31 - Hydrocarbon Processing - Portrait of Process Safety July 2012

 

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 A portrait of process safety: From its it s start st art to present p resent day  07.01.2012 | Mann an, M. S. S., Mary Kay O’Conn O’Connor or Proc ess Safety Safety Center, Ar tie McFerrin Department Department of  Ch Chemical emical Eng Engineering, ineering, Texas &M University System, College Station, Texas; Engin Chowdhury, A.asY., Y. , Mary  Kay O’Connor O’Connor Proce ss Safety Saf ety A Center, Ar tie McFerrin Department of Chemical E ngineering, eering, Tex A&M University System, College Station, Station, Texas; Rey Reyes-Valde es-Valde s, O. J. , Mary Kay O’C O’Connor Proc ess Safety  Safety  Center, Ar tie McFerrin Department of Chemical Engin Engineering, eering, Tex as A&M Univ Univ ersity System, College Station, Stati on, Tex as Thee driv in Th ing g force for proc ess safety safety has been primarily primarily based o n catastrophic catastrophic e ve nts. Keywords: By loo king king at the history history of process safety and the improv ements that each decade has brou ght in terms of  regulations and tec hniques, industry can inv ariably make itself safer. safer. Determining how major incidents such as Bhopal, Bhopal, Flix Flix boro ugh, Chernoby Chernoby l, Piper Piper A lpha and and others hav e influenced influenced the industry , academia, gov ernment and subsequent r egulations can offer offer a firm ffoundation oundation for future endeav ors. There is still researc h needed in the near future future to further c ement the foundation, and and researc hers and proc ess safety  safety  ex perts need t o pay attention to what incidents of this millenni millennium um are telling us about what is still still needed in order to make process safety second nature. Background The 19th ce ntury is known known as the era of iindustrial ndustrial revo lution. Each Each tec hnical progression has brought with it a certain amount of threat and hazardous hazardous activ ity. Chemical proce ss saf safety ety was not a major major pub lic concern prior to almost the end of the the 1 8th century. However, safety c oncerns were always there from the  be ginning ginn ing o f indust indu stria ria lizatio liza tio n bu t no t ne c essar es sar ily as we w e know kn ow o r c all it to da day y . The pr primit imit iv e inst in stinc inc t o f  human beings beings to stay alive and protec t themselv themselv es is probably the most v isceral driver driver for the growth of  process safety initiatives. 1 Process Pr ocess sa safety: fety: An on going phenom enon The driving forc forc e for proc ess safety safety has been primarily based o n catastrophic e v ents. W With ith an increasing number of tragic incidents, the proc ess industry and gov ernments started taking initiative initiative s to minimize minimize loss of lif lifee and propert y , as well as to prote ct the env ironment. In the US, US, safety safety regulations started back in 1899 when the US gov ernment issued issued the Rive Rive r Harbor Harbor A ct to avoid ex cess dumping dumping in waterways. waterways. A t the  be ginning ginn ing o f the 1 9t 9th h c entu en tury ry , esp e spec ec ially iall y in the th e mine m ines, s, t ho usand us andss of o f innoc inno c ent en t liv es we were re lost lo st b ec ause au se of the t he hostile environment. The hostile The y ear 191 0 was reported as the worst, with with 1,7 7 5 deaths in mines mines.. 2  These tragedies forced gov ernments and loc loc al establishments establishments to initiate initiate regulatory r egimes. In order to understand the gro wth of proce ss safety safety , we hav e div ided the significant significant initiative initiative s and incidents into into three bro ad sections. This This categorization is based on the changes that took place between y ears 19 30– 197 0, 197 0–2000 and 2000–2012. This This is shown shown in in Fig. 1.

 Fig. 1. Broad c lassification lassification of proc ess safety deve lopment lopment based on time period. hydrocarbonprocessing.com/…/A-portrait-of-process-safety-From-its-start-to-present-day.html?Pri…

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From 1930–197 1930–197 0. Thi Thiss per iod was mostly about establishing establishing re gulations. The WalshWalsh-H Healy Public Contracts Ac t in 1936 in US restrict ed working hours and employ ing child child labor. 1  This act also was co ncerned with occ upational diseases, diseases, a basis of many many pr esent safety safety regulations. The The 194 7 presidential co nferenc nferenc e on industrial safety safety was another noteworthy step forward. Some Some othe r regulations were established in the years 1936–1969 (see T able able 1). 1). Individually, these acts did not have major impact in ensuring industrial industrial safety safety but they playe d an imperativ imperativ e role for proc ess safety safety to reac h the position that that it has achiev achiev ed.

