1.6 Workshop I - Case Studies - Catasrophic Incidents Caused by Poor Layout

8/8/2017
1.6 Workshop I: Case Studies

Catastrophic Incidents Caused by Poor Layout
• Case Study 1 - Fire at Formosa Plastics
Corporation, Texas - October 6, 2005
• Case Study 2 - Phillips Petroleum, Pasadena,
Texas - Vapor Cloud Explosion 1989
• Case Study 3 – BP Texas City Refinery
Explosion March 23, 2005
Case Study 1 - Fire at Formosa Plastics

• This case study examines a hydrocarbon release and
subsequent fire and explosions that occurred in the
Olefins II unit at the Formosa Plastics Corporation, Point
Comfort, TX, complex. The fire burned for 5 days.
– Sixteen employees were injured, one seriously.
– A shelter-in-place order was issued for the Point Comfort
community, and
– the local elementary school was evacuated.
• CSB makes recommendations to
– Formosa Plastics Corporation;
– Kellogg, Brown, and Root; and the
– Center for Chemical Process Safety.
Nabil Al-Khirdaji, M. Eng., P. Eng. 1

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• At about 3:05 PM on October 6, 2005, a trailer being towed by
a forklift snagged and pulled a small drain valve out of a
strainer in a liquid propylene system. Escaping propylene
rapidly vaporized, forming a large flammable vapor cloud.
• Operators immediately began to shut the plant down and
attempt to isolate the leak.
– They tried to reach and close manual valves that could
stop the release; however, the advancing vapor cloud
forced them to retreat.
– At the same time, control room operators shut off pumps,
closed control valves, and vented equipment to the flare
stack to direct flammable gases away from the fire.
Vehicle Impact Point
Figure 10. Vehicle impact point

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Drain Valve Pulled out of Strainer
Figure 4. Valve and pipe

At about 3:07 PM, the vapor ignited, creating an explosion.
The explosion knocked down several and burned two (one
seriously) operators exiting the unit.
Flames from the fire reached more than 500 feet in the air (Fig. 1)
Because of the size of the
fire, Formosa initiated a
site-wide evacuation.
Fourteen workers sustained
minor injuries including
scrapes and smoke
inhalation.
The extensive damage shut
down Olefins II unit for 5
months.

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The Formosa emergency response strategy was to prevent the fire
from spreading to other units and to isolate fuel sources where
possible.
Ultimately, the fires

burned for five days
About seven million

gallons of water were
used to cool vessels
and contain the fire.
Figure 2 - View of the damaged plant

Incident Analysis
Incident Sequence
• The CSB used physical evidence, electronic data,
video recordings, and interviews to establish the
likely failure sequence. The events are listed in the
order in which they are believed to have occurred,
although an exact timeline could not be established:
1. A worker driving a fork truck towing a trailer under a pipe
rack backed into an opening between two columns to turn
around.
2. When the worker drove forward, the trailer caught on a
valve protruding from a strainer in a propylene piping
system.

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Incident Analysis
4. Pressurized liquid propylene (216 psig) rapidly escaped
through the opening and partially vaporized creating both
a pool of propylene liquid and a rapidly expanding vapor
cloud.
5. The fork truck driver and other contractors saw the release
and evacuated.
6. An operator also heard and saw the escaping propylene
and immediately notified the control room.
7. Control room operators saw the vapor cloud on a closed
circuit television and began to shut down the unit.
8. Outside operators tried unsuccessfully to reach and close
manual valves that could stop the release.

Incident Analysis
9. Outside operators turned on fixed fire monitors.
10. Control room operators shut off pumps from the motor
control center and closed control valves to slow the leak.
11. The vapor cloud ignited.
12. Outside operators left the unit.
13. Control room operators declared a site-wide emergency.
14. Control room operators smelled propylene vapors and
evacuated.
15. A large pool fire burned under the pipe rack8 and the side
of an elevated structure that supported a number of
vessels, heat exchangers, and relief valves.

