Process Safety Management

(PSM)
Module 1 - Review of Industrial
Catastrophes Related to PSM

July, 2010
[Adapted from State of Ohio – Dept. of Commerce, Div. of Labor & Worker Safety]
 History of PSM Catastrophes
A series of catastrophic
releases of chemicals
leading to fires, explosions
and fatalities have occurred
in chemical processing
plants around the world
over the years.
These incidents lead to the
passage of the Process
Safety Management Rule in
1992.
 Purpose of the PSM Standard

 This standard contains requirements for preventing or

minimizing the consequences of catastrophic releases
of chemicals that are:
- Toxic,
– Reactive,
– Flammable,
– Explosive

 These releases may result in toxic, fire or explosion

hazards

 A number of catastrophic accidents have occurred

resulting in loss of life and great property damage.
 Ammonium Nitrate Explosion
Oppau, Germany – Sept. 21, 1921

Photo shows crater and destruction at plant following explosion. At 7:30 a.m. on September
21, 1921, two powerful explosions occurred at the BASF plant in Oppau, Germany.
Hazardous material: Ammonium sulfate & ammonium nitrate (50/50)
Facility type: fertilizer manufacturing
Deaths: 430-530 (differing numbers on reported fatalities)
 Ammonium Nitrate Explosion
Texas City, Texas – April 16, 1947

This aerial photograph , looking south over Monsanto Chemical Co., was taken about 30 minutes
following the blast of the ship S. S. GRANDCAMP during loading of ammonium nitrate. The
accident damaged more than 90% of the city's buildings and killed nearly 600 people.

Source: Fire Prevention And Engineering Bureau Of Texas

 Major PSM related incidents
1974 - 2001

Source: Wharton Risk Management and Decision Processes Center of the University of Pennsylvania.
 Seveso, Italy - 1976

The Seveso accident happened in 1976 at a chemical plant manufacturing pesticides and herbicides.
A dense vapor cloud containing tetrachlorodibenzoparadioxin (Dioxin) was released from a reactor,
used for the production of trichlorofenol.
Commonly known as dioxin, this was a poisonous and carcinogenic by-product of an uncontrolled
exothermic reaction. Although no immediate fatalities were reported, kilogram quantities of the
substance lethal to man even in microgram doses were widely dispersed which resulted in an
immediate contamination of some ten square miles of land and vegetation.
More than 600 people had to be evacuated from their homes and as many as 2,000 were treated for
dioxin poisoning. This lead to the European “Seveso Directive” to try to prevent similar incidents.
 Cyclohexane Release & Explosion
Flixborough, England – June 1, 1974

20” bypass piping fabricated on-site from

shop stock. This pipe ruptured and
released cyclohexane which exploded.
Source: UK Health and Safety Executive, Hazardous Installations Directorate

On June 1, 1974 the Nypro Co. site at Flixborough, England was severely damaged by a large
explosion. Twenty-eight workers were killed and a further 36 suffered injuries. It is recognized
that the number of casualties would have been more if the incident had occurred on a weekday,
as the main office block was not occupied. Offsite consequences resulted in fifty-three reported
injuries. Property in the surrounding area was damaged to a varying degree.
 Methyl Isocyanate Tank Rupture and Release
Bhopal, India – Dec. 2-3, 1984

Photo Source: Indian state government of Madhya Pradesh

Source: United Nations Environment Programme

On the night of December 2-3, 1984, a sudden release of about 30 metric tons of methyl isocyanate (MIC)
occurred at the Union Carbide pesticide plant at Bhopal, India. The accident was a result of poor safety
management practices, poor early warning systems, and the lack of community preparedness. The accident
led to the death of over 2,800 people (other estimates put the immediate death toll as high as 8000) living in
the vicinity and caused respiratory damage and eye damage to over 20,000 others. At least 200,000 people
fled Bhopal during the week after the accident. Estimates of the damage vary widely between $350 million to
as high as $3 billion.

Report – The Accident in Bhopal: Observations 20 years later

 Bhopal Aftermath

Water entered tank 610 in Bhopal flare tower with corroded and
foreground of picture reacting with missing section of pipe.
MIC and caused an uncontrolled Plant enclosed by fence in foreground.
release of a vapor cloud.
 Phillips 66 Houston Chemical Complex
Pasadena, Texas – Oct. 23, 1989

On October 23, 1989, at approximately 1:00 p.m., an explosion and fire ripped through the Phillips 66
Company Houston Chemical Complex in Pasadena, Texas. Twenty-three workers were killed and more than
130 were injured. Property damage was nearly three-quarters of a billion dollars. The accident resulted from
a release of extremely flammable process gases that occurred during regular maintenance operations on one
of the plant's polyethylene reactors. The evidence showed that more than 85,000 pounds of highly flammable
gases were released through an open valve. A vapor cloud formed and traveled rapidly through the
polyethylene plant. Within 90 to 120 seconds, the vapor cloud came into contact with an ignition source and
exploded with the force of 2.4 tons of TNT.