Congress passed the Occupational Safety Safety and Health Health Ac t in 197 0, which is a landmark legislation legislation that put into motion programs that co ntinue to ev olv e. Under this act, the Department Department of Health Health established the Occ upational Safety Safety and Health Health A dministration dministration (OSH (OSHA) A) with wide-ranging wide-ranging authority to enforce safety safety and health standards to ensure a safer workplace. 1  A lso, the US Department Department o f Health Health and Human Serv Serv ices instituted the National Institute for Occupational Safety and Health (NIOSH) which had the responsibility  to c onduct r esearc h, prov ide rec ommendations to OSH OSHA A and train professionals for increasing awareness. 1  In addition, the US Enviro nmental Protec Protec tion Agenc y (EPA) (EPA) was established in 19 7 0 to address environmental issues. From 197 197 0–2000. 0–2000. In  In the 19 7 0s and 1980 s, some of the world’s most shocking and and tragic industrial accidents took place. Consequentl Consequently y , industries industries and government bodies ev ery where were forced to rethink  about the te chnology and management management sy stems in industries industries from from the safety p oint of view. Fig. 2 offers 2  offers a timeline of the the catastr ophes during this time period.

  Fig. 2. Timeline Timeline of major industrial disasters  be twee tw ee n 1 97 4 and an d 1 989 . The Flixbo Flixbo rough ex plosion in 19 7 4 was by far the most sev sev ere disaster in the UK UK chemical industries industries and prov ed to be a major dr ive r for proc ess safety safety issues in the UK. As a result of these initiative initiative s, at the end of  1 97 4, the Adv isory Committee o n Major Major Hazards Hazards (ACMH (ACMH)) was implemented. The impact impact of Flix Flix boro ugh  was re inforc info rc ed by th that at o f the Sev eso es o t ra rage gedy dy in 1 97 6. 3 Howev er, of the3,000 unforgettable Bhopal gas gas0disaster in and India on Dece Dece 3, 1 50 984, which resulted in vary ing estimates to upward of 20,00 fatalities fatalities injuries injuries tomber another 0,00 0, was a wak wake-up e-up call for for the chemic al process industry . Both Both the industry and the public bec ame aware of the potential hazard hazard of  chemic al facilities. facilities. 2  This piloted piloted the intensification intensification of efforts efforts within industry to ensure the safety of major hazard plants. Proc Proc ess safety safety finall finally y gained absolute rec ognition as a standard practice. A fter the Bhopal Bhopal hydrocarbonprocessing.com/…/A-portrait-of-process-safety-From-its-start-to-present-day.html?Pri…

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tragedy, many regulatory initiatives were taken worldwide. In India, the Environment Protection Act (1986), the Air Ac t (19 87 ), the Hazardous Hazardous Waste (Management (Management and Handling) Handling) R Rules ules (1989), the Public Liability Liabil ity Insuranc e Ac t (1991 ) and and the Enviro Enviro nmental Prote Prote ction (Seco (Seco nd Amendment) Rules Rules (1992) were promulgated. 3 In 1984, the Mex ico City disaster represented the largest series of boiling boiling liquid liquid ex panding v apor ex plosions (BLE (BLEVEs) VEs) in history that killed killed almost 5 00 people. 3  The nuclear nuclear disaster which too k place on  A pr pril il 28, 2 8, 1 986 , in Che rno by l, Ukr aine , killed kil led 5 6 peo p eo ple and c ause au sed d tthe he de v elop el op ment me nt o f canc ca nc er and radiation sickness in many many . 3  Th  Thee Piper Alpha accident on July 6, 1 988, resulted in 1 67 deaths. The Piper  A lpha lph a Inq I nquir uir y has be en o f cruc cr uc ial im po rt anc e in the de v el elop op ment me nt o f the o ffshore ffsho re safety safe ty re gime gim e in th thee UK  secto r of the North Sea. On On Octo Octo ber 23, 1 989, in the Phillips Phillips 66 plant in Pasadena, Pasadena, Texas, a massiv e gas ex plosion caused the death of 23 people and more than 300 injuries. 3 These incidents made it eve n more ev ident that implementation of safety safety legislation legislation was indispensably  indispensably  necessary. T abl able e 2 and 2  and T able able 3 show 3  show the significant significant legislativ legislativ e and regulator y steps taken in the US and and Europe.

Process Pr ocess sa safety fety in th e new m illennium Proce ss safety safety has certainly made r emarkable progress. Howev er, it is still still impossible to adequately  answer a simple question, “A re we safe enough?” The in incidents cidents that oc curr ed in this mil millennium lennium are a reminder remind er that proc ess safety safety has a long way to go. The Columbia Columbia disaster on February 1 , 2003 , caused the death of all all seven astronauts onbo ard and 1 1 scattered shuttle shuttle debris ov er 2,00 0 square miles of Texas. Texas.  Thi  Thiss tragic incident can be trac ed back to flaws flaws in decision making at NASA. The Columbia ex plosion was an import ant lesson for c risis co mmunication professionals, as well. In fact, fact, the NASA lessons can be mappe d to many o ther catastro phes, such as the Piper Piper Alpha or the Flixbo rough incidents, that rev eal a sense sense of vulnerability, hydrocarbonprocessing.com/…/A-portrait-of-process-safety-From-its-start-to-present-day.html?Pri…

