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Burns (1987) 13.

lZt,87-102 Prrnfedin Gear Britain 87

The tragedy of San Juanico-the most severe

LPG disaster in history

G. Arturson
Burn Centre, University Hospital, Uppsala, Sweden
88 Burns (19871 Vol. 1YNo 2

INTRODUCTION hortlcrlinc of Mcsico <ity and the Stiltc of Mcx-

IN Swcdcn ;I <ommittcc for Disaster Mctlicinc ice. S;III Juanico hclongs to the municip;dity of
(KAMEDO) ha hccn ~~t;d~lishcd since ll~OS. its Tl;ilncp;mtl;i. onto of the most intlu~triiili~crl arcas
purpose king to collect information ;ritil cspcri- of the country with 2 gnat number of 1.K;
cncc of all kind5 of disaster:, all over tlic wilrld (Liquid Pctrolcuni (iii\. mainly :I misturc of
;rnJ to nlitke the information ;tv;tilddc to all propane and but;mc) storage and rli~tribution
0rg;uiiz;itions ciincsrncd with disaster mcclicinc ccntrcs, t!spcciiillv in San Juxtico. The inkihi-
;ind to nil authorities responsihlc for disa~tcr tants of Mexico City number dlout IS million.
planning. San Junnico has a population of IOOlH)O. 4OOoU
I was sent by KAMEDO to the San Juan of uhoni wcrc living in the immcdiatc arcit of the
Ixhuatepcc di~;I\tcr arca in or&r to study the di4atcr. The built-up iIre: of San Ju;rnico. which
following fcuturcs: was mostly affcctetl by the &astcr, is situatd
south of the I.lYi facilities and with its horder\ at
1. The scene of the disaster, including what
it distance of about I?0 ni from the storage tailis
happen4 and the number ilnd types of casual-
(Pig. I ). The ancient Sm Juanico villngc is Io-
cated in ;I small villlcy. 5 km in the cast-west
2. The organiration at the sccncof the disas-
direction and 3 km xcrc)ss. Through the valley
tsr. as rrg;u& thr control. rcscuc. rekasc, triage
runs the Los Kcmcdios kivcr uxxl us ;I sewage
ad trirrlsport of casualtics.
o\crllow dliinncl for the metropolitan ada.
3. The organization at the hospitals dcsigmltd
fhr majority of the inhabitants of San Ju;mico
for the handling of casudtics arising from the
arc poor country people who went to Mexico
city in the hope of ;I hrightcr future. Their homes
arc mainly one-stormy houses constructed of con-
THE SCENE OF THE DISASTER crctc pikirs filled in with bricks and with roofs of
San Juan lxhuatcpcc. also known ;IS San Juanico, iron sheets.
is a suhurh of Mexico City situated 9itH) m itbOW The lay-out of the LPG hulk storage and dis-
SCil-ICVtl and Aout 10 lim north. just hcyond the tribution tlcpot in San Juanico is given in Kg. 2.
amrson. A LPG disaster 89
99 Burns (1987) Vol. 1YNo. 2

children Table 1. Recordings by the seismograph of the

&+xi University of Mexico on 19 November, 1985

Recording Intensity on the

number Time Richter scale
[Under the debris of the house the bodirs of
his wife Felisa, 30. and his four children. IO, 7, 4 05h 44min 52s
and 2 yrars uld. wcrc discovered. In fhc next 05h 46min 01s 0.5
house 3 family of ten had been killed.] 06h 15min 53s
06 h 31 min 59s
06h 47min 56s
06h 49min 38s
06h 54min 29s 05
06h 59min 22s

cloud was followed by an esten\ive tire in the

plant area.
The tirst explosion registcrcd on the seismo-
graph al the University of hlcxico wits at 05 h
44 min X 5. This explosion was followed by
another tight rxplosions within 2 h (Ttrh/l* I).
Approximately I min after the lirst explosion one
of the Iarpcst explosions of the whole scque~~cc
occurred (OS h JO min OI s). lhc explosions Nos
7 ;wd 7 wcru nw~t likclv CIIICto rupture of the
&llcr spheres and they-wcl-c ;il1 of the HLEVLI
lypc (Ijoiliiig I.iquid I:xp:intlinp Vapour Explo-
sion). According to the Scismlc Service of the
Univcr5ity of Mexico. they had 211 iritcnsity ofO.5
on the liichtcr scale. Unburnctl and burning gas
critcrcd ths hi~tlscs south 0f the pl;mt artil ilntl scl
fire to cvcrythiag. 13l;ist WilVCS from Ihc explo-
sions dcslroyctl ;I number of housch and shift4
THE COURSE OF EVENTS scvcral cylindrical tilnks from their supports
During fhc weekend 17-18 Novcmhcr I0S-l the
Pcmcx storage tanks wcrc hcing filled with l.P(i.
By early in the morning of Monday 19 the two Table II. The distance range of cylindrical bullet
Iqcr spheres and all the cylindrical tanks had tanks and major fragments of spheres
been liktl up. During the feeding of the smaller
sphcrcs B suddsri prcssurc drop was obscrvcd in
Bullets End tubes fragments
the pipe lint at OS. IO h. The rrason for this wils ;I
Distance range (no.) (no.) (no.)
Ic;tkagc: of LPG close to thr smaller spheres (No.
2 in Fig. 2), probably due to a pipe rupture On supports 4
causrd by excess pressure. Eyewitncsscs among In their original
the military guards watching the LPG facilities bund 11
have confirmrd that they noticed ;I vapour cloud Within 100 m 17 3 6
nowing over the walis of about 1 m height which 100-200 m 4 4 6
surround the tanks. The smell of gas prior to the 200-300 m 3 3 7
300-400 m 2 2 1
disaster was also mcntioncd by several obscrvcrs.
400-700 m 1 1 5
The vapour cloud was slowly moved by the
700-l 000 m 1 1
north-east wind (0.4 m/s) towards the ground- 1000-l 200 m 1 1
plrrcrd fkircpit (No. 7 in Fi,q. 2) aricl ignited. A
vapour cloud explosion (IUVCI~) occurred. Total 44 15 25
From nn analysis of various rsports in the press.
it may be concluded that ignition of the vapour Two of them ruptured longitudmally.
Arturson: A LPG disaster 91

