book

What Went Wrong?

by Trevor Kletz

June 2009

Intermediate to advanced

640 pages

21h 3m

English

Elsevier Science

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1.1. Isolation1.2. Identification1.3. Removal of Hazards1.4. Procedures not Followed1.5. Quality of Maintenance1.6. A Personal Note
2.1. Startup Modifications2.2. Minor Modifications2.3. Modifications Made During Maintenance2.4. Temporary Modifications2.5. Sanctioned Modifications2.6. Process Modifications2.7. New Tools2.8. Organizational Changes2.9. Gradual Changes2.10. Modification Chains2.11. Modifications Made to Improve the Environment2.12. Control of Modifications
3.1. Introduction3.2. Accidents that Could be Prevented by Changing the Plant Design or Method of Working3.3. Accidents that Could be Prevented by Better Training
4.1. Labeling of Equipment4.2. Labeling of Instruments4.3. Labeling of Chemicals4.4. Labels not Understood

5.1. Overfilling5.2. Overpressuring5.3. Sucking In5.4. Explosions5.5. Floating-Roof Tanks5.6. Miscellaneous Incidents5.7. Fiberglass-Reinforced (FRP) Tanks
6.1. Stack Explosions6.2. Blocked Stacks6.3. Heat Radiation
7.1. Some Common Sources of Leaks7.2. Control of Leaks7.3. Leaks onto Water, Wet Ground, or Insulation7.4. Detection of Leaks7.5. Fugitive Emissions
8.1. Major Leaks8.2. Minor Leaks8.3. Other Leaks8.4. Safety in the Design of Plants Handling Liquefied Light Hydrocarbons
9.1. Pipe Failures9.1.1. Dead-Ends9.1.2. Poor Support9.1.3. Water Injection9.1.4. Bellows9.2. Pressure Vessel Failures
10.1. Centrifuges10.2. Pumps10.3. Air Coolers10.4. Relief Valves10.5. Heat Exchangers10.6. Cooling Towers10.7. Furnaces
11.1. Vessels not Freed from Hazardous Material11.2. Hazardous Materials Introduced11.3. Vessels not Isolated from Sources of Danger11.4. Unauthorized Entry11.5. Entry into Vessels with Irrespirable Atmospheres11.6. Rescue11.7. Analysis Of Vessel Atmosphere11.8. What is a Confined Space?11.9. Every Possible Error
12.1. Compressed Air12.2. Water12.3. Nitrogen [4,29]12.4. Heavy Oils (Including Heat Transfer Oils)
13.1. Overfilling13.2. Burst Hoses13.3. Fires and Explosions13.4. Liquefied Flammable Gases13.5. Compressed Air13.6. Tipping Up13.7. Emptying into or Filling from the Wrong Place13.8. Contact with Live Power Lines
14.1. Testing Should be Thorough14.2. All Protective Equipment should be Tested14.3. Testing Can be Overdone14.4. Protective Systems Should not Reset Themselves14.5. Trips Should not be Disarmed Without Authorization14.6. Instruments should Measure Directly What we Need to Know14.7. Trips are for Emergencies, not for Routine Use14.8. Tests may Find Faults14.9. Some Miscellaneous Incidents14.10. Some Accidents at Sea
15.1. Static Electricity from Flowing Liquids15.2. Static Electricity from Gas and Water Jets15.3. Static Electricity from Powders and Plastics15.4. Static Electricity from Clothing
16.1. Wrong Material Used16.2. Hydrogen Produced by Corrosion16.3. Other Effects of Corrosion16.4. Loss of Protective Coatings16.5. Some other Incidents Caused by Corrosion16.6. Fires16.7. Choosing Materials
17.1. Trapped Pressure17.2. Clearing Choked Lines17.3. Faulty Valve Positioning17.4. Responsibilities not Defined17.5. Communication Failures17.6. Work at Open Manholes17.7. One Line, Two Duties17.8. Inadvertent Isolation17.9. Incompatible Storage17.10. Maintenance: Is it Really Necessary?17.11. An Interlock Failure17.12. Emulsion Breaking17.13. Chimney Effects
18.1. Reverse Flow from a Product Receiver or Blowdown Line Back into the Plant18.2. Reverse Flow into Service Mains18.3. Reverse Flow Through Pumps18.4. Reverse Flow from Reactors18.5. Reverse Flow from Drains18.6. Other Deviations18.7. A Method for Foreseeing Deviations18.8. Some Pitfalls in Hazop18.9. Hazop of Batch Plants18.10. Hazop of Tank Trucks18.11. Hazop: Conclusions
19.1. Ammonia can Explode19.2. Hydraulic Pressure Tests can be Hazardous19.3. Diesel Engines can Ignite Leaks19.4. Carbon Dioxide can Ignite a Flammable Mixture19.5. Mists can Explode19.6. The Source of the Problem Lay Elsewhere
20.1. Hardware and Software Faults20.2. Treating the Computer as a Black Box20.3. Misjudging the way Operators will Respond20.4. Other Problems20.5. Unauthorized Interference20.6. New Applications20.7. Conclusions
21.1. Bhopal21.2. Other Examples of Inherently Safer Design21.3. User-Friendly Design