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establish an imperativ imperativ e for safety, and reinforce t he need for v alid on-time on-time risk assessments. assessments. 1 1 The Macondo Macondo blowout in the Gulf Gulf of Mex Mex ico (GoM) on Ap ril 20, 201 0, killed killed 1 1 e mploy ees and led to an uncontro lled oil spill lasting lasting 87 day s.1 2  This blowout was the mo st significant significant offshore offshore incident in the US, and it had a pr ofound impact o n safety r egulations in the GoM. The Drilli Drilling ng Safety Safety Rule regarding well-bore  and well-co well-co ntrol equipment was implemented on October 14 , 201 0. The Modif Modified ied Workplace Workplace reliability  and Safety Saf ety Rule was put into place on Octo Octo ber 1 5, 20 1 0, based o n the lessons learned learned from the Macondo  blo  bl o wo ut ut.. Finally, t here was the Fukushima Daiichi Finally, Daiichi nuclear plant incident in March 201 1 that drew the attention o f  the global proc ess and power industries, encour aging them them to incor porate natural disaster risks in in a hazard analysis analysis study . 1 2 T echnical achievem ents prepre-1 1970. Techniques 970.  Techniques to identify identify and ev aluate hazards, calculate co nsequence s and q uantified uantified ev ent pr obabilities and risk (such as What-If, What-If, Checklist, Checklist, HAZOP, HAZOP, Fault- and Eve nt-Tree nt-Tree ana analyses) lyses) were dev eloped in the middle middle of the 20 th century . These developments occ urred in some cases y ears or ev en decades before the well-kn well-known own major major incidents in in the 197 0s and 1980s. Howev er, these catastro phic incidents reflected reflected the need for more under standing standing and researc h regarding the underly ing issues issues about pr oc ess safety safety incidents. For ex ample, the HAZard HAZard and OPerability OPerability (HAZOP) (HAZOP) study , was deve loped by ICI in 1 963, when a team was looking looking for for way s to design a plant plant for for phenol production with production  with the minimum capital cost, but was c onsidering possible deficiencies in the design.1 3  The Flixbor ough and Sev Sev eso incidents clearly showed the importanc e of identif identified ied hazards before fatal fatal incidents occ ur, and HAZOP HAZOP gained gained ex tensive popularity within oper ating and and design companies. In the case of the Flixbo Flixbo rough disaster, disaster, more than 40 tons of cy clohexane were re leased leased due to the rupture of a temporary by pass line. line. The The temporary pipe was designed designed by a person who did not know how to design design large pipes operating at high temperatures. After this in incident, cident, co mpanies started started to include pro ced ures for management of change (MOC) (MOC).. Fault tree analy sis (F (FTA) TA) was dev eloped in the early 19 60s, and its use as a safety safety sy stem and reliability reliability technique qu ickly gained widespread interest, espec ially ially in nuclear nuclear and power installations. Since Since the dev elopment of FTAs, FTAs, great e ff fforts orts and adv ances (analy (analy tic methodo logies, computer pro grams, grams, co mputer codes) have occ urred in the quantitative quantitative ev aluation aluation of fault fault trees.1 4 T echn ical achiev achiev em ents: 197 197 0s and 1980s. In 980s. In the US and Europe Europe , mode ls for for po ol formation, releases, ev aporation and releases, and fire fire and ex plosions plosions were refined refined in the late 1 97 0s and the early 1980s. 1 5  In these two d ecade s, a series of fatal fatal incidents incidents (Fig. ( Fig. 3), 3 ), reinforc reinforc ed the importanc e of these models and were one of the principal motiv ations for for further researc h and improv improv ements.

  Fig. 3. Res Research earch motiv ated by major disasters disasters in the the 1 980s. Bhopal increased substantially the interest and activ ity o f the researc h and academic co mmunities in in a  widee rang  wid r angee o f are as rel r elat ated ed wit with h pr o c ess es s safet sa fety y , 2  principal  principally ly in reactivity hazards hazards (employ (employ ees did not hav e knowledge of the reactiv ity o f MIC MIC mix mix ed with water 1 6 ), inherent inherent safety and chemic al releases. The The 50 0 deaths involv ed in Mex Mex ico City clearly demonstrated the importanc e and hazards hazards involv ed in BLE BLEVEs. VEs.3 Piper Alpha focu sed attention on jet fires, fires, po ol fires, carbo n monox ide fires fires (initial (initial CO CO poisoning caused hydrocarbonprocessing.com/…/A-portrait-of-process-safety-From-its-start-to-present-day.html?Pri…