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Structural Steel Fire Protection
• API Publication 2218, “Fireproofing Practices in
Petroleum and Petrochemical Processing Plants”
(July 1988) recommends that steel supporting
important piping such as relief and flare lines be
fireproofed.
– This API publication was issued after Kellogg was
contracted for the earlier design;
– however, the designs sold to Formosa were never updated
to incorporate this guidance.
– Had the steel been fireproofed as API recommends, the
consequences of this incident would likely have been less
severe.

Incident Analysis
16. About 30 minutes into the event, the side of the elevated
structure collapsed, crimping emergency vent lines to the
flare header.
17. Crimped pipes and steel, softened from fire exposure, led
to multiple ruptures of piping and equipment and the loss
of integrity of the flare header.
18. The Formosa ERT isolated fuel sources where possible,
and allowed small fires to burn the uncontained
hydrocarbons.
19. The fire was extinguished about five days after the start of
the incident.

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Vehicle Impact Protection
Vehicle Impact
Protection
The propylene
piping involved
in this incident
protruded into an
open space, yet
had no impact
protection
(Figure 6).
Figure 6 – Pipe and valve arrangement

• The plant design drawings designate specific access
ways for vehicles; these are not physically marked in
the unit. The area where the impact occurred was not
a designated access way but was large enough for a
vehicle to easily pass.
• Guidance about protecting control stations, pipelines,
and other grade-level plant equipment, although not
specific, states that protective measures should be in
place to prevent impact.

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Impact Protection Requirements
• The ASME B31.3 “Process Piping Code” states, “Impact
forces caused by external or internal conditions shall be taken
into account in the design of piping.”
• Loss Prevention in the Process Industries (Lees, 2001) states:
– “Incidents are numerous in which lift trucks are driven into and damage
buildings and plant; including process plant; pipe work is particularly at
risk.”
– “Particular attention should be paid to plant layout with specific regard
to traffic and impact.”
– “Every precaution should be taken to prevent damage by vehicles,
particularly cranes and forklift trucks.”
• Safety in Process Plant Design (Wells, 1980) provides a
– safety checklist that includes “protection of equipment and pipe work
from vehicles.”

• During the fire, part of a structure supporting the
relief valves and emergency piping to the flare header
collapsed. The collapse caused several pipes to crimp,
likely preventing flow through the pipes and leading
to the rupture of major equipment and piping that
added fuel to the fire.
• Passive fire protection (fireproofing), the fireproofing
was a concrete coating applied over the steel to
insulate it from a fire and slow its failure, was
installed on only three of four support column rows.

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The columns that supported the pressure relief valves and
emergency vent piping had no fireproofing (Figure 7).
The bare steel

columns bent over,
while the fireproofed
columns remained
straight.
Figure 7. Fireproofed and bare steel support columns

• Formosa contracted M. W. Kellogg (Kellogg) to
design the Olefins II unit in 1996.
– The Olefins II unit is an identical copy of the
Olefins I unit, which Formosa contracted Kellogg
for in late 1988.
– Olefins I unit is a nearly identical copy of an
ethylene plant that Kellogg sold to another
company in the mid 1980s.

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Remote Equipment Isolation
Figure 8 shows the general arrangement of the piping and valves
around the leak point. The leak occurred between manual block
valves and a remotely operated control valve.
Figure 8. Propylene product flow

• While a check valve and remotely operated isolation
valve downstream of the leak prevented the backflow
of propylene from product storage, operators were
unable to reach the manual valves capable of
stopping the flow from the distillation column.
• The operators were also unable to reach the local
control station to turn off the pumps supplying
propylene, although they eventually turned off the
pumps at the motor control center located in the
control room building, slowing the rate of propylene
feeding the fire.

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• Had a remotely actuated valve been installed
upstream of the pumps, this incident would likely
have ended quickly, possibly even before ignition
occurred.
• Additionally, had remote control of the pumps been
possible from the control room, the propylene flow
could have been quickly reduced, potentially reducing
the severity of the incident.