At the Llnig;i~ and (ia\oni;itic.o arcas ;thout 20

gas tank trucks lxmicil (Fix. 7) and many
thou~xd smallsr hottlcs of household gas lo;~ckd
A huge nunihcr of
fmgmcnts of cylilltlritill on truck5 wcrc Jcstroyd (bY,g. 8).
hdlcl I;irdi~ ;rritl qhw Ir;rgnwits gStctf spccilic
kinetic cncrpy ;is ;I result of the physktl cxplo-
kn. lhis kin&c cncrgy turticrl the fr;tgnwnts
into ntis\ila which wtrc attered over considcr-
;ihlc dist;incea (7irhle /I antI i;is.s. 3, 4 anti S).
f.orty-four tx~lis from ;I total of 48 could hc
traced. Mod likely ti)ur tmks were fragrncntcd
into mailer picccs. The maximum distance over
which ;I hulkt txnk tr;tvcllctl was 12t)om south of
the site (Fig. 5). This hullct tank dcstroyctl two
houscb from which the inhabitants had already
left due to the intcnkc heat. The weight of this
tdlct tank (cmptv) was c;ricul;ttal to hr 30 tons.
The m;lximum &t;mcc to which fragments of
sphcrcs wcrc found to travel was btbt)m north of
the site. A total arc;1 of about ItM~tMM~m was FYq. J. Wrerkagc ;II the Pcmcx plant steams as the Fire
wvcrcly d;unagcd. including about 270 houhcs Dqwrtmcnt cstinguisha the hl;~zs. Note the shift of
(Fig. 6). the c~lirrrlr~c~d~;mhs from their supports.
THE COURSE OF EVENTS AFTER THE csplosion (OS.40). When the lir~hrigaclc
DISASTER ilpplIKlCllCLl tllc site. the vikkgc WilS burning and
the lcmcx facilities wcrc coved by tlamcs to
Initial action at the disaster site the height of &out 6(N) 111;llxwc ground. Due to
Ilw chronological scqucnc~ of the rcscuc efforts the intcnsc hat the tire forces had to dop south
given by different authorities and rclicf units ih of the village. llalf of the lircmen st;lrtcd to
summarizrd in 7iihk 111. rescue the pcoplr running from the village with
When the first tclephonc csll came to the fire their clothcs on lirc and the other half began to
station at Ecatqxc 3 km cast of the disaster site fight the ncarcst burning houses and tried to
at OS.45 the ptxsonncl at the station had been reach the Irmcx facilities from the south. The
wakcmd by the lirst cxplokn. The head of the hcilt was enormous. A huge number of frxgmcnts
fircbrigade. convincal that a disaster had occur- of cylindrical bullet tanks and hphcrc fragments
red, had nlrcady preporcd for turn-out and wcrt sc;~ttcrcd all ovcr the plxcc. I louses col-
phoned police forces, ambulance crntrcs, and the lapsed. Black heavy smoke ;~ncl dust tklrkcnccl
idarm ccntre of Tlalncpantlas. Ten minutes later the whole vdlcy. In these very dangerous and
the fire-fighting units from Ecatcpcc consisting of dramatic circumstances the lirxt lirumcn on the
IX firemen arrival BS the first rescue team to the spot did heroic rtxuc work (Fig. 9). Only two of
village of San Juxnico. On their way to the site them sustained thermal injuries.
the iircmen obscrvcd a cylindrical bullet tank In the mcantimc. tho highway patrols had been
llying in the air (Fig. S) and they noticd il loud alcrtd and they implcni~ntctl Opcr;ition
Acurson A LPG disaster 93

Tab/e 111.The chronological sequence of events including the rescue efforts tn the San Juan Ixhuatepcc
dtsaster. 19 November 1984