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most of the deaths) and and ex plosions in modules with turbulence ge neration.1 7  This incident, and the sinking sink ing of the A lexander L. Kiellan Kielland d in 1980, we re the mo st important ev ents in the history of offshore offshore oper ations in Europe Europe , and together made a great impact in the use o f quantitative quantitative risk assessment assessment (QRA) (QRA) tec hniques to assess o ffshore ffshore facilities.1 8 The aftermath aftermath of the Chernoby Chernoby l disaster disaster gav e birth to the safety safety culture c oncep t.1 9  Ac cording to the maintenance proc  proc edure. This This Phillips repor t, 2 0  the c ause of the incident was a mo dification Phillips dification in a routine maintenance reinforced to the pro cess industry t he importance of incorpor ating management systems, such as MOC MOC procedures. The 197 0s and 1980s were dec ades of major major incidents incidents and great losses, losses, but there is no doubt that these two decades made a great impa impact ct o n what today we call “proce ss safety.” safety.” T echn ical achievem ents: 1 1990s 990s to present present day. During the 19 90s, in response to new regulations and regulatory regulatory initiat initiatives, ives, c ollection of incident incident history history data started at a rudimentary rudimentary level. A dvances in technology and the research conducted by different centers, such as the Mary Kay O’Connor Process Safety Saf ety Center (which was established in 1995 ), allowed allowed for the de v elopment and av ailabil ailability ity of incre incre asing asingly  ly  reliable incident databases. 2 1  In the late 1 990 s, the Chemical Safety Boar d (CSB (CSB), in its MOC MOC safety  safety   bu lletin lle tin,, highl hi ghligh ighte te d th e im po rt rtanc anc e o f hav ing a sy stem st emat atic ic meth me thod od for MOC, MOC, an and d ho w this th is is an esse e sse ntial nti al ingredient for for safe chemical proc ess operations. In the 1990s and early 2000s, the dev elopment of engineered engineered nano-materi nano-materials als increased increased c onsiderably. onsiderably. This Th is development introduced a new area o f research to proc ess saf safety, ety, an area where researchers are trying to understand the workplace exposure and environmental aspect of nanotechnologies. Research Res earch needed in th e near ffut ut ure There is no doubt that the field field of proc ess safety safety has made great adv ances in terms of regulation and techniques in in the last last 40 y ears, but industry industry changes every day, and more sophisticated and and co mplex proc esses are dev eloped. This, combined with facto facto rs such as human erro rs (whi (which ch will be always present), and challenges in cre ating and maintaini maintaining ng organizational memory memory , among othe rs, is the re ason  why  wh y inc ide nts c o ntinue nti nue to o c c ur. ur . Fata Fa tall inc ide nts in this th is ne w mille mi llenniu nnium m highl hi ghligh ighte te d so me of the t he ar area eass of  o f  proc ess safety safety where resear ch is still still needed (T (T able able 4). 4 ).

Dust explosion. Dust explosion research has been c onducted on and off ffor or mo re than 10 0 y ears.2 2 Howev er, ev ents such as the I mperial Sugar Sugar Co. incident in Georgia Georgia (14 deaths, 1 4 life-threatening life-threatening burns, 38 total injures2 3 ) demonstrate the need for further researc h, awareness and ma management nagement systems. I n orde r to prev ent these kinds kinds of incidents, it is imperativ imperativ e to perform ex perimental and theore tical work to understand the chemistry and physics o f dust cloud generation and combustion, flame propagation and potential ignition ignition sourc es. It is also important to understand and deve lop models for ffire ire and exp losion of  nano-materials. Reactive chemicals. Reactive chemicals. Reactive chemistry incidents continue continue to o ccur in the chemical processing processing industry , and in other industries which handle chemicals in their manuf manufacturing acturing pro cesses. A CSB CSB study , released in in 2002, identifi identified ed 167 reactive incidents that that occurr ed between 1980 and 2001 , which caused 10 8 deaths deaths.. 2 4  More exp erimental and and theoret ical research is necessary to fully fully under stand the kinetics kinetics hydrocarbonprocessing.com/…/A-portrait-of-process-safety-From-its-start-to-present-day.html?Pri…

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and thermal behavio r of industrial industrial chemical reac tions.4 Saf afety ety cult ure. The tragic Columbia Columbia shuttle incident showed the po ssible fatal fatal conseque nces of bad industrial communication. It is important that resear ch and safety pr ofessionals understand and ev aluate good safety culture that enables the sharing of inf information ormation and improv ement of safety safety within the industries, taking taking into acc ount different different spe cialties and enviro nments. Nucle ar safety safety . The Fukushima Fukushima incident incident definitely definitely changed the risk perc eption of nuclear powe r plants. Managers Mana gers and researc hers hav e a long journey in both risk communicatio n and risk risk assessment models of  nuclear power plants. Make safety safety second n ature  A ltho lth o ugh “p ro c ess es s safet sa fety y” w was as no t rec r ec og ognize nize d as a pr ac tic e o r disc d isc ipline ipl ine be fore for e the t he mid mid-1 -1 980 s, c o nc ern er n about the health, safety and e nviro nment is intrinsic intrinsic in human beings and as old as civ ilization. ilization. Great Great adv ances in safety safety regulations and techniques have oc curr ed during the last last century . But But as industry  industry  grows and changes every day, processes present new challenges. challenges. Manag Managers, ers, operators and researchers must continue working together to improv e their ov erall safety safety knowledge in orde r to make safety safety seco nd nature. HP LITERATURE CITED 1  Mannan, M. S., J. Makris and H. J. Overman, “Process Safety and Risk Management Regulations: Impact

