety and control systems,
and b) recommendations: implementing an integrated control sys­
tem, restrictive access to control system devices, and more infor­
mation dissemination about VCM and its hazards (CSB, 2007).
In addition, PEMEX suffered an accident in the “Clorados III” plant of

* Corresponding author.
** Corresponding author.
E-mail addresses: christian.do@roque.tecnm.mx (C.O. Díaz-Ovalle), antioco.lopez@ujat.mx (A. López-Molina).

https://doi.org/10.1016/j.jlp.2021.104404
Received 28 October 2020; Received in revised form 19 December 2020; Accepted 18 January 2021
Available online 30 January 2021
0950-4230/© 2021 Elsevier Ltd. All rights reserved.
H.M. Aquino-Gaspar et al. Journal of Loss Prevention in the Process Industries 70 (2021) 104404

explain the main concerns about the catastrophe, which is discussed in Table 1
the next sections. Graphic information sources on the consequences of the incident.
Description Internet route
2. Production of PVC
Exact location of the event, depiction of https://www.youtube.com/watch?v%20
material damages, data about the =%20WE_DDDVgoJM&t%20=%20351s
PVC comes from the systematic transformation of ethylene. This layout and size of the plant.
process starts in the production of 1,2-dichloroethane (EDC) from Dimension of the smoke cloud https://i.ytimg.com/vi/7H8OLg5iczY/
ethylene, C2H4, through two possible paths (Rossberg et al., 2006): a) generated by the blast maxresdefault.jpg
Visible material damage after the https://i2.wp.com/lopezdoriga.com/wp
direct chlorination: injection of pure Cl2, and b) oxy-chlorination: use of explosion and detection of the -content/uploads/2016/04/Explosi%
fresh HCl with recycling stream. Later, EDC suffers an exothermal possible release point. C3%B3n-Coatzacoalcos.jpg?resize
decomposition reaction to yield vinyl chloride monomer (VCM), which =960%2C480&ssl=1
is characterized by: a) high flammability, b) heavy gas behavior, and c) Damage to the reactors and heat https://xalapaenlanoticia.files.wordp
exchangers areas. ress.com/2016/04/adolfoooo_jasso
heat of combustion similar to butane (Guido et al., 2016). The final step
_ajm_04541.jpg?w=547
is the polymerization of VCM in order to obtain PVC. Herein, the anal­
ysis focuses on the steps before polymerization, as Fig. 1 depicts.
inhabitants to avoid outdoor activities. Through a statement, PEMEX
3. Incident description reported the progress of control over the accident. At 6:20 p.m. that day,
the fire was controlled.
The “Clorados III” plant of the “Pajaritos” petrochemical complex
was designed to yield 900 t/day of PVC (Reuters Staff, 2016). The 4. Identification of hazards
company Mexichem S.A.B. de C.V. managed the plant in association
with PEMEX. This chemical plant operated both pathways of EDC pro­ Process streams are high-risk elements in a chemical plant. The
duction. On April 20th, 2016, at 15:45 a massive explosion took place. hazard identification technique determines their level of risk. A suitable
During the blast 32 workers were killed and around one hundred people strategy is the process stream index (PSI), which demands a succinct
were injured. Previously, the plant had several accidents, but the safety description of the streams through the following parameters: a) density,
measures were not modified. At the time of the incident, welding works b) pressure, c) thermal energy, and d) combustibility. The last parameter
were being carried out to install equipment. The catastrophic event was refers to the difference between the lower (LFL) and upper (UFL)
captured by eyewitnesses, who provided photographs via internet; some flammability limits of the mixture. High combustibility values indicate
of them are in Table 1. The chronological description of the event can be high explosiveness in the stream (Heikkilä, 1999). Finally, the PSI re­
summarized as follows: lates all parameters to obtain a hazard score where high values reflect
the severity of a process stream (Shariff et al., 2012). However, to obtain
• 08:00: The leak alarm sounded in the feed stream to R3 and the the stream parameters is a hard task and demands the use of a process
safety personnel applied the evacuation plan to the personnel. simulation software. In this work, this issue applied ASPEN PLUS ®
• 11:00: The leak alarm sounded for the second time in the same area. v10.0 into the PVC production process.
The overall works were stopped, and the personnel was evacuated
until 14:00. 4.1. Simulation process of PVC
• 15:00: The leak alarm and the flame alarm were activated in the
same area. The safety personnel verified the alarms and later on This simulation included the two ethylene reaction options (direct
authorized the overall works. The safety staff said the situation was chlorination and oxy-chlorination). Fig. 2 shows the complete process
under control without explosion risk. described in ASPEN PLUS ® v10.0, in which consecutive numbers
• 15:15: An explosion occurred in the same area and released EDC and indicate the process sections. The main items are reaction and refining
VCM. The blast produced an expansive wave, which destroyed the systems. The operating conditions for each process unit come from the
plant and severely damaged different areas 6 km away. literature. The exact process condition at the time of the disaster is un­
known, except for 900 t of PVC’s daily production. On the other hand,
the CPROB stream presented the leak in the boiler area. It came from the
3.1. Emergency response exothermal decomposition reactor (Noticias, 2016; Sanchez, 2016),
indicated by R3 in Fig. 1 and B19 in Fig. 2.
Internal safety protocols were applied after the explosion, which
included the closing of ducts and valves in the plant and the total 4.1.1. Reaction systems
evacuation of personnel. Additionally, the alarm was extended to The simulation of reaction systems depends on the information of the
neighboring plants and the oil extraction zone and the Coatzacoalcos 1 reaction kinetics. This information has been documented in most cases,
bridge was closed. The visible toxic cloud and corrosive dust forced the but its absence suggests the use of final conversions, Xreactive. For the

