Still Going Wrong!: Case Histories of Process Plant Disasters and How They Could Have Been Avoided

front cover......Page 1
copyright......Page 5
table of contents......Page 6
Forethoughts......Page 8
Introduction......Page 10
ACKNOWLEDGMENT......Page 16
A NOTE ON NOMENCLATURE......Page 18
1.1 INADEQUATE PREPARATION ON A DISTANT PLANT......Page 22
1.2 PRECAUTIONS RELAXED TOO SOON......Page 23
1.3 FAILURE TO ISOLATE RESULTS IN A FIRE......Page 25
1.4 UNINTENTIONAL ISOLATION......Page 26
1.5 BAD PRACTICE AND POOR DETAILED DESIGN......Page 28
1.6 DISMANTLING......Page 29
1.7 COMMISSIONING......Page 32
1.9 CHANGES IN PROCEDURE......Page 33
1.10 DEAD-ENDS......Page 35
2.1 INCOMPLETE ISOLATION......Page 39
2.2 HAZARDOUS MATERIALS INTRODUCED......Page 40
2.3 WEAKNESSES IN PROTECTIVE EQUIPMENT......Page 41
2.4 POOR ANALYSIS OF ATMOSPHERE......Page 42
2.5 WHEN DOES A SPACE BECOME CONFINED?......Page 43
2.6 MY FIRST ENTRY AND A GASHOLDER EXPLOSION......Page 46
2.7 FAILURE OF A COMPLEX PROCEDURE......Page 49
2.8 AVOIDING THE NEED FOR ENTRY......Page 51
3. Changes to Processes and Plants......Page 53
3.1 CHANGES TO PROCESSES......Page 54
3.2 CHANGES TO PLANT EQUIPMENT......Page 58
3.3 GRADUAL CHANGES......Page 66
3.4 CHANGES MADE BECAUSE THE REASON FOR EQUIPMENT OR PROCEDURES HAS BEEN FORGOTTEN......Page 68
4. Changes in Organization......Page 71
4.1 AN INCIDENT AT AN ETHYLENE PLANT......Page 72
4.2 THE LONGFORD EXPLOSION......Page 75
4.3 OUTSOURCING......Page 78
4.4 MULTISKILLING AND DOWNSIZING......Page 79
4.5 ADMINISTRATIVE CONVENIENCE VERSUS GOOD SCIENCE......Page 80
4.6 THE CONTROL OF MANAGERIAL MODIFICATIONS......Page 81
5. Changing Procedures Instead of Designs......Page 84
5.1 MISLEADING VALVE LAYOUTS......Page 86
5.3 UNIMAGINATIVE THINKING......Page 89
5.4 JUST TELLING PEOPLE TO FOLLOW THE RULES......Page 90
5.5 DONÌT ASSEMBLE IT INCORRECTLY......Page 92
5.7 SHOULD IMPROVEMENTS TO PROCEDURES EVER BE THE FIRST CHOICE?......Page 95
6.1 RUST......Page 97
6.2 INSULATION......Page 101
6.3 BRITTLE FAILURE......Page 104
6.4 WRONG MATERIALS OF CONSTRUCTION......Page 105
6.5 CORROSION SENDS A COLUMN INTO ORBIT......Page 108
6.7 ANOTHER FAILURE TO INSPECT PIPEWORK......Page 109
6.8 HOW NOT TO WRITE AN ACCIDENT REPORT......Page 111
7.1 THE ALARM MUST BE FALSE......Page 113
7.2 A FAMILIAR ACCIDENT Û BUT NOT AS SIMPLE AS IT SEEMED......Page 114
7.4 THE LIMITATIONS OF INSTRUCTIONS......Page 116
7.5 THE LIMITATIONS OF INSTRUCTIONS AGAIN......Page 117
7.6 EMPTY PLANT THAT IS OUT OF USE......Page 118
7.7 A MINOR JOB FORGOTTEN -- UNTIL THERE WAS A LEAK......Page 119
7.8 DESIGN ERROR + CONSTRUCTION ERROR + OPERATING ERROR = SPILLAGE......Page 120
8.1 AN EXPLOSION IN A GAS-OIL TANK......Page 123
8.2 ANOTHER SORT OF EXPLOSION......Page 125
8.3 ONE + ONE = MORE THAN TWO......Page 126
8.4 "NEAR ENOUGH IS GOOD ENOUGH"......Page 127
8.5 ANOTHER EXPLOSION IGNITED BY A CARBON BED......Page 128
8.6 AN EXPLOSION IN AN ALTERNATIVE TO A CARBON BED......Page 129
8.7 ONLY A MINOR CHANGE......Page 130