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 Psy c ho lo logy gy , 1991. 2 0  Company, P.P., A P.P., A Rep o rt o n the th e Houst Ho ust o n Che mic al Compl Co mplex ex A c c ide nt, Bartlesv ille, Oklahoma, Oklahoma, 19 90. 2 1  Mannan  Mannan,, M. S., T. M. O’C O’Connor onnor and H. H. H. West, West, “A cc ident history database: An o pportu nity,”

 Enviro nme nta l Progre Pro gre ss,  1999. 2 2  E  Eckhoff ckhoff,, R.K., R.K., “Current status and exp ecte d future trends in dust ex plosion researc h,” Jo h,” Journ urnal al o f Loss Los s

 Preve  Pre ve ntio nti o n in the t he Pro Procc es s Indu I ndu strie st ries, s, 2005.  2005. 2 3  US Chemical Safety and Hazard Investigation Board (US CSB), “Investigation Report on Sugar Dust

Explosion and Fire,” Report No.2008-050I-GA, 2009. Available online at  www.c  ww w.c sb sb.go .go v / asset ass et s/ s/do do c umen um ent/ t/ Im pe ria l_Sugar _Repo rt _Final_upd _Final_u pdat ated ed.p .pdf, df, ac a c c esse es sed d o n Marc Mar c h 1 5 , 2012. 2 4  US Chemical Safety and Hazard Investigation Board (US CSB), “Improving Reactive Hazard

Management,” Report No. 2001-01-H, 2002. Available online at:  www.c  ww w.c sb sb.go .go v / asset ass et s/ s/do do c umen um ent/ t/ Reac Rea c tiv eHazard eHaza rdIn Inv v estig es tigati ation onRep Repo o rt rt.p .pdf, df, ac a c c es esse sed d o n Marc Mar c h 1 5 , 20 2 0 1 2. T he authors authors M. Sam Sam Mannan, PhD PhD,, PE, CSP CSP,, is a chemic al engineering professor and direc tor of the Mary Kay O’C ’Connor onnor Pro cess Safety Center at Tex as A&M Unive Unive rsity. He is an internationally  internationally  rec ognized exp ert on pro cess safety and risk assessment. His His research interests include hazard assessment and risk analysis, analysis, flammable and toxic gas cloud d ispersion modeling, inherently safer design, reac tive c hemicals and run-away reac tions, aerosols and abnormal situation management.  Am  A m ira Y . Chow Ch ow dh u ry , BS, is a PhD student in materials science and engineering, and a researc h assistant assistant at the Mary Kay O’C O’Connor Proc ess Safety Safety Center at Tex as A&M Univer Univer sity. She is a chemical engineer from the Bangladesh Unive Unive rsity of Engin Engineering eering and Technology . Her resear ch interests include hazard assessment and dust ex plosions. Olga J. Reyes-Valde Rey es-Valde s, BS, is a materials science and engineering PhD student at Tex as A &M University and researc h assistant assistant of the Mary Kay O’C O’Connor Pro cess Safety Center. She is a chemic al engineer engineer from Unive rsidad Industrial de Santander, Santander, Colombia. Her Her re search interests include reactive chemicals and run-away reactions, dust explosion, hazard assessment and risk analysis.

Top 10 worst process safety incidents in history  This article discusses what the Mary Kay O’Connor Process Safety Center at Texas  A&M Universi University ty in Colleg College e Station Station,, T Texas exas,, cons conside ider r the top 10 proce process ss safe safety ty inciden incidents ts in history. The incidents were ranked based on the cumulative impact on loss of lives and economic economic losse losses, s, and tthe he resultin resulting g impact on the developmen developmentt of what today we know as process safety. 1. Bho pal On the early morning of Dece Dece mber 3 , 1 984, at the Union Carbide Carbide plant in India, a storage tank containing containing hydrocarbonprocessing.com/…/A-portrait-of-process-safety-From-its-start-to-present-day.html?Pri…