Fig. 1. Section of the production process for PVC: R1. Direct chlorination reactor, R2. Oxy-chlorination reactor, S1. Refining of EDC, R3. Exothermal decomposition
reactor and S2. Refining of VCM.

2
H.M. Aquino-Gaspar et al.
Fig. 2. Flow diagram for the PVC process production in ASPEN PLUS ® in three sections.
simulation of the process, reactions of both types were used. Table 2
contains the chemical kinetic data for reactors R1 and R3. Table 3
contains the reaction conversion data for reactors R2 and R3.
The direct chlorination reactor, R1, was simulated as a plug flow
reactor (PFR), which contains the reactants, and the conditions of 90 ◦ C
and 1.5 atm. This is the DCRT item in Section 1 of Fig. 2. The oxy-
chlorination reactor, R2, was considered to be a fluidized bed (Mor­
eira and Pires, 2010; Wachi and Morikawa, 1986). However, the
particular lack of knowledge of the operating conditions suggested a
stoichiometric reactor (RStoic). This corresponds to item B11 in Section
1 of Fig. 2. The exothermal decomposition reactor, R3, requires energy
3
Journal of Loss Prevention in the Process Industries 70 (2021) 104404
by combustion (Ranzi et al., 1992); this reactor consists of two sections,
preheating and radiation. Therefore, this reactor was simulated as two
reactors, PFR, and RStoic, which are in Section 2 of Fig. 2 with the labels
B13 and B19, respectively. Table 4 contains the design features and
operating conditions of all the reactors. Additionally, the reaction sys­
tem requires a fast cooling of the product. Flash tanks with heat ex­
changers are included before the refining section. These equipments are
items B22, B24, B25, and B28 from Section 3 of Fig. 2.
4.1.2. Refining systems
Four distillation towers are involved in this process (Rossberg et al.,
H.M. Aquino-Gaspar et al. Journal of Loss Prevention in the Process Industries 70 (2021) 104404