05.00 Feeding with LPG of the four spherical storage tanks (volume 1600n?)
Omin 05.10 Pressure drop in the pipeline to Pemex. Leakage of LPG and a vapour cloud
flowing over the bund walls
30 min 05.35-05.40 The vapour cloud reaches the flare p11.200 m from the LPG leaking point, and is
ignited. A vapour cloud explosion (PUVCE) occurs followed by an extensive fire
at the plant area
05.44.52 Flrst explosion registered on the seismograph at the University of Mexico. A
BLEVE probably due to the first rupture of one of the four smaller spherical tanks
05.45 First telephone call to the fire station at Ecatepec, 3 km east of the disaster site
05.46.01 First major explosion (registered) probably due to BLEVE of two smaller
spherical tanks
05.55 First fire-fighting units from Ecatepec reach the San Juanico village
06.00 Police close roads
lh 06.10 Various emergency services such as ambulances and rescue teams arrive
together with additional firebrigades
06.15 The Secretary for National Defence proclaimed the disaster DN-111-E Plan (an
earthquake plan) to be put into action
06.54.29 A second major explosion (registered), probably due to BLEVE of the fourth
small spherical tank
2h 07.00 Panicking, caused especially by information via radio and TV from the area of
the disaster
3h 08.00 All roads from San Juanico congested by refugees
4h 09.00 Nearby hospitals overcrowded by patients. The Governor of the State of Mexico
arrives at the site
5h 10.00 Most injured from the disaster have been taken care of and transported to a safe
6h 11.00 Last registered explosion. Fire in San Juanico village extinguished
-. 10h 15.30 Fire within Pemex under control
-15h 20.00 Fire extinguished. Environmental sanitation. Removal of debris etc.
94 Burns (1987) Vol. 1YNo. 2

Volcano. In conformity with this operation untlcr control at I.F..Ufh and all rrniaining fire
schcmc. cvcry highway that led to the diaastcr had heen put out by 3f.00 h.
;nxx W;I\ closed to ;dI private traffic (0(x00 h).

Only ~rl~oiil I h cl;ipscd hcforc the v:irioir5 Evacuation of people from the disaster site
emergency service\. such as ;lmblllance~ and rc\- LlOst pcoplc living in the Villil~C of S;ln .flI;inico
cue tcams (F@. IO and I I). ild~fiti0ll;ll firchri- ilnd on the hills south of IIIC village took Ilight
gndcs and policemen arrived on the spot. lhc tire tow;lrds highwily.
the Avcnuc
nearby ln-
was prcvkWcif from sf)rc;ding ;inif lirst aid w;iS surgentcs Nortc. amI \urrountlin~ hills soon ;Iftcr
given u here ncccsxkry. During thcx xtion4 the the q~lo.Gons ;uid lircs startcif. f hc lird rdugccs
sccoii~lmajor csfdosion took pl;icc. liycwitncbscs ILId ilfrGltly ;lrrivcd at Oh. I5 h at Indies VcrJcs
SpOkC Of il W;lfi of tire ill111 IlC;it th;lt WA3 cloain~ in subw;iy station situ;ltcil 2.5 kill ;lWilV I from the
on them ;lnd forcccf stiiergcncy pcr5cwicI into il villqc. Ch;iotic sccnc~ iloniin;itcd and thcrc was
tcnilxxiry withdrilwal. no orpni~cd cv;lcuation during the IirSt Icw
At 00. 15 the for N;ltiond
Sccrctilry Lkfcncc IiourS.

f>rod;lim~~f the I>i\atcr l)N-I I I-I! lfi1tI to bc plot At OS.tH) h a11 the rods from S;m Jui~nk<) wcrc
into ;iction. This fkln is 0fxrr;itcd by the ilrrlly ;intf congcstcd by rcfilgccs.
llscd m;linlv 3s an C;lrthcfllilkC pl;lrl. I:fonl t11;lt According to rcf)orts from the ;luthoriticS.

time on ;I ev;~St ;lnil coinf~fcs lirclwigxfc tc;mi altogcthcr alrout hOtHNf cv;~cuccs wcrc trans-
(lMncp;mtl;~ ;u~f Fsdcr;d dktrict fircfightcrh and ported to makeshift camps, sports antI hcitlth
firchrigdc5 from Mexico <i(y). togcthcr with ccntrcs and the klsifica of ~iu;~tl;~lupc, ;I rclicf
pcrsonncl from the f&l Croa, Mexican Inatitutc ccntre some 5 km away.;intl 7000 fktwcen StNfO

of Socid Security ;incl Govcrnnicnt I lospitalx. pcoplc sfxnt the ni@ inside the prcmiscs of the
wcrc rcxxing and trxnqxxting the injured to National Polytcchmc fnstitutc. Most of this oft
provi5ion;il rdicf ccntrcs ;lIltf 10 hOSpitillS. triition WiIS organird by voluntccrs. ~spccinlly
Altopcthcr 250 fircmcn wcrc working on the stutfcnt3. Mainly due to fxddicity in the ncws-
spot. After sonic time they were able to install paper reports. different sorts of collections for
jctsfxxyh to cool the storage tanks at fkmts in the food. clothing ;mtf footwe;lr. etc. startctf Within a