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methy l isocy anate (MIC) (MIC) was contaminated with water leading leading to a runaway re action causing the release of  more than 40 to ns of tox ic MIC gas through a relief v alve . The incident incident killed killed more than 3,00 0 peo ple and injured hundreds of thousands more. This This was arguably the worst c hemical industry incident in terms of  people affecte affecte d, howev er; it was just after after this fatal fatal tragedy that the c hemical proc ess industry be came really c onscientious of the importanc importanc e of process safety and it gained gained complete ac cept ance as a standard standard practice. 1  As a direct respo nse to Bhopal, Bhopal, many regulatory initiative initiative s were implemented worldwide. In India, this ev ent led to the Enviro Enviro nment Prote Prote ction Ac t (1986), the Air Ac t (1987 ), the Hazardous Hazardous Waste Waste (Management (M anagement and Handlin Handling) g) Rules Rules (19 89), the Public Liability Liability Insurance Ac t (1991 ) and the Enviro nmental Protection (Second A mendment) Rules Rules (199 2). In the US, the Emergenc Emergenc y Planning Planning and and Community Communi ty Right-to-K Right-to-Know now A ct (EPC (EPCRA) RA) was pro mulgated in 1 986,2  and the Clean Clean Air Ac t Amendments 1

(CAA (CAA A) were signed into law in 1 990. 2. Chernoby l On April 28, 1986, in a power plant in Chernoby Chernoby l, Ukraine, Ukraine, an exper iment performed in order to v erify the emergency power supply o f a reactor resulted in unf unfortunate consequences. Th Thee co re of the reactor was  blo  bl o wn o ut by two v iole io lent nt e x plo sio ns c aus ing a se serie rie s of o f fires and th thee rel r elea ease se of ton t onss of o f radio rad ioac ac tiv e materials. It is considered to b e the worst nuclear d isaster in history . The incident incident directly kil killed led 56 people and influenced influenced the dev elopment of cancer and radiation sickness of hundreds in the subsequent  y ears ea rs.. 3  Before  Before the incident, there were no written rules for for the te st that led to the catastrophic co nsequence s. This This ffact act has made the adherenc e to safety-related instruc tions as the most highlighted highlighted lesson learned regarding to process safety. 4

3. Piper Piper Alph a Piper Alpha was a North Sea oil productio n platform. platform. On July July 6 , 1 988, the backup co ndensate pump maintenance.. Howev Howev er, since the maintenance maintenance c ould not be pressure safety safety v alve was remov ed for routine routine maintenance co mpleted within the shift, shift, it was was decided to c omplete the remaining work the next day . As a temporary  measure, the c ondensate pipe was sealed with a b lind flange. flange. Communication Communication gaps b etween different different shifts resulted in a catastro phe when the night shif shiftt cre w unknowingly unknowingly starte d the bac kup condensate pump after the failure failure of the primary pu mp. In just 22 minutes, fire fire broke out ev ery where and the ev ent escalated further bec ause of design and and oper ational flaws flaws resulting in in 167 deaths. The Piper Piper A lpha incident was a  wakeu  wak eu p c all fo r tthe he offsho offsh o re indus ind ustr tries ies . Signific Sign ificant ant c hange han gess in ssafet afet y pr prac ac tic e inc in c lude lud e dev d ev elop el op ment me nt and a nd implementation of safety safety c ase regulations in UK, UK, adherenc e to a pe rmit-to-work system and re alistic alistic training for emergency response. 4 4. The Macondo blowout blowout The Maco Maco ndo ex ploration well located in the Gulf of Mexico (GoM) (GoM) was drilled drilled by a deep water horizontal semi-submersible rig. On On April 20, 20 10 , a blowout c aused a fire fire and exp losion on the rig that killed killed 11 employ ees and caused a major oil spill that continued uncontro lled for for 87 day s. A series of mechanical failures, failures, lack of human judgment, faulty faulty engineering design an and d imprope r team interac tion came t ogether to r esult in the largest oil spill known known to mankind. The blowout was the biggest offshore offshore incident in the US and it had a profound impact on safety re gulations in the GoM. As a direct o utco me of the Macondo  and well control eq uipment was incident, the Drilling rilling Safety Safety Rule regarding wellbore reliability  and implemented on Octo Octo ber 1 4, 201 0. The Modified Modified Workplace Workplace Safety Rule was also implemented on Octo Octo ber 15 , 201 0, based on the lessons learned learned ffrom rom the Macondo blowout.5 –6 5. BP T exas City 

O n March 23, 20 05to, during of hydro an isomerization uni unit, t,tothe safety v alves o f a distill distillation ationwith tower o pened due o v erfilling, erfillthe ing,startup allowing allowing carb on liquids flow flow into raelief disposal blowdown drum a stack, which were also ov erfilled, erfilled, resulting in a liquid release. The The ev aporation of the hydr oc arbons produ ced a flammable vapo r clo ud that ignited and led led to a ser ies of fires fires and ex plosions. Fifteen Fifteen workers died and about 1 80 were injured.7 This incident incident led to major investigations including the milestone Baker hydrocarbonprocessing.com/…/A-portrait-of-process-safety-From-its-start-to-present-day.html?Pri…