Table 2 4.2. Application of the PSI

Chemical kinetic data.
Reactor Reactions Reaction rate Value of k Reference Quantification of inherently safe design is recommended to prevent
expression the risk of accidents and learn from the occurred events. The PSI de­
R1 C2H4 + Cl2→ r1 = k1[C2H4] 0.132 m3 [9] scribes the level of risk in a process plant by taking into account the flow
C2H4Cl2 [Cl2] mol− 1 s− 1 streams, whereby the interaction of the components and all the flow
C2H4 + 2Cl2→ r2 = k2[C2H4] 0.0239 m6 parameters make a precise quantification (Leong and Shariff, 2009;
C2H3Cl3 + HCl [Cl2]2 mol− 2 Shariff et al., 2012). Through this method, each stream, j, takes part into
R3 C2H4Cl2→ HCl + r7 = k1 0.0143 s− 1 [12]
C2H3Cl [C2H4Cl2]
the analysis by considering its parameters, ϕj, and the average value of
C2H3Cl → HCl + r8 = k2[C2H3Cl] 2.39 × 10− 5 the parameters for all streams, Φ. Normalization provides a represen­
C2H2 s− 1 tative index for each parameter in the stream j, Iϕ,j, such as Iϕ,j = ϕj/Φ.
5
C2H4Cl2→Cl2 + C2H4 r9 = k3 7.62 × 10− Hence, the PSI value for each stream j is computed by the product of all
[C2H4Cl2] s− 1
the stream parameters: PSIj = Iρ,j⋅ I.P.,j⋅ I.E.,j⋅IFL,j. A high PSI value in­
dicates a higher risk stream in the process.

Table 3 5. Incident analysis

Reaction conversion data.
Reactor Rections Conversion Reference The case has a lack of information because there is no official report
R2 r3: C2H4 + 2HCl +0.5O2→ C2H4Cl2+ H2O XHCl = 0.96 [11] of the event. Thus, the only available source of information is the public
r4: C2H4 + 3O2→ 2CO2+ 2H2O XC2H4 = 0.08 description of the event by eyewitnesses. The inhabitants of Coat­
r5: 2HCl + 0.5O2→Cl2+ H2O XHCl = 0.03 zacoalcos City experienced an overpressure wave. The incident pro­
r6: C2H4Cl2 +Cl2 → C2H3Cl3 + HCl XEDC = 0.09 duced an explosion that fractured glass windows in the center of
R3 r10: 2C2H4Cl2→ Cl2 + C4H8Cl2 XEDC = 0.3 [12]
Coatzacoalcos, 4500 m away from the plant. This description is equiv­
r11: C2H3Cl + Cl2→C2H3Cl3 XCl2 = 0.5
r12: C2H4Cl2 + Cl2→C2H3Cl3 + HCl XCl2 = 0.2 alent to an overpressure between 0.7 and 1 kPa (Clancey, 1972).
r13: C2H2 + 2Cl2→C2HCl3 + HCl XCl2 = 0.3 To describe the possible scenarios at the time of the accident in an
r14: C2H3Cl + C2H2→C4H5Cl XC2H2 = 0.5 acceptable way, this analysis was carried out following the chronolog­
ical events, which were treated with various simulation tools such as:

Table 4 1. Leak from the R3 outlet stream: this event comes from the CPROB
Design features and operating conditions of the reactors involved. stream data, as indicated in the previous section.
Parameter DCRT B11 B13 B19 2. Toxic and explosive cloud: the development of gas dispersion re­
quires suitable computational packages. ALOHA ® is a relevant
Temperature (◦ C) 90 305 530 530
Pressure (atm) 1.5 5 18 18 computation software used to describe industrial incidents. During
Volume (m3) 94.24 297.51 141.37 156.79 dispersion, physical obstacles and barriers modify the dynamic
Length (m) 30 – 45 – behavior of the cloud, which is not considered by ALOHA ® despite
its acceptability. Therefore, the CFD (computational fluid dynamics)
tool is recommended to complement the results of ALOHA ®. In this
2006): a) refining of EDC previous to R3 (B5 and B20 from Section 2 in
analysis, ANSYS ® FLUENT 2020 R2 solves the case in a 3D scenario.
Fig. 2) and b) refining of VCM from impurities after R3 (B26 and B33
3. Explosion event: this phenomenon demands proper methods to
from Section 3 in Fig. 2). In the simulation, the Soave-Redlich equation
consider the physical characteristics: turbulence, heat dissipation,
of state provided the phase equilibrium in polar solutions, which is valid
volume expansion, etc. The TNT method represents a well qualified
for these components and operating conditions. Table 5 contains the
short-method to obtain information from an explosion. Also, ALOHA
features of each separator column and all columns processed with a
® contains an appropriate procedure to obtain the effect of this event
pressure drop of 0.5 atm.
based on an explosive cloud scenario. Both cases have been experi­
mentally validated, but they do not consider the physical effect that
4.1.3. Simulation results
produces the obstacles and barriers through the explosion. There­
ASPEN PLUS provided the main parameters of the streams: mass
fore, the CFD tool includes 3D behavior and the time-variability of
density, pressure, thermal energy and ΔFL, difference of UFLmix and
the expansive wave.
LFLmix, which are the upper and lower flammability limit in a mixture
respectively. The last parameters are related to an ideal gas mixture
The next sections thoroughly explain the use of the proposed
through FLmix=(Σi yi/FLi)− 1, where FLmix is either UFLmix or LFLmix, y is
computation softwares for this analysis. For each event, the results ob­
the mole fraction and i is the component index (Crowl and Louvar,
tained from each tool are compared in order to complement the analysis.
2019). Table 6 contains the results for the main streams analysis. Table 7
contains the mass fraction of the CPROB stream, where the EDC (wt%) is
5.1. Use of ALOHA ® software
the highest value and indicates that CPROB is a high-risk stream.

This software is acceptable to analyze industrial events. It provided a

global visualization of the level of affectation by the explosion and
dispersion of the chemical cloud. ALOHA ® required specific data on
Table 5 meteorology and storage conditions to represent the environment and
Features of the separation tower for the PVC process in Fig. 2. release scenarios succinctly. In detail, the CPROB stream was indicated
Feature B5 B20 B26 B33 as VCM (CAS 75-1-4) at ground level with a sudden release of 50 t, and
Number of trays 9 32 41 16 the meteorological data are: a) wind speed 7.72 m/s from the south at
Top pressure (atm) 13 6 10 5 10 m above ground, b) stability class D without thermal inversion, c)
Top temperature (◦ C) 33 152.09 5.05 47.88 partly cloudy with a relative humidity of 75% at 32 ◦ C and d) urban
Bottom temperature (◦ C) 195.56 162.50 128.91 149.8 roughness. The overpressure simulation followed an ignition by
Reflux ratio 3 1.757 3.1 0.6
detonation.

4
H.M. Aquino-Gaspar et al. Journal of Loss Prevention in the Process Industries 70 (2021) 104404

Table 6
Results for the main streams from Fig. 2.
Stream Density (kg/ Pressure Thermal energy (Mcal/ ΔFL (% Stream Density (kg/ Pressure Thermal energy (Mcal/ ΔFL (%
m3) (kPa) s) vol) m3) (kPa) s) vol)

DCERECI 888.5 506.63 16.226 8.331 Q 836.5 1317.23 24.897 9.778

DCERECI2 890.5 1367.88 16.211 8.331 S 863.3 1317.23 41.108 9.237
D 1044.0 1013.25 13.714 11.151 T 874.7 607.95 17.843 8.178
H 844.5 6313.63 39.89 3.792 U 927.0 607.95 24.154 9.976
I 997.4 1013.25 31.921 1.66 V 930.2 1925.18 24.121 9.976
K 1038.5 1013.25 16.039 17.592 AC 873.4 1519.88 27.341 9.525
M 1041.2 1013.25 29.753 9.587 AF 873.4 1519.88 13.67 9.525
N 1043.9 1013.25 28.96 10.886 AH 995.1 1013.25 22.505 14.801
P 981.2 1519.88 27.882 10.886 AI 865.6 1215.9 15.951 12.833
AD 873.4 1519.88 13.67 9.525 CPROB 21.8 1823.85 8.193 9.209