• Plant designers specify where remote operation of
isolation valves and equipment should be used.
• Kellogg, the designer of Formosa’s Olefins II unit,
specified remotely actuated valves for raw material
supply and final product lines, but only local manual
valves pump controls for equipment within the unit
that contained large hydrocarbon inventories.

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• Limited information is available in consensus
standards on the degree of isolation designers should
incorporate into the design, guidance is available.
– Kletz (1998) and Health & Safety Executive
(HSE) (1999) both recommend that large vessels
and columns with hazardous inventories be
equipped with a rapid isolation capability.
• Had Formosa been able to isolate the major hazard
inventories in the unit as recommended in industry
guidance, the consequences of this incident would
likely have been lessened.

Process Hazard Analysis
• Formosa performed a series of hazard reviews
including a hazard and operability study (HAZOP);
facility siting analysis; and a pre-startup safety review
(PSSR) prior to the operation of the Olefins II unit.
– The PSSR team verified that traffic protection around
emergency equipment had been installed, but did not look
at specific process equipment.
– During the facility siting analysis, the consequences of a
truck impact were judged as “severe,” however, the
frequency of occurrence was judged very low (i.e., not
occurring within 20 years), resulting in a low overall risk
rank (Risk = Probability x Consequences)

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Lessons Learned /Recommendations
• Hazard Reviews
– While Formosa conducted a preliminary hazard analysis, a
process hazard analysis, a siting analysis, and a PSSR prior
to operating the Olefins II unit, these reviews did not fully
address protection of specific process equipment from
vehicle impact or the use of remotely actuated valves to
control a catastrophic release.
– When performing hazard analysis, facility siting analysis,
or pre-startup safety review, vehicle impact and remote
isolation of catastrophic releases should be investigated.

Lessons Learned /Recommendations
• Use of Current Standards
– Evaluate the applicability and use of current
consensus safety standards when designing and
constructing a chemical or petrochemical process
plant. This should include reviewing and updating
earlier designs used for new facilities.
– Recommendation to Kellogg, Brown, and Root -
Emphasize the importance of using current consensus
safety standards when designing and constructing
petrochemical process plants, including the earlier
designs reused for new facilities

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And …… Formosa Fined
• November 05, 2008 - Formosa Plastics' Point
Comfort plant was fined $121,443 for repeated air
violations.
• Formosa was fined for emissions that lasted a period
of 55 days, stemming from the Oct. 6, 2005, fire at
the Olefins II Unit. Explosions and fires started when
a forklift ran into the propylene pipeline.
Case Study 2 - Phillips Petroleum, TX

Vapor Cloud Explosion 1989
• On the 23rd October 1989 Phillips’ 66 chemical
complex at Pasadena, Texas, experienced a chemical
release on the polyethylene plant.
– A flammable vapour cloud formed which subsequently
ignited resulting in a massive vapour cloud explosion.
– Following this initial explosion there was a series of
further explosions and fires.
• Explosions resulted in
– 23 fatalities, and between 130 – 300 people were
injured.
– Extensive damage to the plant facilities occurred

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• A large quantity of gas was released during a
maintenance operation when a plug of material
jammed in a settling leg on a reactor, but then
suddenly let go when the repair crew went to
get help.
• An automatic valve that was supposedly shut
had the air hoses cross-connected in error, so
that the valve was in fact open, allowing the
gas to escape.

This incident at
Phillips Petroleum’s
polyethylene plant at
Pasadena, Texas led
to regulation of
process safety
management (PSM)
in the U.S.

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Case Study 2 - Phillips

Petroleum, TX Vapor
Cloud Explosion 1989
The day before the incident

scheduled maintenance work
had begun to clear three of the
six settling legs on a reactor.
A specialist maintenance
contractor was employed to
carry out the work.
A procedure was in place to
isolate the leg to be worked on.
Figure: Typical detail of leg arrangement

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In the HCC reactor, the plastic material
frequently clogged the settling legs.
When this happened, the DEMCO
valve for the blocked leg was closed,
the leg disassembled, and the block
removed.
During this maintenance process, the
reaction continued and the product
settled out in the legs that remained in
place.
If the DEMCO valve were to open
during a cleaning-out operation, there
would be nothing to prevent the escape
Figure: DEMCO Valve
of the gas to the atmosphere.