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panel repor t headed by former US Secr Secr etary of State State James Baker Baker III . This incident also resulted in signifi signi ficantly cantly more interest in and attention to issues suc h as facility facility siting, siting, atmospheric v enting, leadin leading g and lagging lagging indicato indicato rs and safety safety culture . 6. Th e Flixborough disaster disaster line ne ruptured , resulting in in the On June June 1 , 1 97 4, in a caprolactam production plant, production plant, a temporary by pass li leak of almost 40 tons of cy clohex ane that caused a huge vapor-c loud ex plosion. The tragic disaster killed killed 28 people including all the employ ees working in the co ntrol roo m. There was the alarming alarming possibility possibility o f  kil killing ling more than 500 employ ees if it it were a nor mal working day instead of weekend. Also, widespre ad damage to pro perty within a 6-mile 6-mile radius around the plant was another major c onsequenc e. The Flixbor ough ex plosion was a critical driv er in moving proc ess saf safety ety issues forward forward in the UK. UK. As a result of the Flixb Flixb oro ugh incident, at the end of 19 7 4, the Ad v isory Committee on Major Major Hazards Hazards (ACMH (ACMH) was formed. The lessons learned from this disaster highlight the importance of HAZO HAZOP P analysis, blast resistant co ntrol roo ms and thoro ugh studies prior to any modification in in proce ss plants. plants.4 7 . Mexico Mexico City  On Nove mber 1 9, 1 984, in an LPG LPG install installation ation in Mexico Ci City ty , the failure of the safety v alve of an LPG LPG storage tank caused an o v erpre ssure inside the tank and and a pipe rupture , leading to a leakage leakage of LPG followed fol lowed by an igni ignition tion and and v iolent iolent ex plosions. plosions. Approx imately imately 5 00 people were killed killed and more than 7 00  were  we re inju re d. 9  Thi  Thiss incident represents the largest series of boiling liquid expanding vapo r ex plosions (B (BLE LEV V Es) in histor y . 4  Mexic o City c learly demonstrated the risk of BLE BLEVEs VEs in proce ss facilities facilities and lessons learned from this ev ent hav e significantly significantly impac ted standards for design and operation. 8. Philli ps On Octo Octo ber 2 3, 1 989, in the Phillips Phillips 66 plant plant in Pasadena, Pasadena, Texas, the rupt ure of a seal on a poly ethy lene reac tor c aused the release of highly highly fl flammable ammable ethy lene and isobute isobute ne gas, forming forming a gas cloud and leading to a massive ex plosion in less than two minutes. Twenty-three people wer e killed killed and more than 300 injured. The day before the incident, a maintenance maintenance procedure  procedure had been performed by co ntractor perso nnel. This This incident incident undersco red the importance o f rigid adherence to ope rating procedur es and the implementation of an appropriate management system for c ontract wo rkers. In response to this incident incident and other incidents that occ urred b efore in the 1980s (including Bhopal, Bhopal, Shell Shell Norc Norc o, A rco Channelview  Channelview  and Ex Ex xo n Baton Baton Rouge), the US D Department epartment o f Labor, Labor, Occ upational Safety Safety and Health Health Ad ministration ministration dev eloped the Proc ess Safety Safety Management Management (PSM) (PSM) regulation. regulation. 1 0

9. Colu m bia disaster disaster The physic al cause o f the Columbia Columbia shuttle disaster was separatio n of insulation insulation foam foam that then hit the carb on–carbon reinforced panel of the left left wing, thus thus damaging the thermal prote ction sy stem.  A er od y namic nam ic pr pres essu sure re c au ause sed d by b y su supe pe rh rhea eate ted d air ai r des d estr tro o y ed th thee wing w ing whe w hen n the th e shu s hutt ttle le was w as r ee nte ring rin g earth’ss atmosphere earth’ atmosphere at about 1 0,000 mph on February 1 , 2003 . The tragic tragic incident incident caused the death of all all sev en astronauts and resulted in shuttl shuttlee debris being scattered ov er 2,00 0 square miles in Texas. Howev er, the underly ing causes for for the disaster c an be traced b ack to flaws flaws in dec ision making making at NASA. NASA. The Columbia Columbia incident also prov ided important lessons for crisis co mmunication professionals, as well. In fact, the lessons learned from from the Columbia in incident cident can be mappe d to many o ther catastro phes such as the Piper Alpha or the Flixb oro ugh incident, cov ering issues such such as sense of vulnerability , establishing establishing an imperativ e for safety and v alid on-time on-time risk assessment.1 1 10. Fukushim a Daiichi Daiichi n uclear incident On March March 1 1, 20 11 , this incident drew the attention of the proc ess and power industries around the world, enco uraging them to incorp orate natural disaster risk in an any y hazard analy analy sis study. When a powerful earthquake hit the plant, plant, the reacto rs shut down automatically. Howev Howev er, bec ause of the earthquake and and the following tsunami, a power blackout e nsued, leading to the loss of coo ling, ling, which, in turn, led to hydrocarbonprocessing.com/…/A-portrait-of-process-safety-From-its-start-to-present-day.html?Pri…

