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!
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