Operators didn’t see the tank overfilling. Part of the problem was mechanical, but part was inattention. How much can we expect from individual operators? The Buncefield fuel depot fire was somewhat akin to leaving the tub filling in the upstairs bathroom, going somewhere else in the house and forgetting the water is running. On one […]
INCIDENT Mechanical Failures and Misunderstandings On March 23, 2005, the raffinate splitter process was being restarted after a turndown. The unit had been shut down February 21 so that the tower could be drained, purged, and steam cleaned to remove residues. Apparently nothing had been done to check level sensors installed in the tower, and […]
When disasters like the Sayano–Shushenskaya hydroelectric power station collapse in Khakassia, Russia, occur, it is difficult to get past the overpowering tragedy of 75 people losing their lives and 40 other sustaining injuries. The only way to draw positives from such an incident is to learn from the experience so that the same mistakes never […]
INCIDENT A Process Hazard Analysis of the Human Factor: Piper Alpha Incident Operator and supervisor errors escalated a process safety incident into a disaster. Could people better trained in oil and gas safety procedures have prevented it, or stopped the process safety incident once the fire stated? On the night of July 6, 1988, five […]
INCIDENT When the lower layers of protection are effective, upper layers may not get much attention. But then something fails and other weaknesses exposed. The Buncefield oil storage depot fire on December 10, 2005 provides an interesting examination of a fire at a site that most people probably considered safe. It was simply a tank […]
INCIDENT T2 Laboratories: Why Hazard Recognition is Step 1 in Bolstering Plant Safety On December 19, 2007, an exothermic reaction at T2 Laboratories, a Jacksonville, Florida-based chemical manufacturer, led to a runaway condition resulting in a massive explosion that killed four workers, injured 32 others and destroyed neighboring businesses. That day, the workers were mixing […]
INCIDENT Assessing & Learning From The Tragedy To Build Better Safety Measures When Turbine 2 broke apart violently at the power station, death and injury were not the only tragic outcome. The flooding of the turbine hall and engine room, and a collapsed ceiling damaged or destroyed 9 of 10 turbines resulting in over a […]
INCIDENT Ignoring a problem doesn’t make it less of a problem. It can allow a situation to escalate until something breaks. When the EAF exploded at Carbide Industries, March 21, 2011, the two fatalities were operators working in the control room only 12 ft. from the lid of the furnace. The explosion was violent enough […]
Catastrophic situations often occur as a result of complacency. If, over time, warnings of abnormal conditions are ignored without any apparent consequence, those situations begin to slide into the realm of routine. Then, if the pattern of consistent oversight persists, stakeholders suddenly and unexpectedly find themselves in a crisis situation that endangers both life and property. […]
Looking at the 2005 Texas City refinery fire with the benefit of nearly 10 years of reflection and much discussion of what was going on at the facility, it is difficult to imagine how anybody working there could have had any sense of personal security. Those individuals who spend most of their waking hours surrounded […]
During the startup, malfunctioning equipment surfaced. But that sort of thing happens on every startup, right? In spite of the fact that the new DCS implementation was still incomplete, restart of the methomyl proceeded anyway, but there were many more equipment problems lurking within the unit. The residue treater vessel had been replaced during the […]
On March 23, 2005, the raffinate splitter process was being restarted after a turndown. The unit had been shut down February 21 so that the tower could be drained, purged, and steam cleaned to remove residues. Apparently nothing had been done to check level se… When the corporate culture ignores safety, what do you think […]
All it took was three minutes. The Williams Olefins chemical plant in Geismar, Louisiana, which was routinely executing everyday operations, was instantly transformed into a scene of destruction, panic and mayhem. A catastrophic equipment rupture led to an explosion and fire killing two workers and injuring 167. In retrospect, it was a tragedy that could […]