vicinitv. Not until the Gtuation at nciphbour- the few hours. The gocds wcrc clircctly transported
ing plant\ had hccn brought under control. wcrc to the makeshift rclicf ccntres.
the lirchrifack~ at>lc to vcnturs out into the Approximately 3SW) hot meals wcrc pro-
ground\ of the burning I_l(i dor;qc illltl tlistrihu- vi&d each tl;~y with an overall total of apfxox-
[ion ccntrc. whcrc they tricil to put out the iniately 17StMM).
rcniaining cool the untl;un;~gd
fire ;incl t;inks.
As the water pipes iincf sprinkler SyStclllS ilt [hc Primary medical care and transport of the
Site wcrtz clcstroycd ;y the lirst q~lo\ions and no injured from the site of the disaster
water pipe5 csistd m the viflagc. all the water For the first hour.
thcrc was total chaos at the
nccdcd for the lirc-lighting hxl hc hc brought to site of the and tliS;lstcr
all the rcscuc work was
the arc;1 hy lorrick. About 1000 ~ch lorries wcrc imf>roviscrl ;lnd without guidance ~UC to the Iitrgc
ofxrating on hfonday 19. The lirc w;i)r brought Sc:lfc of cvcnls. Attempts to S;IVC pcoplc from
Arturson- A LPG disaster

To allow for smooth tr;iii~),c)rt;ltioii id the in-

iurcd ;I liugc p;irking arc;1 for ;I~~INII~I~~~~ Ix-
limping 10 the various rclicf scrviccs w;i\ rrc;itctl
off the river 1.0s I<cmctlios. in thi* way. spcc pcrsonncl ~inishcd the iclcntific;1tion \rt)rk williin
was ;ilso rcscrvctl for w;i(cr-arrving lorries 2s 3, h. Only 15 out of the 1W corpc\ could IW
well ;is vcliicks xid hclicoyMcr5. i:cbr tr:inyort;t- itlcntilictl. Tlic authorities thcrcfr,rc dcdctl 11i;b1
tion purpox3 the cmcrgcncy scrviccs u~l 30.3 the burial of the hodics should hc m;rtk in ;I nwss
;unbul;lncc\ ilntl 5 hclicoptcrs in shuttle traflic. gr;ic. at ;I nearby coiickry in I.os (ilr;lCOiC\. the
Scvcii thouxind two hundrctl md thirty pcoldc d:ry ;iflcr the dkistcr.
nc~Acil mdicd help. Of thcw. 1070 of 1hcni
wcrc 30 scvcrclv iniurctl that tlicv hd to Ix
hqdaiizd. ;mci 025 of thchc hd s&x t hcrmal
injuries. The injured wcrc t;rkn to 33 tlilfcrcnl
hospit;ils, most of thcni Iocatal within Mcuico
Hospitals designated for the handling of
Transportation of corpses and identification severely burned patients
Duriy the lirst thy _W ccqscs wcrc found at the Out of the 730 pcoplc who wcrc (r;mq)ortccl (0
cik id the iliastcr (/*;S. II!). h&N of the hodics 3.1 diffcrcnt hospids, 1070 hatI to hc hospital-
\ccrc grcatlv chart-cd xd unrcco~iiiz~rl~lc. izcd. The most plausihk numhcr of inp;iticnt\
Attcnq~s at Sitlcntilication were mark cithcr at with scvcrc thermal injuries i5 625. This ligurc
rhc site or Ixkzr itI :I spccial morruary near San differs 3onicwh;d in rhffcrcnl reports for scbcrd
Juanico. lhc idcntilkxtion work W;IS primarily reasons. The lists of patients with hurnc av;iil;ihlc
mxlc both hy an cxprf in forensic mctlicinc and at tliffcrcnt hospitals wcrc not alwavs correct.
by rcl;itiva. A qkd;il group con\iating of ;I Sonic pMient5 wcrc sent honic or Ait to orher
forensic palhologisl. il prosecutor and sanit;iry hospit;rls without changing the lists. (onfusion trf
96 Burns 11987)Vol. 13340.2

Table /V. Distribution of pattents with thermal injuries to

different hospitals

Specral Patients 5 days after
burn beds admitted the
Hospitals {IlO.) Ino.) disaster

Magdalena de las Salinas 32 175 67

Hosp. de Traumat Lomas
Verdes 32 175 40
Centro Medico* 48 88 37
La Raza Hosp. 20 70 64
Hosp. 10 de Octubre* 20 60 40
Hosp. 20 de Noviembre 32 28 23
Hosp. Adolf0 Lopez
Mateus - 8 8
Hosp. General de Zona
No. 29 - 6 6
Hosp. General de Zona
No. 57 - 5 5
Hosp. Tacuba - 5 5
Hosp. General de Zona
No. 58 - 3 3
Hosp. lgmaris Zaragora - 2 2

