Incidents That Define Process Safety

Incidents that Define Process Safety......Page 5
Contents......Page 7
Foreword......Page 11
Acknowledgments......Page 13
1. INTRODUCTION......Page 15
2. BLIND OPERATIONS......Page 17
Major Airplane Crash at Tenerife Airport, Pan Am 1736/KLM 4805, March 27, 1977......Page 19
MD 83/Shorts 330 Crash at Paris Charles de Gaulle, France, May 25,2000......Page 24
Three Mile Island Nuclear Reactor Core Meltdown, Pennyslvania, March 28, 1979......Page 31
3. DESIGN......Page 37
Methy lsocyante Release, Bhopal, India, Dec. 3, 1984......Page 39
NASA Challenger Disaster, Florida, USA, January 28, 1986......Page 45
K-Boats - British Steam Powered Submarines in the First World War......Page 52
Loss of Boeing 747-1 31 TWA Flight 800, July 17, 1996......Page 59
Hindenburg Disaster, Lakehurst, NJ, USA, May 6, 1937......Page 66
4. EXTERNAL CAUSES......Page 71
Mexico City - Pemex LPG Terminal, November 19, 1984......Page 72
Earthquake at Tupras Refinery, Izmit, Turkey, August 17, 1999......Page 78
5. INSPECTION AND MAINTENANCE......Page 83
Fire and Explosion at Whiddy Island, Bantry Bay, Ireland, January 8,1979......Page 85
Sinking of the "Erika", December 12, 1999......Page 92
Flight TS 236 Loss of Fuel Over the Altlantic, August 24, 2001......Page 98
Fire on Board HMS Glagow, Newcastle-Upon-Tyne, UK, September 23, 1976......Page 105
HF Release at Marathon Oil Refinery, Texas City, USA, October 30, 1987......Page 115
Oil Refinery Explosion and Fire at Texaco Milford Haven, July 24, 1994......Page 119
FCCU Explosion at Total La Mede, France, November 9, 1992......Page 126
6. KNOWLEDGE AND TRAINING......Page 137
BLEVE at Elf Refinery, Feyzin, January 4, 1966......Page 139
Ammonium Nitrate - Dangerous Fertiliser......Page 147
Massive Dust Explosion at Courrieres Mine, France, March 10, 1906......Page 154
7. LACK OF HAZID (HAZard IDentification)......Page 163
Sinking of the Titanic, North Atlantic, April 15, 1912......Page 165
Sinking of the Petrobras P-36 Semi-Submersible Production Vessel, Roncador Field, Brazil, May 15, 2001......Page 174
Esso Longford Gas Plant Explosion, Australia, September 25, 1998......Page 181
Explosion at BP Grangemouth Hydrocracker, March 22, 1987......Page 189
Reactive Chemicals......Page 198
8. MANAGEMENT OF CHANGE......Page 207
Chernobyl, USSR - How a Safety Enhancement Experiment Turned into a World Scale Disaster, April 26, 1986......Page 209
Dutch State Mines Nypro Plant, Flixborough, UK, June 1, 1974......Page 216
9. NOT LEARNING FROM NEAR MISSES......Page 223
The Loss of the Space Shuttle "Columbia," Over Texas, USA, February 1,2003......Page 225
The Capsize of the Herald of Free Enterprise, Zebrugge, Belgium, March 6, 1987......Page 234
Air France Concorde Crash, Paris, France, July 25, 2000......Page 241
10. OPERATING PRACTICES......Page 247
The British R101 Airship Disaster, France, October 5, 1930......Page 249
Hydrocracker Effluent Pipe Rupture, Tosco, Avon Refinery, California, USA, January 21, 1997......Page 258
BP Texas City lsomerisation Unit Explosion, Texas, USA, March 23, 2005......Page 265
11. PERMIT TO WORK SYSTEMS......Page 279
Motiva Enterprises LLC, Delware, USA, July 17, 2001......Page 281
Phillips Pasadena, Texas, October 23, 1989......Page 286
Piper Alpha Platform, UK, North Sea, July 6, 1988......Page 291
Shell Port Edouard Herriot Depot, Lyon, France, June 2, 1987......Page 298
BP Grangemouth Flare Line Fire, Scotland, UK, March 13 1987......Page 301
12. EMERGENCY RESPONSE......Page 307
ICMESA Seveso Italy Toxic Cloud Release, July 10, 1976......Page 309
Sandoz SA Warehouse Fire, Bale, Switzerland, November 1,1986......Page 314
Tacoa Power Station Boil Over, Venezuela, December 19, 1982......Page 320
13. HUMAN FACTORS......Page 327
Exxon Valdez, Alaska, July 10, 1976......Page 328
Flash Airlines Boeing 737 Crash, Sharm El Sheikh, Egypt, January 3,2004......Page 334
GLOSSARY......Page 339
STANDARDS AND REGULATIONS REFERRED TO IN THIS BOOK......Page 341
INDEX......Page 343