This event and the Bhopal disaster triggered the development of the PSM standard
 Summary of Chemical Accidents 1994-1999

Source:
Kleindorfer, P., Belke, J., Elliott, M., Lee, K., Lowe, R., Feldman, H.,"Accident Epidemiology & U.S. Chemical
Industry: Accident History & Worst-Case Data from RMP*Info", Risk Analysis, Vol.23, No 4, 2003, pp 865-881.
 Recent Accidents
It was the terrible accident at Flixborough that led to
major changes in the UK regulations and the Seveso
Italy catastrophe that led to the EU Seveso directive,
but both of these events had little impact on laws and
regulations in the USA.

The Bhopal tragedy reinforced by the 1989 Phillips

accident were needed before the USA the OSHA
Process Management Standard (PSM) and EPA Risk
Management Program (RMP) and industry trade
associations adopted the Canadian Responsible Care
program.

Accidents continue to occur even after the advent of

legislation aimed at curbing PSM related catastrophes.

The following slides outline three recent accidents, one

in Washington state.
 Ammonium Nitrate Explosion
Toulouse, France – September, 21 2001
Accident occurred exactly 80 years after the Oppau, Germany disaster!

A huge explosion ripped through AZF (Azote de France) fertilizer factory in an industrial zone on the outskirts of Toulouse,
southwest of France, at 10:15 am, Friday September 21, 2001. Immediately after the accident, 30 people were reported dead
The total number of injuries was said to be 2,442. More than 350 people were in the plant at the time (266 AZF employees and
100 subcontractors).
The explosion had occurred in a warehouse in which granular ammonium nitrate was stored flat, separated by partitions. The
amount is said to be between 200 to 300 metric tons of ammonium nitrate, which is used to make fertilizers. A spokesman for
the Interior Ministry in Paris ruled out a criminal attack, saying the explosion had been caused by an accident following an
"incident in the handling of products". The exact cause remains unknown.

Source: United Nations Environment Programme

BP American Refinery Explosion – Texas City, Texas
March 23, 2005

At approximately 1:20 p.m. on March 23, 2005, a series of explosions occurred at

the BP Texas City refinery during the restarting of a hydrocarbon isomerization unit.
Fifteen workers were killed and 180 others were injured. Many of the victims were
in or around work trailers located near an atmospheric vent stack. The explosions
occurred when a distillation tower flooded with hydrocarbons and was
overpressurized, causing a geyser-like release from the vent stack.

Link to Chemical Safety board final report

 Equilon Refinery Accident
November 25, 1998
 Equilon Oil Refinery –
Anacortes, Washington, now
owned by Shell Oil.

 Multiple Fatalities – 6 workers

killed
This was the worst worker fatality
incident in the history of Washington
State until the April, 2010 Tesoro Oil
Refinery explosion where seven workers
were killed. The Tesoro incident is
currently under investigation as of July,
2010

Link to short history of Equilon incident

 Events Leading Up to Incident

 On Tuesday, Nov. 24, 1998, high

winds cause power outage &
complete refinery shutdown

 A large vessel known as “Drum A”

was about 1 hour into a routine
charging cycle

 46,000 gallons of hot coke

hydrocarbons @ 900 F became
trapped in Drum “A” Coke Drum “A”
 Coke Producing Process
Heavy oil from crude oil processing
called vacuum residuum is heated and
pumped into an on-line coke drum. X
Heavy long-chain hydrocarbon
molecules are “cracked” under high
temperature and pressure. The lighter

Fractionation
hydrocarbons produced are carried to

Coke Drum
Y
the top of the drum and over to a
fractioning column for further
processing.

Since no reaction is 100%, the remain

long chain molecules combine to form a
high carbon material called “coke” which Z
ends up at the bottom of the coke drum XYZ
and must be removed at the end of the Coke
cycle before the process can be
repeated.

Coke is a heavy, dense black material

similar to a charcoal briquettes.
Vacuum Residuum
 Normal Coke Removal Operation
 Drum A is cooled first with steam followed by water.