(1.25 m), and c) Zone 3: surrounding area (5 m). The tetrahedral ele­
Table 7 ments formed the mesh and reached the limit on an academic license,
CPROB stream (wt%).
whereby a test of mesh was omitted. The total number of elements was
Component wt% Component wt% 461,802 with an average skewness of 0.289, which is a mesh quality
C2H4Cl2 (EDC) 52.053 C2H3Cl3 6.1E-3 parameter where the value close to zero indicates a good mesh quality.
C2H3Cl (VCM) 16.381 C2HCl3 5.88E-3 Thus, the number of elements and the skewness value per each zone are:
C4H8Cl2 14.316 C2H2 5.92E-4 a) Zone 1: 323,380–0.2638, b) Zone 2: 44,160–0.5273, and c) Zone 3:
HCl 9.227 C2H4 3.48E-4
Cl2 7.992 CO2 2.32E-5
94,262–0.2623.
C4H5Cl 0.017 O2 7.14E-10 In this simulation, the meteorological data from Section 3.1 was
taken into account. The wind speed profile followed the model: v = 7.72
m/s⋅(z/10 m)0.38, which describes a stability class D with z as the ver­
5.2. Application of TNT method tical position (Mannan, 2012). The scenario was under buoyancy effects,
and the gases followed the ideal gas equation. The leak corresponded to
This method calculates overpressure at distances greater than 5 km, CPROB stream and was 10.6 kg/s at the Release boundary. ASPEN PLUS
in which the shockwave is equal in all directions (TNO, 2005). The provided the stream properties, such as: a) density: 21.772 kg/m3, b)
calculation considers the equivalent mass of the explosive component heat capacity: 2.93 kcal/kg⋅K, c) viscosity: 2.6E-5 Pa s, d) thermal
with regard to the TNT mass, which is related as mTNT = η⋅mC⋅HC/ETNT, conductivity: 0.04882 W/m⋅K, e) molecular weight: 78 kg/kg mol y f)
where ETNT is the energy of explosion of TNT (4686 kJ/kg), η is the diffusivity: 0.02 m2/s. On the other hand, the overpressure analysis
empirical explosion efficiency (~10%), H.C. is the energy of explosion of consisted in the description in Section 3.2. Here, the simulation followed
the explosive component, m is the mass, and the subscript C corresponds the strategy proposed by Díaz-Ovalle et al. (2016), where an arbitrary
to the component. The mTNT value relates the desired affectation dis­ spherical zone (radius of 5 m) contained the overpressure energy at
tance to the explosion, r, as: Ze = r/(mTNT)1/3, where Ze is a parameter to 1500 k and 160 atm for an ideal gas. In addition, the model SST κ-ω
calculate the overpressure using equation (1). represented the turbulence phenomenon. This model is suitable for a