Total number .- 625 300

hc)spit;ils h;rtl iiliti;illy 10 t;ilic c;irc olii very I;irgc

ntrnibcr of p;ilicnt\ ~roiii the dki\tcr. Iliis prob-
kin was. howcvcr. scrlvc~l cithcr by c;irlg di+
Illc tr;ttl\~~ort;ttit,rl ol ptictih \r.itli hi-ii5 u;is trihutiou idsonic pticiits 10 olhcr hcbpit;ils or by
soniclimcs ni;itk rlircctlv to the lin;il dcstinalioti; cdling up sxtr;l p_xs~mncl in I;irgc nunibcr\.
sc~tiictinics ;i1 lirst to ii l)rovision;ll burn carc Sonic of the iJig hc+Lils wcrc ahlc. within :I
Ixilil\ ;incl later 10 ii hurii unit Ior spkdiml short tiiiic. to c;ill iip :i grc;lt nunibcr of ldiysi-
c;irc. fhrcc ilab illlCF the ilisastcr Ihc 015 burn ckins ;inil nurses who wcrc well tr;iincd in the c;irc
paticrits were tlktributcd at 12 iliffcrcnt hospitals of traumxk tliscxscs. Ihcsc hospitds ilIsl> hild
with gocxl burn fkilitics (/k/)/t- IV). lhcsc hos- ;~dcqu;~te operating thcatrcs. wml rooms. CW. for
pitill! ilrC gcl~gr;lpllicilll~ hitu;itccl over ;I Idrgc ail tlic p;iticnts.
ilrC;l in ;I tlcnwly i~optthtcd pirt of Illcsiso City All ;bgc-groups were rcprcscntctl aiiion~ the
with hmvy. ollcn co,n~cstcd. trdtic. Due 10 this it burn p;iticnts. A qua1 nunihcr of chilclrcn kitI
was inyossiblc to visit more than ;I few of them susl;iinctl burns. fortunately most of thcni of
\hithin ;I rc;~son;ihlc t&c. In or&r to get iin smxllcr sxtcnt. ;iiid of only Ixirtiiil rhickncss
ovcrvicw ofthe gcner;d stmclarcl of c;m at these tlcpth (Fig. I-!). In gencrd thcrc wcrc rather few
hospitals. I visitctl four of thcnl (ndicil with very estcrisivc illlll tlccp burns and very few H hi)
st;lr> in Iirhk IL). All thsbc hospit;lls hxl :I ncctlcd trc;itnicnt with ;I respirator (kY<q. 15).
surprisin_cly iargc nurnhcr ol pcrsonncl. enough Prim;iry excision and grafting of n10\1 deep burns
spxc arid wcrc, in gcmml. well cquippxl. All kv;is pcrformcd. when the cstcnt w;is Icss thxn
burn piticnb wsrc isikirctl cithcr in privq ifi dx)ul 30 per cent of the tot;il ho+ surfxc :irea.
I;lrgc room or ;~lonc in cubicdid w:lrtls. The I:ivc d+s after the disaster only IO0 out of the
gcncral trc;itmcnt was ch;trxtcrizcil by Wilrnl hz.5 burn p;iticnts atlniiltcd wcrc still in burn
hunimi care with ;ill kinds of conifort for the units. Oric hundred xi~l forty kitI did (22 per
piticnts. lhc reiativcs ucrc :illowcd to visit ;iI all ttnt niort;ility rate) ;intl IS.S kitI hccn sent hcWc
times anal any without rclxtivss hxl ;I close friend or tr;ursferrctl to sm;lllcr hospit;lis.
at his klc helping him with kliiy prohlcms and A more ilctailcd tlcscription of the trcatnicnt
supporting him in dilfcrcnl W;I~S. Sornc of the ;ipplicil will hc reportccl frocii two burn units with
Arturson A LPG d~ssster

Table W. Boiling-liquid expanding-vapour explosions: 1951-84

Date State/Country Scene injuries

7 July 1951 Post Newark, New Jersev, Explosion and fire of 70 tanks at tankyard -Ill
19 July 1955 Ludwigshafen. Germany Explosion and fire of tank car -I2
29 July 1956 Amarillo. Texas. USA BLEVE of 3 oil tanks 20132
22 October 1965 Cottage Grove, -Oregon, USA BLEVE of LPG storage tank 12112
8 January 1957 Montreal, Canada Overflow butane. Sphere l/-
28 May 1959 McKittrict, California, USA Explosion in storage tanks -12
4 January 1966 Feyzin, France Explosion of tanks at refinery 18140
25 January 1969 Laurel, Mississippi, USA Derailment of train tank cars, explosion 2133
and fire
21 June1970 Crescent City, Illinois. USA Derailment and explosion of 9 tank cars -166
19 October 1971 Houston, Texas. USA Derailment of 18 tank cars, explosions and 1150
9 February 1972 Tewkesburv, Massachussetts, Collision tank vehicle with pipelines 2121
USA causing BLEVE of storage tank
30 March 1972 Rio de Janeiro, Brazil Explosion and BLEVE of aball tank 37153
5 July 1973 Kingman, Arizona, USA BLEVE of tank car caused bv exolosion 13196
and fire of LPG distribution plant
11 January 1974 West Saint Paul, Minnesota, Explosion of tank 4/6
12 February 1974 Oneonta. New York, USA Derailment and explosion of tank cars -125
17 April 1974 Bielefeld, Brackwcdde. Derailment of 36 tank cars, fire explosion --l
Germany and BLEVE
2 December 1974 Haarlemmermeer-Rijsenhout, Fire at car repair -/l
1 September 1975 Des Moines, Iowa, USA Derailment and rupture of tank cars -I3
31 August 1976 Gadsen, Alabama, USA Explosion tank vehicle and storage tanks 3128
during transshipmenl
26 November Belt, Montana, USA Derailment and explosion of several tank -I22
1976 cars
6 February 1977 Boynton Beach, Florida, USA BLEVE of LPG cylinders caused by --l
derailment of freight train
20 February 1977 Dallas. Texas, USA Derailment of tank cars -I1
23 April 1977 Long Island, New York, USA BLEVE cylinders on truck ll-
19 May 1977 Pocono Mountains, Leakage supply line caused explosion of van -11
Pennsylvania. USA
22 February 1978 Waverly, Tennessee, USA Derailment of several tank cars caused by 16143
broken wheel
11 July 1978 Los Alfaques, Spain BLEVEs of LPG storage tanks 102/140
30 May 1978 Texas CitY, Texas, USA 11 tanks exploded by unknown cause in 7110
45 min
16 May 1979 Vlaardingen, Holland Fire in van and explosion of gas -I2
8 September Paxton, Texas, USA Derailment of 33 train cars with chemicals, -18
1979 explosion and fire for 2.5 days
5 January 1980 Rotterdam, Holland Fire in bus station, LPG tank exploded -I1
8 January 1980 Erlecom, River Waal, Holland Collision of tanker Kombi 21 and Vessel -I2
Rodort 6. explosion
3 March 1980 Los Angeles, California, USA Overturn and explosion of tank vehicle 212
loaded with gasoline
26 November Oosterwolde, Holland Explosion of tank in car during assembly -/l
1980 Krcis Borken-Weseke. Fire and explosion of tank vehicle -12
13 July 1981 Beunigen, Holland Explosion of gas cylinder in house -/l
16 August 1981 Oldeholtpade, Wolvega, Explosion of gas tank in car by collision -11
1981 USA BLEVE of cvlinder in converted coach 13117
Arturson: A LPG disaster 99

