In 1989 an explosion occurred in the Phillips 66 plant in Texas killing many.
The following is a summary of the major findings of OSHA's investigation of the accident.
"1. A process hazard analysis or other equivalent method had not been utilized in the Phillips polyethylene plants to identify the process hazards and the potential for malfunction or human error and to reduce or eliminate such hazards.
2. Phillips' existing safe operating procedures for opening lines in hydrocarbon service, which could have prevented the flammable gas release, were not required for maintenance of the polyethylene plant settling legs. The alternate procedure devised for opening settling legs was inadequate; there was no provision for redundancy on DEMCO valves, no adequate lockout / tagout procedure, and improper design of the valve actuator mechanism and its air hose connections.
3. An effective safety permit system was not enforced with respect to Phillips or contractor employees to ensure that proper safety precautions were observed during maintenance operations, such as unblocking reactor settling legs.
4. There was no permanent combustible gas detection and alarm system in the reactor units or in adjacent strategic locations to monitor hydrocarbon levels and to provide early warning of leaks or releases.
5. Ignition sources were located in proximity to, or downwind (based on prevailing winds) from, large hydrocarbon inventories. Ignition sources also were introduced into high hazard areas without flammable gas testing.
6. Buildings containing personnel or vital control equipment were not separated from process units in accordance with accepted engineering principles or designed with sufficient resistance to fire and explosion.
7. Ventilation system intakes for buildings in close proximity to, or downwind from, hydrocarbon processes or inventories were not designed or configured to prevent the intake of gases in the event of a release.
8. The fire protection system was not maintained in a state of readiness necessary to provide effective firefighting capability. Unknown to the fire chief, one of three emergency standby diesel-powered water pumps had been taken out of service, and another was not fully fueled, with the result that it ran out of fuel during firefighting activities. Further, electric cables supplying power to regular service fire pumps were not located underground, thereby exposing them to blast and fire damage."
In many accident investigations I conduct and also during PSM audits, I still see many of the findings of OSHA for the Phillips accident being repeated.
It seems we have an inherent ability NOT to learn from past incidents because, often, Money Matters More than Mankind!
Contribute to the surviving victims of Bhopal by buying my book "Practical Process Safety Management"
The following is a summary of the major findings of OSHA's investigation of the accident.
"1. A process hazard analysis or other equivalent method had not been utilized in the Phillips polyethylene plants to identify the process hazards and the potential for malfunction or human error and to reduce or eliminate such hazards.
2. Phillips' existing safe operating procedures for opening lines in hydrocarbon service, which could have prevented the flammable gas release, were not required for maintenance of the polyethylene plant settling legs. The alternate procedure devised for opening settling legs was inadequate; there was no provision for redundancy on DEMCO valves, no adequate lockout / tagout procedure, and improper design of the valve actuator mechanism and its air hose connections.
3. An effective safety permit system was not enforced with respect to Phillips or contractor employees to ensure that proper safety precautions were observed during maintenance operations, such as unblocking reactor settling legs.
4. There was no permanent combustible gas detection and alarm system in the reactor units or in adjacent strategic locations to monitor hydrocarbon levels and to provide early warning of leaks or releases.
5. Ignition sources were located in proximity to, or downwind (based on prevailing winds) from, large hydrocarbon inventories. Ignition sources also were introduced into high hazard areas without flammable gas testing.
6. Buildings containing personnel or vital control equipment were not separated from process units in accordance with accepted engineering principles or designed with sufficient resistance to fire and explosion.
7. Ventilation system intakes for buildings in close proximity to, or downwind from, hydrocarbon processes or inventories were not designed or configured to prevent the intake of gases in the event of a release.
8. The fire protection system was not maintained in a state of readiness necessary to provide effective firefighting capability. Unknown to the fire chief, one of three emergency standby diesel-powered water pumps had been taken out of service, and another was not fully fueled, with the result that it ran out of fuel during firefighting activities. Further, electric cables supplying power to regular service fire pumps were not located underground, thereby exposing them to blast and fire damage."
In many accident investigations I conduct and also during PSM audits, I still see many of the findings of OSHA for the Phillips accident being repeated.
It seems we have an inherent ability NOT to learn from past incidents because, often, Money Matters More than Mankind!
Contribute to the surviving victims of Bhopal by buying my book "Practical Process Safety Management"
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