( ( )2 )[( ( )2 )( ( )2 )( ( )2 )]− 0.5

Po Ze Ze Ze Ze
= 1616 1 + 1+ 1+ 1+ (1)
Pa 4.5 0.048 0.32 1.35

scenario with obstacles and different spatial scales (Sklavounos and

where Pa is the ambient pressure and Po is the peak side-on overpressure
at the r distance. In this case, the total released mass was 50t from the
CPROB stream, and Hc was obtained by the molar average combustion
energy of the mixture 11,754.38 kJ/kg. The TNT equivalent mass was
2548.75 kg.
5.3. Analysis via CFD
CFD is a valuable tool for process safety. Shen et al. (2020) described
a set of published works under CFDs applied to fire, dispersion, explo­
sion, accident investigation, etc. Herein, the ANSYS FLUENT 2020 R2
software provided the dynamic behavior of the event by considering the
dispersion and overpressure.
The event scenario was presented using approximated geometry, and
details were avoided to reduce computational efforts. Furthermore, the
computational domain presented different spatial scales, and a sectional
mesh treatment was adopted. Fig. 3 shows the computational domain in
three zones. The mesh zones and the average length of the elements per
each zone are: a) Zone 1: process area (0.6 m), b) Zone 2: piping systems
Rigas, 2004).
The numerical solution was possible with the SIMPLE algorithm. The
scenario was transitional with time steps of a) 1 s for dispersion and b)
0.0001 s for overpressure. A numerical test was developed to determine
the number of iterations per time step, where the tested values were 10,
20, 40, and 160. The numerical test collected the values of mass fraction
of the mixture after obstructions, which corresponded from 15 m after
the leak in northerly direction. Fig. 4 shows the trial results and indicates
a suggested value of 40 iterations per time step. On the other hand, the
scenarios of dispersion and overpressure were independently solved.
The solution was possible in a computer with 24 GB RAM and an Intel-i7
® 3.9 GHz processor, which required 6 h to simulate 120 s for dispersion
and 13 h to simulate 3 s for overpressure.
6. Analysis of results
The ASPEN PLUS ® software provided the values of the parameters
for ρ, P, E and ΔFL for all the process streams: 885.197 kg/m3, 1425.12
kPa, 22.7 Mcal/s and 9.74 %vol, respectively. These average values

5
H.M. Aquino-Gaspar et al.
Fig. 3. Computational domain for the scenario with boundary conditions.
were obtained by PSI method. Table 8 contains all the PSI values for the
main streams, where the H stream presented the highest value in
contrast with the CPROB stream. The PSI method indicates that a stream
with a low value has low risk. Nevertheless, CPROM stream is a highly
flammable mixture, but the low PSI value is due to the density value
(gas). This suggests that the PSI method considers liquid streams to be
more dangerous, since the gas streams might produce either explosive or
toxic clouds.
The leak from the R3 outlet stream yielded a yellowish cloud (Acp,
2016; Sanchez, 2016). This corresponds to chlorine emission, which
coincides with the mixture obtained in the CPROB stream by ASPEN
PLUS ®; see Table 7 for mass fraction values. The results of the disper­
sion determined the greatest risk areas for an explosion. ALOHA ®
software calculated a wide vulnerable zone, as shown in Fig. 5 a). Fig. 5
b) shows the CFD results in comparison with the section obtained by
ALOHA ® at 25 ppm. This indicates that CFD under-predicted the con­
centration values but considered the equipment obstruction, which is an
important factor. In both cases, the cloud covers a considered length in
response to the wind direction. This increased the risk of an explosion
due to invading a neighboring plant without announcement.
The explosion caused glass fracture in the center of Coatzacoalcos,
Veracruz, 4500 m away from the plant. At that distance, the TNT
method predicted an overpressure of 0.86 kPa, which is consistent with
that reported by witnesses. Fig. 6 a) depicts the obtained overpressure
scenario, where the ALOHA® results located the same pressures ob­
tained by the TNT method at a greater distance. Thus, based on
Fig. 4. Results of the numerical test for the number of iterations per time step.
6
Journal of Loss Prevention in the Process Industries 70 (2021) 104404
testimonials, the ALOHA® results overpredicted overpressure. Fig. 6 b)
schematizes the CFD results contrasted with the results of the TNT
method and ALOHA® at an overpressure of 100 kPa. It can be observed
that the times and distances at which this overpressure value is reached
vary with the method used; notice that the time predicted by the TNT
method is shorter than that of ALOHA®, 0.8s 1.09s, respectively. CFD
provided iso-surfaces of 100 kPa at different times in comparison with
results by TNT method and ALOHA ®. These iso-surfaces do not describe
a perfect sphere, which is a consequence of obstructions in the process
area. Additionally, Fig. 6 c) presents a temperature profile on the iso-
surface of 100 kPa at 0.1 s, where the central area of the structure
received the highest temperature. This is approximate to the combustion
temperature as shown by the images in the area.
7. Health and environment risk
VCM is a carcinogenic agent that has been listed by the U.S. Envi­
ronmental Protection Agency (EPA) with an ERPG-3 value of 20,000
ppm (Becker et al., 2001). This indicates that long exposures can cause
liver cancer and genetic alterations. Short exposures can cause dizziness,
vomiting, and suffocation. VCM is an unstable compound when inter­
acting with the environment due to the degradation of chlorinated
compounds with volatile organic compounds. On the other hand, EDC is
an existing compound in the manufacture of PVC. This agent has a
similar effect to VCM under an ERPG-3 value of 40,000 ppm (Hughes
et al., 1994). In the environment, EDC affects the following: a) acid rain
due to chlorine free radicals, b) atmospheric pollution due to its pro­
longed permanence (up to 5 months before degradation), c) immediate
absorption into the soil, and d) filtration to groundwater.
The results obtained by ALOHA ® and CFD coincided in the spatial
location of the dispersion, where a point with 10,000 ppm was 200 m
from the release point. This confirms an imminent risk for VCM. The
exposed area is large and neighboring companies are affected. The
process area contained the highest concentration. Fig. 5 shows the ex­
istence of an open area with environmental risk.
8. Discussion
The witnesses described the continuous occurrence of leaks in the R3
area, where a leak began on the day of the tragedy. Despite this, the
maintenance staff made no immediate changes, but postponed it for
review in scheduled preventive maintenance. This worsened the
H.M. Aquino-Gaspar et al. Journal of Loss Prevention in the Process Industries 70 (2021) 104404

