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Mexico City

14th November 1984


Boiling liquid expanding vapour explosion (BLEVE) at LPG terminal. 500 killed.
Plant was being filled from refinery 400km away. Drop in pressure noticed in
control room & at pumping station. Pipe had ruptured.
Operators could not identify cause of pressure drop, as they had no gas
detection equipment. No emergency shutdown at that stage and release of
LPG continued for about 5-10 minutes, when gas cloud drifted to flare stack.
Causal analysis failure of overall basis for safety, including layout of plant
and emergency isolation features. Fire water system was disabled in initial
blast. Inadequate water spray systems did not keep remaining storage
vessels cool and failed to prevent spread of fire from vessel to vessel. Plant
had no gas detection system and therefore when isolation system was
initiated it was probably too late. Installation of more effective gas detection
and emergency isolation system could have averted incident. Traffic chaos as
residents tried to escape area hindered arrival of emergency services.
www.hse.gov.uk/comah/sragtech/casepemex84.htm

Brent Cross
Crane Collapse

20th June 1964


Material failure due to overloading. Fell onto coach 7 died.
Causal analysis - crane modified incorrectly
Human factors errors in manufacturing and maintaining
crane. Safe working load indicator inoperative. Lugs
manufactured to wrong spec, recognised during manufacture
but no check against drawings. Inspection revealed deviation
but inspector did not want to reject something passed by
parent company. Weekly inspection not carried out in
presence of operator and defective safe working load
indicator undetected. Records of inspection not completed by
inspector but probably by someone retrospectively with the
words good order against safe load indicator.

Markham Colliery
30th July 1973
Material failure to fatigue. Riding cage fell to pit
bottom. 18 died, 11 injured.
Causal analysis Braking system suffered from a
fatigue crack. Dirt in bearing braking rod resulted
in it being bent. Brake supposed to be failsafe.
Human factors Braking system had not been
inspected for about 10 years prior to accident.
Information on fatigue had been found at another
colliery but not passed on. Poor design of braking
system.

Flixborough Exposion
1st June 1974
Explosion caused by poor change management. 28 died.
Causal analysis failure of pipe leading to release of chemical
cloud that ignited.
Management deficiencies inadequate procedures involving
plant modifications. Engineers had no special expertise in high
pressure pipework & no proper drawings. Process with large
amount of hydrocarbons under pressure above flashpoint
installed in area that could expose many to severe hazard.
Human factors Primarily weak management. Individuals
overworked and liable to error. There was no mechanical
engineer on site of sufficient qualification, status or authority to
deal with complex and novel engineering problems and insist on
necessary measures being taken.

Littlebrook D Power
Station
9th January 1978
Material failure due to corrosion. Suspension cable on riding cage
failed. Hoist operated by contractor. 4 died.
Causal analysis Suspension cable broke at point weakened by
corrosion and devoid of lubricant. Corrosion happened over short
period so not detected. Water in shaft contained salt, adding to
corrosion. Safety system did not operate as clamping mechanisms
also corroded.
Human factors need for stringent maintenance standards not
recognised by staff or management. Statutory 6-monthly
inspections overdue. Weekly inspections failed to see defects.
Cage carrying more than recommended number of passengers.
Maintenance records not well kept and exact regime could not be
determined. Lack of clear policies and procedures for contractor.

BP Grangemouth
22nd March 1987
Explosion at hydrocracker unit. 1 killed.
Causal analysis air operated control valve on high-pressure separator
had been opened and closed manually. Liquid level fell and the valve
was opened, allowing remaining liquid in separator to drain away and for
high-pressure gas to break through into low-pressure separator and
vessel exploded.
Human factors control valve did not close automatically as the extralow trip on the high-pressure separator had been disconnected several
years earlier, operators assuming that these were no longer needed and
training reflected this. Operators did not trust main level control reading
and referred to a chart recorder for back up level reading; there was an
offset on this recorder which led them to assume the level in the highpressure separator was normal. Pressure relief had been designed for fire
relief not gas breakthrough. There was excessive reliance on operators
with inadequate appreciation of risks associated with gas breakthrough.

