Mexico City

14th November 1984

Boiling liquid expanding vapour explosion (BLEVE) at LPG terminal. 500 killed.
Plant was being filled from refinery 400km away. Drop in pressure noticed in
control room & at pumping station. Pipe had ruptured.
Operators’ could not identify cause of pressure drop, as they had no gas
detection equipment. No emergency shutdown at that stage and release of
LPG continued for about 5-10 minutes, when gas cloud drifted to flare stack.
Causal analysis – failure of overall basis for safety, including layout of plant
and emergency isolation features. Fire water system was disabled in initial
blast. Inadequate water spray systems did not keep remaining storage vessels
cool and failed to prevent spread of fire from vessel to vessel. Plant had no
gas detection system and therefore when isolation system was initiated it was
probably too late. Installation of more effective gas detection and emergency
isolation system could have averted incident. Traffic chaos as residents tried
to escape area hindered arrival of emergency services.
www.hse.gov.uk/comah/sragtech/casepemex84.htm
 Brent Cross
Crane Collapse
20th June 1964
Material failure due to overloading. Fell onto coach – 7 died.
Causal analysis - crane modified incorrectly
Human factors – errors in manufacturing and maintaining
crane. Safe working load indicator inoperative. Lugs
manufactured to wrong spec, recognised during manufacture
but no check against drawings. Inspection revealed deviation
but inspector did not want to reject something passed by
parent company. Weekly inspection not carried out in
presence of operator and defective safe working load
indicator undetected. Records of inspection not completed by
inspector but probably by someone retrospectively with the
words “good order against” safe load indicator.
 Markham Colliery
30th July 1973
Material failure to fatigue. Riding cage fell to pit
bottom. 18 died, 11 injured.
Causal analysis – Braking system suffered from a
fatigue crack. Dirt in bearing braking rod resulted in
it being bent. Brake supposed to be failsafe.
Human factors – Braking system had not been
inspected for about 10 years prior to accident.
Information on fatigue had been found at another
colliery but not passed on. Poor design of braking
system.
 Flixborough Exposion
1st June 1974
Explosion caused by poor change management. 28 died.
Causal analysis – failure of pipe leading to release of chemical cloud
that ignited.
Management deficiencies – inadequate procedures involving plant
modifications. Engineers had no special expertise in high pressure
pipework & no proper drawings. Process with large amount of
hydrocarbons under pressure above flashpoint installed in area that
could expose many to severe hazard.
Human factors – Primarily weak management. Individuals overworked
and liable to error. “There was no mechanical engineer on site of
sufficient qualification, status or authority to deal with complex and
novel engineering problems and insist on necessary measures being
taken.”
 Littlebrook “D” Power Station
9th January 1978
Material failure due to corrosion. Suspension cable on riding cage
failed. Hoist operated by contractor. 4 died.
Causal analysis – Suspension cable broke at point weakened by
corrosion and devoid of lubricant. Corrosion happened over short
period so not detected. Water in shaft contained salt, adding to
corrosion. Safety system did not operate as clamping mechanisms also
corroded.
Human factors – need for stringent maintenance standards not
recognised by staff or management. Statutory 6-monthly inspections
overdue. Weekly inspections failed to see defects. Cage carrying more
than recommended number of passengers. Maintenance records not
well kept and exact regime could not be determined. Lack of clear
policies and procedures for contractor.
 BP Grangemouth
22nd March 1987
Explosion at “hydrocracker” unit. 1 killed.
Causal analysis – air operated control valve on high-pressure separator
had been opened and closed manually. Liquid level fell and the valve was
opened, allowing remaining liquid in separator to drain away and for high-
pressure gas to break through into low-pressure separator and vessel
exploded.
Human factors – control valve did not close automatically as the extra-low
trip on the high-pressure separator had been disconnected several years
earlier, operators assuming that these were no longer needed and training
reflected this. Operators did not trust main level control reading and
referred to a chart recorder for back up level reading; there was an offset
on this recorder which led them to assume the level in the high-pressure
separator was normal. Pressure relief had been designed for fire relief not
gas breakthrough. There was excessive reliance on operators with
inadequate appreciation of risks associated with gas breakthrough.
 Allied Colloids
21st July 1992
Fire and explosion at raw materials warehouse. Fire spread to adjacent
warehouses and an external chemical drum store. Damage only.