• Investigation Findings
– Both the company and industry safety required
isolation by means of a double-block system or
the use of blind flange. However, at a plant level
a procedure had been adopted which did not
comply with this.
– The accident investigation established that the
single isolating ball valve was actually open at the
time of the release. The air hoses to the valve had
been cross-connected so that the air supply that
should have closed the valve actually opened it.

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Failings in Technical Measures
• Both the company and industry safety required isolation
by means of a double-block system or the use of blind
flange. However, at a plant level a procedure had been
adopted which did not comply with this.
• Site procedures laid down details that air hoses to valves
were to be disconnected prior to maintenance work. This
task was not carried out.
• The site held a large inventory of flammable materials
under high pressure yet it had no fixed gas detection
system.

• Ventilation intakes of buildings close to or downwind of the
process plant were not arranged so as to prevent the intake of
gas in the event of a release.
• An effective permit to work (PTW) for both company
employees and contractors was not enforced by the company.
• There was no dedicated fire water system. Firewater was
drawn off from the process water system. This system was
severely damaged in the explosions resulting in a loss of water
pressure. The fire water pumps failed when the raging fires
attacked their electrical supply cables. Of the three standby
diesel pumps units, one was under maintenance and another
ran out of fuel.

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• Some concern was expressed as to the audible level
of the emergency alarm. It was likely that individuals
in certain parts of the plant were unable to hear the
siren.
• The intended control centre was damaged beyond use
and telephone communications disrupted.
• The location of the control room, separation
distances between plant and escape routes
(particularly for administrative staff) were all
criticised.

• The site layout and proximity of normally high occupancy
structures and process equipment also contributed to the
severity of the event.
• The large number of fatally injured personnel was due in part
to the inadequate separation between buildings in the complex.
• The distances between process equipment were in violation of
accepted engineering practices and did not allow personnel
to leave the polyethylene plants safely during the initial vapor
release; nor was there sufficient separation between the
reactors and the control room to carry out emergency
shutdown procedures. The control room, in fact, was
destroyed by the initial explosion.

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Case Study 3 - BP Texas City

Refinery Explosion - March 23, 2005
• Texas City refinery is located 40 miles from
Houston in Texas, USA
• 1600 people work at the refinery plus
contractors
• It is one of the largest refineries in the USA,
processing 460,000 barrels of crude oil/day,
around 3% of gasoline US supplies

The Accident
• An explosion and fire
occurred at the refinery’s
isomerization unit
• The explosion happened at
13:20 (Houston time) on
March 23, 2005
• 15 people died and many
more were injured
Note: The isomerization unit

boosts the octane of gasoline
blend stocks.

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Hydrostatic Head of Liquid in Overhead Piping

Leads to the Three Relief Valves Opening
As the liquid filled the overhead line, the resulting hydrostatic
head in the line increased. The tower pressure (which remained
relatively constant) combined with the increased hydrostatic head
and exceeded the set pressures of the safety relief valves.
The minimum closing (blowdown)
pressure for the three safety relief
valves to stop flowing was 37.2
psig (256.5 kPa).
Computerized control system data
indicate that all three safety relief
valves were fully open and
flowing at capacity for slightly
longer than six minutes. An
average pressure of 61 psig (421
kPa) at the inlet to the three safety
relief valves maintained the flow

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Tower Overfills and Blowdown Drum

Releases Hydrocarbons
Blast Overpressure Map Depicting the Areas of

Highest Blast Pressure (10+, 5+, and 2.5+ psi)