8.8 AN EXPLOSION IN A PIPE......Page 131
8.9 A DUST EXPLOSION IN A DUCT......Page 133
8.10 OBVIOUS PRECAUTIONS NEGLECTED......Page 134
8.11 A DRUM EXPLOSION......Page 135
8.12 FOAM-OVER -- THE CINDERELLA OF THE OIL AND CHEMICAL INDUSTRIES......Page 136
9.1 WHAT IS MEANT BY SIMILAR?......Page 139
9.2 MORE SIMILAR ERRORS......Page 141
9.4 PACKAGED DEALS......Page 142
9.6 TOO MUCH COMMUNICATION......Page 144
9.7 NO ONE TOLD THE DESIGNERS......Page 145
10.1 ...THAT METALS CAN BURN......Page 147
10.3 ...THAT RUBBER AND PLASTICS ARE PERMEABLE......Page 149
10.5 ...WHAT LAY UNDERNEATH......Page 150
10.6 ...THE METHOD OF CONSTRUCTION......Page 151
10.7 ...MUCH ABOUT STATIC ELECTRICITY......Page 153
10.8 ...THAT A LITTLE CONTAMINATION CAN HAVE A BIG EFFECT......Page 156
10.9 ...THAT WE CANNOT GET A TIGHT SEAL BETWEEN THIN BOLTED SHEETS......Page 157
10.10 ...THAT UNFORESEEN SOURCES OF IGNITION ARE OFTEN PRESENT......Page 158
10.11 ...THAT KEEPING THE LETTER OF THE LAW IS NOT ENOUGH......Page 159
10.12 ...THE POWER OF COMPRESSED AIR......Page 161
11.1 INSTRUMENTS THAT CANNOT DO WHAT WE WANT THEM TO DO......Page 164
11.2 TOO LITTLE INSTRUMENTATION......Page 173
11.3 DIAGRAMS WERE NOT UP-TO-DATE......Page 174
11.4 AN AUTOMATIC RESTART FAILS TO RESTART......Page 175
12. Leaks......Page 177
12.1 LEAKS FROM TANKS......Page 178
12.2 LEAKS FROM LINED PIPES......Page 179
12.3 A LEAK THROUGH CLOSED VALVES......Page 180
12.4 A LEAK DUE TO SURGE PRESSURE......Page 182
12.5 LEAKS FROM SCREWED FITTINGS......Page 183
12.6 OTHER WEAK SPOTS IN PIPEWORK......Page 184
13.1 DELAYED MIXING......Page 187
13.3 LOWER TEMPERATURE MAY NOT MEAN LESS RISK......Page 190
13.4 FORGETTING TO ADD A REACTANT......Page 191
13.5 INADEQUATE TESTS......Page 193
13.7 AN UNSTABLE SUBSTANCE LEFT STANDING FOR TOO LONG......Page 194
14.1 WATER IN RELIEF VALVE TAILPIPES......Page 197
14.2 A JOURNEY IN A TIME MACHINE......Page 198
14.3 CHOKES IN FLARE STACKS......Page 200
14.4 OTHER EXPLOSIONS IN FLARE STACKS......Page 201
14.5 DESIGN POOR, PROTECTION NEGLECTED......Page 203
14.6 SEVERAL POOR SYSTEMS DO NOT MAKE A GOOD SYSTEM......Page 205
14.7 "FAILURES IN MANAGEMENT, EQUIPMENT, AND CONTROL SYSTEMS"......Page 209
14.8 CHANGES TO DESIGN AND OPERATIONS......Page 212
14.9 THE IRRELEVANCE OF BLAME......Page 213
15.1 AN EXPLOSION IN A COAL MINE......Page 215
15.2 MARINE ACCIDENTS......Page 216
15.3 HUMAN ERROR......Page 220
15.5 LOAD AND STRENGTH TOO CLOSE......Page 221
16.1 ACCIDENT INVESTIGATIONS OFTEN FIND ONLY A SINGLE CAUSE......Page 225
16.2 ACCIDENT INVESTIGATIONS ARE OFTEN SUPERFICIAL......Page 226
16.3 ACCIDENT INVESTIGATIONS LIST HUMAN ERROR AS A CAUSE......Page 227
16.5 ACCIDENT REPORTS LIST CAUSES THAT ARE DIFFICULT OR IMPOSSIBLE TO REMOVE......Page 228
16.6 WE CHANGE PROCEDURES RATHER THAN DESIGNS......Page 229
16.8 WE DO NOT LET OTHERS LEARN FROM OUR EXPERIENCE......Page 230
16.10 WE FORGET THE LESSONS LEARNED AND ALLOW THE ACCIDENT TO HAPPEN AGAIN......Page 231
SOME TIPS FOR ACCIDENT INVESTIGATORS......Page 237
AFTERTHOUGHTS......Page 238