Date State/Country Scene injuries

21 June 1982 Grootbroek, Holland Cyclist hit fatally by fragment of cylinder l/-
1982 Suez, Egypt Fire and explosion of gas pipeline 49
23 July 1984 Romeoville and Lemont, Explosion and fire at refinery 15l22
Illinois, USA
19 November San Juanico, Mexico BLEVEs of LPG storage tanks 550/7000

After treatment in the intensive care unit for 3 c, Last stage of the programme covering the
days all the iatrogenic problems were solved and period Y0 days to I year was aimed at the total
he recovered rapidly. recovery of normality, including follow-up of the
previous stages especially the medical care. In
Emergency organization and services this case the construction of a technical school
As soon as the magnitude of the disaster was will be included as well as a new health centre
obvious, that is. at 06.15 h. the so-called National and a kindergarten school.
Defence, DN-I II-E Plan was put into action,
This plan is operated by the army and includes a DISCUSSION
broad coordination of different institutions of the Catastrophes caused by accidents in handling
health sectors in case of a major disaster, for dangerous goods have increased in number dur-
instance an earthquake. ing the past few years (OECD. 1985). Out of 43
The Governor of the State of Mexico decided very severe industrial accidents during a IS-year
at this moment to appoint the State General period (IY70-8-t). 34 involved dangerous goods
Attorney to act as the executive coordinator in and 25 of these accidents were caused by noxious
assisting the civil population. When the Gover- or intlammable gases. The world consumption of
nor arrived at the disaster arca 4 h after the liquid petroleum gases has increased every year
accident hc commanded that the necessary meas- which is also reflcctcd in the statistics of accidents
ures be established according to five predetcr- (Tub/t* V).
mined criteria: During the 15-year period IY5.%Y about 20
BLEVEs occurred causing 60 deaths and around
I, Assistance to the affcctcd population.
ltto severe thermal injuries. During the IS-year
2. Supply of material and economic support.
period lY70+ more than 30 BLEVEs occurred
3. Establishment of a public opinion and
with WH) deaths and 22tMjsevere burns. The most
affected population communication system.
serious of these accidents was the Los Alfaques
4. Adoption of sound measures to prevent
disaster in Spain in 197X, when a road tanker ex-
similar catastrophes. and
5. Determination of responsibilities. ploded in a camping area and killed I02 people
and caused I40 severe burns (Arturson. 19x1).
All these actions were set in a plan to be ex-
ecuted in a specific time-frame: What causes a BLEVE?
a, Immediate action, first 15 days after the In a BLEVE two events occur simultaneously
disaster. This action included temporary evacua- resulting in an enormous release of energy. If the
tion from the area, rescue and transportation of container is punctured or torn apart in pieces at
the injured to hospitals. prevention of epidemics the same time as the liquid in the container has a
(vaccination. fumigation, environmental sanitii- temperature over its boiling point at normal
tion, medical supplies, etc.), removal of debris, atmospheric pressure, a BLEVE occurs. Since all
removal of the dead and their identification, legal flammable gases are stored and transported
and funeral assistance for the bereaved. under pressure, they can always contribute to a
b. Short-term action, lbY0 days after the dis- BLEVE. If the liquid is heated. for example by
aster, was aimed at totally restoring normal com- fire, it vaporizes. Mechanical causes can also
munity life. This action included environmental underly a BLEVE. Collision or puncturing are
sanitation. distribution of canned food, recon- two such possible mechanical causes. Flammable
struction of the affected houses and urban infra- liquids not under pressure cannot cause a
structure. BLEVE merely through collision. The container
100 Burns (1987) Vol. 13N0. 2