Table 8
PSI values for the stream of the VCM process (sorted from the highest to lowest).
Corriente Iρ IP IE IFL PSI Corriente Iρ IP IE IFL PSI

H 0.954 4.33 1.757 0.389 2.826 AH 0.978 0.695 0.703 1.52 0.726
P 1.108 1.042 1.228 1.118 1.586 AD 0.987 1.042 0.602 0.978 0.606
S 0.975 0.903 1.811 0.948 1.513 AF 0.987 1.042 0.602 0.978 0.606
V 1.051 1.32 1.063 1.024 1.51 DCERECI2 1.006 0.938 0.714 0.855 0.576
AI 1.124 0.834 0.991 1.318 1.225 D 1.179 0.695 0.604 1.145 0.567
AC 0.987 1.042 1.204 0.978 1.211 U 1.047 0.417 1.064 1.024 0.476
N 1.179 0.695 1.276 1.118 1.168 T 0.988 0.417 0.786 0.84 0.272
M 1.176 0.695 1.311 0.984 1.054 DCERECI 1.004 0.347 0.715 0.855 0.213
K 1.173 0.695 0.706 1.806 1.04 I 1.127 0.695 1.406 0.17 0.188
Q 0.945 0.903 1.097 1.004 0.94 CPROB 0.025 1.251 0.361 0.946 0.01

Fig. 5. Results of the dispersion: a) ALOHA ® and b) CFD: iso-surface at 25 ppm.