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Fatalities and Injuries
• In the explosion, 15 contract employees working in
or near the trailers sited between the ISOM and
the NDU unit were killed. Autopsy reports revealed
that the cause of death for all 15 was blunt force
trauma, probably resulting from being struck by
structural components of the trailers.
– Three occupants in the Quality Assurance/Quality
Control (QA/QC) trailer perished, and
– 12 of 20 workers inside the double-wide trailer were
killed; the others were seriously injured.
BP Texas City Refinery Explosion

Destroyed Trailers West of the Blowdown Drum
(red arrow in upper left of the figure)

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Trailer Area and Adjacent ISOM Unit

Trailer Area and Adjacent ISOM Unit

1.6 Workshop I - Case Studies - Catasrophic Incidents Caused by Poor Layout

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8/8/2017

1.6 Workshop I: Case Studies

Case Study 1 - Fire at Formosa Plastics

Nabil Al-Khirdaji, M. Eng., P. Eng. 1

Case Study 1 - Fire at Formosa Plastics

Vehicle Impact Point

Figure 10. Vehicle impact point

Nabil Al-Khirdaji, M. Eng., P. Eng. 2

Drain Valve Pulled out of Strainer

Figure 4. Valve and pipe

Case Study 1 - Fire at Formosa Plastics

Nabil Al-Khirdaji, M. Eng., P. Eng. 3

Case Study 1 - Fire at Formosa Plastics

Ultimately, the fires

About seven million

Figure 2 - View of the damaged plant

Case Study 1 - Fire at Formosa Plastics

Nabil Al-Khirdaji, M. Eng., P. Eng. 4

Case Study 1 - Fire at Formosa Plastics

Case Study 1 - Fire at Formosa Plastics

Nabil Al-Khirdaji, M. Eng., P. Eng. 5

Case Study 1 - Fire at Formosa Plastics

Case Study 1 - Fire at Formosa Plastics

Nabil Al-Khirdaji, M. Eng., P. Eng. 6

Case Study 1 - Fire at Formosa Plastics

Figure 6 – Pipe and valve arrangement

Case Study 1 - Fire at Formosa Plastics

Nabil Al-Khirdaji, M. Eng., P. Eng. 7

Case Study 1 - Fire at Formosa Plastics

Case Study 1 - Fire at Formosa Plastics

Nabil Al-Khirdaji, M. Eng., P. Eng. 8

Case Study 1 - Fire at Formosa Plastics

The bare steel

Figure 7. Fireproofed and bare steel support columns

Case Study 1 - Fire at Formosa Plastics

Nabil Al-Khirdaji, M. Eng., P. Eng. 9

Case Study 1 - Fire at Formosa Plastics

Case Study 1 - Fire at Formosa Plastics

Nabil Al-Khirdaji, M. Eng., P. Eng. 10

Case Study 1 - Fire at Formosa Plastics

Case Study 1 - Fire at Formosa Plastics

Nabil Al-Khirdaji, M. Eng., P. Eng. 11

Case Study 1 - Fire at Formosa Plastics

Case Study 1 - Fire at Formosa Plastics

Nabil Al-Khirdaji, M. Eng., P. Eng. 12

Case Study 1 - Fire at Formosa Plastics

Case Study 1 - Fire at Formosa Plastics

Nabil Al-Khirdaji, M. Eng., P. Eng. 13

Case Study 1 - Fire at Formosa Plastics

Case Study 2 - Phillips Petroleum, TX

Nabil Al-Khirdaji, M. Eng., P. Eng. 14

Case Study 2 - Phillips Petroleum, TX

Case Study 2 - Phillips Petroleum, TX

Nabil Al-Khirdaji, M. Eng., P. Eng. 15

Case Study 2 - Phillips Petroleum, TX

Case Study 2 - Phillips

The day before the incident

Figure: Typical detail of leg arrangement

Nabil Al-Khirdaji, M. Eng., P. Eng. 16

Case Study 2 - Phillips Petroleum, TX

Case Study 2 - Phillips Petroleum, TX

Nabil Al-Khirdaji, M. Eng., P. Eng. 17

Case Study 2 - Phillips Petroleum, TX