can of course break, but it does not explode. authorities had been unable to prevent a relative-
There do not appear to have been any accidents ly primitive settlement from pushing ahead to-
involving chilled gases in transport. One of the ward the depots. The shortest distance from the
first options for the tire-fighters within the Pemex rows of houses was reduced to 13Om. In each
depot was to cool the storage tanks with jet- little dwelling lived at least five people. There
sprays. were also numerous livestock such as horses, pigs
A BLEVE which involves large containers cre- and poultry.
ates a shock wave so powerful that people 75- Part of the area had houses built illegally,
IM)m away can be knocked down. Windows at a without proper regard to regulations and facili-
distance of several kilometres can be broken. ties. Thus the streets were bad and narrow. No
The tank involved in connection with a water pipes existed. All water needed for the
BLEVE becomes a dangerous projectile. The fire-fighting had to be brought to the area by
trajectory of the container is determined by the lorries. These circumstances. together with the
size of the tank. A tank containing 1Sm of tremendous energy release causing the enormous
condensed gas will fly at least 30%600m. some- heat. fires with black heavy smoke. shock waves
times up to Xo0m. In San Juanico a 4Sm3 tank and a huge number of fragments of pas cylinders
Hew I200 m. and spheres scattering all over the place. delayed
The very high temperature connected with the rescue work and thereby increased the sever-
BLEVE causes severe thermal injuries. The risk ity of the disaster.
zone for serious burns from small containers in a What were the reasons for the disaster and
BLEVE is a IO-IS m radius. Flammable liquids what preventive measures could have been
in barrels and containers filled with condensed taken? There were several additional factors con-
gas have a danger radius of 75 m. A tanker truck tributing to the disaster.
involved in a BLEVE entails a risk of serious The accident started early on Mo~lry nrorn-
burns within a ISOm radius, while railroad cars big. All the time during the filling of the tanks a
have a risk radius of about 2SOm (Arturson, ground level /lure WiIs burning in a device sub-
IYXI). merged in the ground for the burning-off of
A BLEVE generally produces a fireball upon CXCCSS gas. The Ilare was burning below ground
ignition. The actual sizes and duration of the level instead, a~ is usual, high above ground. It
fireballs in the San Juanico disaster are diflicult to WaS aISo pIaCed IOO CIOSC~IO lhe RUV de/~>~. The
estimatC. From the documentation available the s/rorfK witids preViiiling in the Villley Could easily
lirc looked more like a huge Ilare. ascending extinguish a Ilame above ground.
hundreds of mctres into the sky and with a At 05.30 h u rupnrre in WI X in (31.3 cm) JiBecling
diamCtCr ranging from 2trO to 3tM m. The tompcr- pipeline occurred above ground inside the Pcmcx
ature around the Ilare rcachcd about 1So0C. and tank area and a pressure fall was registered.
in the pcriphCral areas of the plant, as well as From the control room of the retinery an attempt
2ot)m into the habitations, between 300 and was made to lind the reason for the fall in press-
S(H)C. The videotape of the San Juanico accident ure, but without any result; nor was anybody able
reveals a BLEVE-type explosion with a fireball to get in contact with the six-man staff in the
lasting at ICast 90s. The fire was most likely fed depot that night. The reason for this was that live
by a huge release of LPG, indeed the largest of the workers were found iti various areas within
amount every involved in a BLEVE went up in the plant, dead and badly burned. The only worker
smoke at the Pcmex distribution plant. from the Pemex depot who survived ran out to
his car and drove to another depot nearby to
fetch help. Thus there was no contuct between rhe
Why such an enormous disaster? corm-ol room utrd the outside of the plum. Other
The San Juanico tragedy is one of the largest important facts are that the disfunce between rhe
disasters in industrial history and the most severe dvferent spheres und cylimlers wus IOO short. The
LPG accident ever to occur. The reason for the San Juanico plant did not huve uny PUS ulurms,
large number of fatalities and injuries is because nor any wuter sprinkler system. There was no
the built-up area, with a very high population emergency plun und no plum for muinrenance and
density. was situated close to the site. control in this large gas depot. The plants Health
When the plant. now struck by disaster, was and Safety Committee had severely criticized the
erected 25 years ago. the distance from the maintenance of some components of the plant in
habitations was about 3(M)m. Under pressure documents written on several occasions before
from the large number of people moving in, the the accident in November 19X4.
Arturson: A LPG disaster 101