physical characteristics of the leak. Therefore, this area was considered a
high-risk section within the plant.
With the herein tools proposed, the dispersion and overpressure
analysis coincides with the information from the witnesses. In addition,
a sample carried out two days after the incident detected the presence of
VCM in the area (Greenpeace, 2016). This was confirmed by the ASPEN
PLUS® simulation results, which provided relevant information on the
process conditions and steered the PSI index analysis and the simula­
tions of the consequences for dispersion and overpressure. Despite the
danger of VCM, the PSI index indicated that the released mixture pre­
sented a low level of risk, which was due to the low value of the density.
On the other hand, the consequence analysis acceptably described the
dispersion and overpressure conditions. This indicated the importance
of diversifying simulation software (ASPEN PLUS®, ALOHA® and
FLUENT®) to describe the circumstances of an accident accurately.
9. Lessons learned from the incident
This analysis provides important aspects to improve process safety,
which is useful to prevent accidents, improving inherent safety and
understanding the situation of process plants similar to the case study.
The following learning points are obtained based on the herein results
and the analysis of the accident:
1. Process safety must prevail over production in plants with a high risk
of accidents.
2. Identifying the process streams with the highest level of risk is
essential in a process plant.
3. The safety strategy in maintaining equipment (welding, dismantling,
construction, etc.) must be rigorous in plants with a high-risk level.
4. Safety culture should be promoted within the personnel to respond
professionally to the first alarm.
5. Maintenance of process plants under imminent risk of an accident
should not be delayed.
6. Society loses confidence in the process industry with this type of
accidents, despite being located in exclusively industrial areas.
7. Toxic gas mitigation systems must exist in plants with chemical
components at risk of harm to the environment and personnel.
8. Neighboring process plants should be aware of any emergency or
potential accident at a neighboring plant.
9. Preventive maintenance of high-risk streams must be rigorous and
continuous.

7
H.M. Aquino-Gaspar et al.
Fig. 6. Results of overpressure: a) comparison between ALOHA ® and TNT method (dotted lines), b) CFD: iso-surfaces of 100 kPa at 0.8 s and 1.09 s, and a detailed
view of the temperature profile over an iso-surface of 100 kPa at 0.1 s.
10. Conclusion
This work analyzed the accident at the “Pajaritos” petrochemical
complex, in Coatzacoalcos, Mexico, which caused U.S. $ 244 million in
property damage. To date government authorities have not indicated the
environmental damage. They have reported 32 human losses and more
than 100 injuries. The analysis applied strategies to identify the most
dangerous process flows and the consequences of the accident. Process
simulation and the PSI index defined the most dangerous streams. The
ALOHA ® package, the TNT method, and ANSYS FLUENT software
described the emission and explosion consequences. The numerical re­
sults coincided with the testimony of witnesses to the catastrophe. The
application of these methodologies described in detail the starting point
and the consequences of the accident. Unfortunately, the responsible
company and the government have not provided a similar analysis.
Therefore, this work provided sufficient elements to understand the
tragedy and learn from its causes and consequences. It is important to
point out that this type of accidents can be avoided if the directive
boards consider the safety of the process a priority over the production
8
Journal of Loss Prevention in the Process Industries 70 (2021) 104404
and administrative processes. Suppose this philosophy is adopted and
the process plants are in an open atmosphere. In that case, these pro­
cesses that handle toxic and corrosive substances can be operated safely.
Petrochemical complex
All persons who meet authorship criteria are listed as authors, and all
authors certify that they have participated sufficiently in the work to
take public responsibility for the content, including participation in the
concept, design, analysis, writing, or revision of the manuscript.
Furthermore, each author certifies that this material or similar material
has not been and will not be submitted to or published in any other
publication before its appearance in the Journal of Loss Prevention in the
Process Industries (ISSN: 0950–4230).
Authorship contributions
Conception and design of study: A. López-Molina, C. O. Díaz-Ovalle,
C. Conde-Mejia, L. M. Valenzuela-Gómez; Acquisition of data: H. M.
H.M. Aquino-Gaspar et al. Journal of Loss Prevention in the Process Industries 70 (2021) 104404

Aquino-Gaspar, L. M. Valenzuela-Gómez, C. Conde Mejía, A. López- TNT trinitrotoluene

Molina, C. O. Díaz-Ovalle; analysis and/or interpretation of data: H. M. ρ density
Aquino-Gaspar, A. López-Molina, C. O. Díaz-Ovalle, C. Conde-Mejía. ϕ PSI parameters index
Drafting the manuscript: H. M. Aquino-Gaspar, A. López-Molina, C. O.
Díaz-Ovalle, C. Conde-Mejía; revising the manuscript critically for References
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