Allied Colloids
21st July 1992
Fire and explosion at raw materials warehouse. Fire spread to adjacent
warehouses and an external chemical drum store. Damage only.
Causal analysis one of the stores (intended for storing frost sensitive
products) had steam heated blowers turned on to dry out moisture. Heating
caused some kegs to rupture and spill powder on floor. The alarm was raised
when an employee thought it was smoke. After determining there was no
immediate hazard the MSDS was consulted for spillage arrangements and
cleanup devised. An exothermic reaction was caused when the kegs
contents mixed, leading to ignition, explosion and major fire.
Human factors The wrong classification of substances leading to storage
of incompatible chemicals together. Operator error (or failure of heating
system) meant heating was applied to store in addition to main warehouse.
Lack of appropriate spillage training and procedures. Lack of management
to ensure appropriate fire detection and fire fighting facilities fire brigade
not notified until 50 minutes after initial incident.

Windsor Castle
20th October 1992
Fire. Damage only.
Causal analysis heat of a high-powered spotlight
ignited a curtain. Fire spread quickly, venting itself
through the roof.
In the post-fire investigations it was discovered that
the rapid spread of fire was due to the lack of fire
stopping in cavities and roof voids, allowing the fire
free reign of the building. This matter was specifically
addressed in the restoration project, and fire breaks
were placed into the void to avoid a similar disaster
happening in future

Hickson & Welch


21st September 1992
Fire and explosion at factory batch still. 5 killed.
Causal analysis still base cleaned out for first time
in 30 years. Heat was applied to soften sludge.
Human factors decision to clean out still base with
no prior testing of residue and atmosphere in vessel.
Lack of communication between operatives &
management. Absence of policies & procedures. Failure
to blank off still base inlet before work started.
Presence of building materials in control room impeding
escape. Inward opening door in control room. Holes in
brickwork above false ceiling of protected route
allowing smoke ingress into toilets where one victim
was found. Inadequate permit to work systems

Port of Ramsgate
14th September 1994
Collapse of passenger walkway. 6 killed.
Causal analysis failure of a weld in a safety critical
support element. Design deficiencies.
Human factors no provision for ongoing
maintenance. Design deficiencies ignored by all
interested parties; important environmental
considerations not addressed. Lack of liaison between
classification society and designer/installer in Sweden.
Note Swedish design/install company refused to pay
fine.

Albright and Wilson


3rd October 1996
Fire and explosion at chemical storage site at
Avonmouth Damage only.
Causal analysis tanker believed to contain
epichlorohydrin off-loaded. Later found to contain
sodium chlorite, which reacts explosively with
epichlorohydrin.
Human factors No check of documentation
carried by driver which would have shown
contents of tanker. No preventative measures in
place to safeguard against addition of material
reactive with substance already in storage tank.
No raw material control/sampling or operating

Buncefield Oil Depot


11th December 2005
Fire and explosion. Damage only.
Causal analysis pumping of too much fuel
into storage vessel. Automatic level gauge
recorded unchanged level despite continued
pumping. Rich fuel vapour formed around
bund, ignited by unknown source.
Human factors reliance on automated
systems which did not activate. Failure of
COMAH procedures.

Imperial Sugar
7th February 2008
Dust explosion at sugar factory, Georgia. 14 killed.
Causal analysis sugar dust in enclosed conveyor
belt likely ignited by overheated bearing.
Human factors conveying equipment not deigned
or maintained to minimise release of sugar dust, nor
were there explosion relief vents. Dust could easily
accumulate, and inadequate housekeeping resulted in
considerable accumulation of combustible dust on
floors and elevated surfaces throughout packing
building. Previous sugar fires, similarly caused,
although none had caused explosion or major fire, did
not result in managers or workers recognising hazards
posed by sugar dust accumulation: danger had been

Banbury-Seer Green
11th December 1981
Rail crash caused by human failure. 3 killed.
Inexperienced signalman at Gerrards Cross miss-read or
failed to comprehend indication on signal diagram;
proceeded on assumption that locked signal lever was
frozen, and track circuit reading that line was unclear was
activated by fallen branch from passing stock train, which
in fact was stationary.
Driver of passenger train travelling too fast for conditions
after being specifically warned to take care and to travel
between 5-10mph. Estimated speed was 35mph. Was given
authorisation to pass danger signal- communication
between driver and signalman may have been ambiguous
and led to driver believing situation was not serious.
Driver and Guard of stock train failed to provide detonator
protection to rear of train, but may not have had time

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