What lessons can be learned from the vent damage from flying tanks or parts thereof.
tragedy of San Jurnico? In San Juanico a tank weighing about 30 tons
Even if we do not have all the facts it is possible landed 12OOm away from the plant. This is a new
to analyse the events and learn some important record. The previous distance considered to be
lessons. Some are so dramatic that a re- entirely safe was 800m. It is difficult to set a
evaluation of previous rules for distance and risk definite limit. therefore total safety cannot be
areas should be undertaken, especially when achieved. In connection with transport of LPG.
assessing the rules and regulations for LPG in- for example, there are risks that must be elimin-
stallation in various countries. The TN0 report ated in ways other than by setting distances
and analysis (1984) constitutes an excellent (Arturson. 1981).
source of information about the San Juanico
disaster in this respect (Pietersen and Huerta. 3. The disaster could have been even worse
1984). Of special interest from the technical point of
view are the very large number of BLEVEs that
1. Prevention occurred in the plant, the manner in which the
The status of an LPC distribution plant is com- droplets spread and the consequences they had.
pletely dependent on the allocation of sufficient When the first explosion was under way, there
resources for maintenance and daily inspection. was no possibility of preventing others, yet the
Advanced training of personnel is also necessary. two largest spheres, each with a volume of
in order to provide the greatest degree of secur- 2400 m, burned out without any BLEVE. There
ity. In order to discover a gas leak at an early are different theories as to why this happened.
stage there are now gas alarms, which should be However, if a BLEVE had occurred there during
placed in sufficient numbers inside and around the late morning, a large number of those 3OUO
the installation. They go off before the quantity people who were engaged in rescue and guarding
of gas approaches the explosion limit. would have been killed or severely injured. Fire-
An emergency plan. including a check-list for men tried to cool off the burning spheres with
emergency measures. names and telephone num- water. Photographic documentation shows how
bers, must be formulated. The plan presupposes the water vaporized immediately (Fig. 9). No one
that good preventive protection has been im- knows how close these spheres were to a
plemcntcd and that regular drills are held both BLEVE. Eyewitnesses reported that an explo-
with personnel and management from the com- sion took place in a cylindrical tank while firemen
pany and from the fire department and other were trying to cool it.
agcncics providing emergency help. If this is
carried out at least once a year, an updating is 4. Disaster medicine
ohtaincd of the plants measures to limit gas The most positive lessons are learned from the
Icakagc or prevent a flame from becoming a rescue and medical field. After the understand-
holocaust. able confusion caused by the chaos during the
first hours the different rescue efforts functioned
2. Safe distance well, working through various organizations,
Requirements regarding the safe distance be- physicians and other health specialists, police and
tween a major plant and local buildings involve military teams. There is no firebrigade in the
more than just the risk of fires spreading if gas world trained to control such a situation from the
begins to burn or if BLEVEs occur. It also beginning. The work done in the first few hours
includes the risk of damage by flying tanks or was particularly risky, considering the large num-
other fragments of plant equipment. Other en- ber of BEEVES that rocked the area. Traffic
vironmental factors, such as noise and odour. chaos and other obstacles initially prevented
also make the existence of a free zone around the effective rescue. Taking all this into account,
plant a priority. injured people who could be saved probably
The free area around the Pemex plant had received all possible help within the shortest
shrunk bit by bit: at the time of the accident only possible time-span.
l3Om separated the closest tanks from the local There are several important reasons for the
populations houses. The distance should have fact that the disaster, in spite of its enormous
been at least 4tW)m. In that case there would have dimensions, could be mastered in a satisfactory
been no danger of heat from the fireball or of way. A disaster plan operated by the army and
LPG droplets falling on clothing. The distance used mainly as an earthquake plan was put into
would, however, not have been sufficient to pre- action. From that time on large and complex
102 Burns (1987) Vol. 1YNo. 2

multidisciplinary rescue teams were functioning, given by Dr J. A. D. Settle in improving the

headed by a very competent chief commander. It English language in this article.
is interesting to notice that the total number of
personnel in these rescue teams was about the
same as the number of injured. It must have been
hard work to structure the rescue and restoration
measures. The prerequisites for a disaster-
Artur~~n G. (1981) The Los Alfaques Disaster: a
medicine success were there, however, namely
boiling-liquid expanding-vapour explosion. Burns 7,
enough resources in trained personnel and equip- 233.
ment, an enormous transport capacity and suf- OEDC. Compendium, (1985).
ficient hospital beds in special bum units within Pietetsen C. M. and Huerta S. C. (1984) Analysis off/w
short distances. LPG Incident in San Juan Ixhuatepec, Mexico City.
19 November 1984. The Hague: TNO.

The author acknowledges with thanks the help Paper accepted 14 November 1986.

Corrmpondcncr should br oddrcssrd fo: Dr G. Arturson. Burn Ccnlrc. University Hospital. Uppsda. Swcdcn.


Saturday 3 October 1987, Leuven, Belgium

The aim of this international interdisciplinary symposium is to

gather worldwide experience on this very difficult subject in order
to improve knowledge of treatment of inhalation injuries and
other pulmonary complications in major burns.
Speakers include: J. W. L. Davies (Glasgow), T. H. Prien
(Miinster), D. Traber (Galveston), C. H. Clark (Glasgow),
B. Vanacker (Leuven), W. Boeckx (Leuven), R. E. Spijker and
D. T. Mackie (Beverwijk), D. Herndon (Galveston), H. Klasen
(Groningen), C. H. Puchstein (Miinster) and W. L. Manson
For further information contact: Department of Anaesthesia,
Katholieke Universiteit Leuven, Gasthuisberg, Herestraat 49,
B-3000 Leuven, Belgium.