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ov erheating of the reacto rs (creating serious radiation hazards). Fortunately , no one was killed killed because of  the radiation, but there may be long-term co nsequence s to the workers and to the neighboring neighboring communities communiti es who were expo sed to radiation. radiation. Conclusions These tragic ev ents and the consequences of these ev ents have pro v ided us with numerous These numerous lessons that that help our understanding of the hazards hazards and risk riskss of the modern proc ess industry and, mor e importantly , how design, technology , equipment, management systems, human factor factor s and safety safety culture c an be used to improv e the safety safety performance of the industry. Understanding the roo t causes of incidents incidents and learning from from mistakes within the company , as well as other organizations, is vital. These lessons need to  be imple imp leme mente nte d bo b o th in i n the th e e nginee ngin ee ring rin g and the th e mana m anage geme me nt sec s ec to rs. rs . LITERATURE CITED 1 Mann Mannan, an, M. S., S., et al., “The legacy of Bhopal: Bhopal: The The impact ov er the last 20 y ears and future directio n,”

 Journ  Jo urnal al o f Loss Los s Pre ve ntio nti o n in the t he Proc Pro c es s Indu I ndu strie st ries, s, 200 5. 1 8(4–6): 8(4–6): pp. 21 8–224. 8–224. 2 Mannan, M. S., S., J. Makris and H. J. Ov Ov erma n, Pro n, Procc e ss Safet Sa fety y and a nd Risk Ris k Mana ge me nt Re gu gulat latio ions: ns: I mpa c t 

on Proce ss Industry, Encyc Encyc lopedia o f C Chemica hemica l Proc Proc essing and Design, Design, ed.  ed. R. G. Anthony , Vol. 69, Supplement 1, pp. 168–193, Marcel Dekker, Dekker, Inc., New Yo rk, 2002. 3 Dara, S. I. and J. C. Farmer, “Preparedness Lessons from Moder n Disasters Disasters and Wars,” Critical Care

Clinics, 2009. Clinics,  2009. 25 (1): pp. 47 –65. 4 Mannan, M. S., Le S., Lees es’’ Lo ss Pre ve ntio nti o n in the t he Proc Pro c e ss I ndu strie st ries, s, 3rd  3rd Edition, Edition, Elsevier Elsevier , 200 5. 5 McAndre ws, K. L., L., “Consequences o f Macondo Macondo : A Summary o f Rece Rece ntly Prop osed and Enacted Enacted Changes

to US O Off ffshore shore Drilling rilling Safety Safety and Env Env ironmental Regulation,” Society of Petroleum Engineers A mericas E&P Health, Safety Safety , Security and Enviro Enviro nmental Conference, Conference, Houston 20 11 . A v ailable online: online: http://www.js http: //www.jsg.utexas.edu/new g.utexas.edu/news/f s/files iles/mcandrews_ /mcandrews_spe_ spe_1437 1437 18-pp.pdf, 18-pp.pdf, accessed on March 1 6, 201 2. 7 Kaszniak, M. M. and D. D. Holmstro m, “Trailer siting issues: BP Tex as City City ,” ,” Jo  Journa urna l of o f Haza Haza rdo us Ma te rials, rial s,

2008. 159(1): pp. 105-111 . 8 Sn Snorre orre , S., “Comparison “Comparison of some selec ted metho ds for incident investigation,” Jo investigation,”  Journa urna l of o f Haza Haza rdo us

 Mater  Mat erial ials, s, 2004.  2004. 11 1(1–3): pp. 29–37 29–37 . 9 C.M C.M,, P., “A nalysis of the LPG-disaster LPG-disaster in Mexic o City,” Jo City,”  Journ urnal al o f Haza Haza rdo us Ma te rials, rial s, 19  19 88. 20(0): pp.

85-107. 1 0 Guidelines for Vapor Cloud Explosion, Pressure Vessel Burst, BLEVE, and Flash Fire Hazards, 2n Hazards, 2nd d

Edition, dition, August 201 0, Process Safety Safety Progress, 2011 . 30(2): p. 187 . 1 1  A meri me ricc an I nstitu nst itu te of Chemic Che mic al Enginee Engin ee rs (A IChE), Le IChE),  Lesso sso ns fro from m th e Colum Co lum bia Disaste Disast e r-Safety r-Safe ty and 

Organizational Culture, C Culture, Center enter for Chemical Chemical Proce ss Saf Safety ety , 200 5.

 

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