 When acceptable temperatures are reached “safe work

permits” are issued and acknowledged by the coke cutting
contractor to unhead the drum.

 A high pressure water wand is lowered into the drum, and

coke is “cut” into chunks which flow out of the bottom of
Drum A into a pit below.

 The cooling steps are extremely important to ensure

the drum contents are adequately cooled prior to vessel
unheading.
 Drum A Schematic

In this situation workers needed to get

this coke out of the vessel. But, they
couldn’t move any steam or water
through the charge line (“DCU” line) to
cool the hot coke in the drum because
it was clogged with coke material that
cooled and hardened during the power
outage.
46,000 gallons
of hot coke

Heater “Gooseneck”
90 Degree
Elbow

Clogged Charge Line

 November 24th - During The Day

 Attempts are made to clear the DCU heater lines when

steam is restored around 10:00 AM.

 Operators are optimistic that steam made its way

through the heater and up into the bottom of the “A”
Drum.

 Instead, it is likely the pressure relief valves were lifting

and simply diverting steam to their blowdown system
 The “Night Orders”
 Unit foreman writes the night orders and
discusses at a 3 PM managers meeting on
November 24th.

 He says “…drum is cooling without water. Do not

put water into drum. Day shift will un-head
Wednesday morning.”

 Little activity during the night shift, drum sits idle.

 Several impromptu meetings held the next

morning between unit foreman and operators.

 Additional attempts made to clear the line into

the drum without success.
Actual temperature of hot coke unknown

This picture shows the approximate locations

of the available temperature indicators - one
TEMP at the gooseneck, one on the overhead vapor
line and one skin temperature sensor about a
third of the way up (above the level of
material in the drum). Employees had no way
Coke Drum

to actually determine the temperature of the

material inside the drum. By all accounts no
technical assistance was requested or
TEMP provided to even estimate the temperatures.
(SKIN) Later estimates were that it would take over
200 days for the coke to cool down to a safe
temperature.

On November 25, unit foreman and operators

TEMP
review available drum parameters and
conclude drum contents sufficiently cooled to
un-head.
Top head of drum was removed without
incident or indication of temperature of coke
at bottom of Drum A.
 The Tragic Results
 Using hydraulic
controls, employees
lower the bottom head.

 Coke spews out in a

360 degree fashion.

 Coke is still at auto-

ignition temperature.
Operating
HeadCart
 46,000 gallons dumps (hydraulics)

in about 6 seconds and Tugger

ignites enveloping six nd
2 Deck Operator

workers in flames.
Observers &
Standby Personnel
= employees
 The Cost
 Six Lives Lost
 Equipment Damage
 Lost Production
 DOSH Citations
 Third Party Lawsuits
 Worker Morale
 Standing in the community
DOSH citations ultimately cost the company 4 million dollars in the form of a settlement
agreement. Lost production and equipment damage estimated to be 10 to 20 million dollars.
Third party lawsuits totaled about 45 million dollars.
 Lessons Learned
 Management of Changes

 Emergency Preparedness

 Operator Training

 Procedural Development
MOC- It’s not enough to just have a system to manage changes. The system has to be alive
and well. At the first suggestion of a procedural change, the system should have been
 Permit
triggered. Audit yourSystems
own programs to ensure your managing changes (this includes
equipment, procedures even manpower issues)
Emergency Preparedness- Review your emergency operating procedures-do they cover all
the credible events. (PHA’s should cover this in detail and flush out the deficiencies)
Operator training - Is the training adequate. Do operators know the true hazards of the
process they’re operating. What about responding to upsets and unusual operating conditions.
Procedures-Are they current and accurate? Have they been effectively communicated to
operations?
Permit Systems- If you don’t have them, develop them. In this case the system was seriously
flawed. It was acknowledged that they thought drum parameters were adequate for
deheading when they really had no way of knowing the temperature.
 To Do List
 Audit your facilities !!
 Encourage participation from the trenches.
 Document deficiencies and establish target dates for
correction.
 Investigate the small stuff and fix it.
 Review operation procedures to ensure as many “what
if” scenarios are included.
 Ensure upper management is included in the decision-
making for unusual situations.
 Resources for More Information
 American Institute of Chemical Engineers
 International Institute of Ammonia Refrigeration
 The Chlorine Institute

 AcuSafe – Internet resource for safety & risk management

information

 DOSH Directive 24.25 – Chemical Facility Process Safety

Management NEP

 DOSH Directive 24.10 – Process Safety Management

 Your Own Industry Organization

Click here for videos of recent chemical

plant explosions and accidents U.S. Chemical Safety Board