Causal analysis – one of the stores (intended for storing frost sensitive
products) had steam heated blowers turned on to dry out moisture. Heating
caused some kegs to rupture and spill powder on floor. The alarm was raised
when an employee thought it was smoke. After determining there was no
immediate hazard the MSDS was consulted for spillage arrangements and
cleanup devised. An exothermic reaction was caused when the kegs’ contents
mixed, leading to ignition, explosion and major fire.
Human factors – The wrong classification of substances leading to storage of
incompatible chemicals together. Operator error (or failure of heating system)
meant heating was applied to store in addition to main warehouse. Lack of
appropriate spillage training and procedures. Lack of management to ensure
appropriate fire detection and fire fighting facilities – fire brigade not notified
until 50 minutes after initial incident.
 Windsor Castle
20th October 1992
Fire. Damage only.
Causal analysis – heat of a high-powered spotlight ignited
a curtain. Fire spread quickly, venting itself through the
roof.
In the post-fire investigations it was discovered that the
rapid spread of fire was due to the lack of fire stopping in
cavities and roof voids, allowing the fire free reign of the
building. This matter was specifically addressed in the
restoration project, and fire breaks were placed into the
void to avoid a similar disaster happening in future
 Hickson & Welch
21st September 1992
Fire and explosion at factory batch still. 5 killed.
Causal analysis – still base cleaned out for first time in 30 years. Heat
was applied to soften sludge.
Human factors – decision to clean out still base with no prior testing
of residue and atmosphere in vessel. Lack of communication
between operatives & management. Absence of policies &
procedures. Failure to blank off still base inlet before work started.
Presence of building materials in control room impeding escape.
Inward opening door in control room. Holes in brickwork above false
ceiling of protected route allowing smoke ingress into toilets where
one victim was found. Inadequate permit to work systems
 Port of Ramsgate
14th September 1994
Collapse of passenger walkway. 6 killed.
Causal analysis – failure of a weld in a safety critical
support element. Design deficiencies.
Human factors – no provision for ongoing maintenance.
Design deficiencies ignored by all interested parties;
important environmental considerations not addressed.
Lack of liaison between classification society and
designer/installer in Sweden.
Note – Swedish design/install company refused to pay
fine.
 Albright and Wilson
3rd October 1996
Fire and explosion at chemical storage site at Avonmouth
Damage only.
Causal analysis – tanker believed to contain epichlorohydrin
off-loaded. Later found to contain sodium chlorite, which
reacts explosively with epichlorohydrin.
Human factors – No check of documentation carried by driver
which would have shown contents of tanker. No preventative
measures in place to safeguard against addition of material
reactive with substance already in storage tank. No raw
material control/sampling or operating procedures,
particularly for receipt of materials.
 Buncefield Oil Depot
11th December 2005
Fire and explosion. Damage only.
Causal analysis – pumping of too much fuel into
storage vessel. Automatic level gauge recorded
unchanged level despite continued pumping. Rich
fuel vapour formed around bund, ignited by
unknown source.
Human factors – reliance on automated systems
which did not activate. Failure of COMAH
procedures.
 Imperial Sugar
7th February 2008
Dust explosion at sugar factory, Georgia. 14 killed.
Causal analysis – sugar dust in enclosed conveyor belt likely ignited
by overheated bearing.
Human factors – conveying equipment not deigned or maintained
to minimise release of sugar dust, nor were there explosion relief
vents. Dust could easily accumulate, and inadequate housekeeping
resulted in considerable accumulation of combustible dust on
floors and elevated surfaces throughout packing building. Previous
sugar fires, similarly caused, although none had caused explosion
or major fire, did not result in managers or workers recognising
hazards posed by sugar dust accumulation: danger had been known
about as far back as 1925.
 Banbury-Seer Green
11th December 1981
Rail crash caused by human failure. 3 killed.
Inexperienced signalman at Gerrards Cross miss-read or failed to
comprehend indication on signal diagram; proceeded on assumption that
locked signal lever was frozen, and track circuit reading that line was
unclear was activated by fallen branch from passing stock train, which in
fact was stationary.
Driver of passenger train travelling too fast for conditions after being
specifically warned to take care and to travel between 5-10mph.
Estimated speed was 35mph. Was given authorisation to pass danger
signal- communication between driver and signalman may have been
ambiguous and led to driver believing situation was not serious.
Driver and Guard of stock train failed to provide detonator protection to
rear of train, but may not have had time before accident occurred.