22.1. Lack of Knowledge22.2. Poor Mixing22.3. Contamination22.4. Reactions with Auxiliary Materials22.5. Poor Training or Procedures22.6. Use-by Dates
23.1. Inadequate Preparation on a Distant Plant23.2. Precautions Relaxed too Soon23.3. Failure to Isolate Results in a Fire23.4. Unintentional Isolation23.5. Bad Practice and Poor Detailed Design23.6. Dismantling23.7. Commissioning23.8. Other Hidden Hazards23.9. Changes in Procedure23.10. Dead-Ends
24.1. Incomplete Isolation24.2. Hazardous Materials Introduced24.3. Weaknesses in Protective Equipment24.4. Poor Analysis of Atmosphere24.5. When Does a Space Become Confined?24.6. My First Entry and a Gasholder Explosion24.7. Failure of a Complex Procedure24.8. Epidemics of Unsafe Entries
25.1. Changes to Processes25.2. Changes to Plant Equipment25.3. Gradual Changes25.4. Changes made Because the Reasons for Equipment or Procedures has Been Forgotten
26.1. An Incident at an Ethylene Plant26.2. The Longford Explosion26.3. The Texas City Explosion26.4. Outsourcing26.5. Multiskilling and Downsizing26.6. How to Lose your Reputation26.7. Administrative Convenience Versus Good Science26.8. The Control of Managerial Modifications26.9. Some Points a Guide Sheet Should Cover26.10. Afterthoughts
27.1. Misleading Valve Layouts27.2. Simple Redesign Overlooked27.3. Unimaginative Thinking27.4. Just Telling People to Follow the Rules27.5. Don't Assemble it Incorrectly27.6. Tighten Correctly or Remove the Need27.7. Should Improvements to Procedures Ever be the First Choice?
28.1. Rust28.2. Insulation28.3. Brittle Failure28.4. Wrong Materials of Construction28.5. Corrosion Sends a Column into Orbit28.6. Unexpected Corrosion28.7. Another Failure to Inspect Pipework28.8. How not to Write an Accident Report
29.1. The Alarm Must be False29.2. A Familiar Accident—But not as Simple as it Seemed29.3. More Reluctance to Believe the Alarm29.4. The Limitations of Instructions29.5. The Limitations of Instructions Again29.6. Empty Plant That is Out of Use29.7. A Minor Job Forgotten—Until there was a Leak29.8. Design Error + Construction Error + Operating Error = Spillage
30.1. An Explosion in a Gas-Oil Tank30.2. Another Sort of Explosion30.3. One + One = More than Two30.4. “Near Enough is Good Enough”30.5. Another Explosion Ignited by a Carbon Bed30.6. An Explosion in an Alternative to a Carbon Bed30.7. Only a Minor Change30.8. An Explosion in a Pipe30.9. A Dust Explosion in a Duct30.10. Obvious Precautions Neglected30.11. A Drum Explosion30.12. Foam-Over—The Cinderella of the Oil and Chemical Industries30.13. Explosions of Cold Gasoline in the Open Air30.14. The Inevitability of Ignition
31.1. What is Meant By Similar?31.3. Wrong Material Delivered31.4. Packaged Deals31.5. “Draftsmen's Delusions”31.6. Same Plant and Product, but no Communication31.7. A Failure at the Design/Construction Interface31.8. Failure of Communication Between Marketing and Technology31.9. Too Much Communication31.10. No One Told the Designers31.11. Conclusions
32.1. … That Metals Can Burn32.2. … That Aluminum is Dangerous When Wet32.3. … That Rubber and Plastics are Permeable32.4. …That Some Plastics can Absorb Process Materials and Swell32.5. … What Lay Underneath32.6. … The Method of Construction32.7. … Much about Static Electricity32.8. … That a Little Contamination can have a Big Effect32.9. … That we cannot get a Tight Seal between Thin Bolted Sheets32.10. … That Unforeseen Sources of Ignition are Often Present32.11. … That Keeping the Letter of the Law is not Enough32.12. … The Power of Compres Sed Air
33.1. Instruments that cannot do what we want them to do33.2. Too Little Instrumentation33.3. Diagrams were not up to Date33.4. An Automatic Restart Fails to Restart33.5. Procedures: An Essential Feature of Control Systems
34.1. Leaks from Tanks34.2. Leaks from Lined Pipes34.3. A Leak through Closed Valves34.4. A Leak caused by Surge Pressure34.5. Leaks from Screwed Fittings34.6. Other weak Spots in Pipework
35.1. Delayed Mixing35.2. Waiting Until after the Fourth Accident35.3. Lower Temperature may not mean less Risk35.4. Forgetting to add a Reactant35.5. Inadequate Tests35.6. A Heating Medium was too Hot35.7. An Unstable Substance Left Standing for too Long
36.1. Water in Relief Valve Tailpipes36.2. A Journey in a Time Machine36.3. Chokes in Flarestacks36.4. Other Explosions in Flarestacks36.5. Design Poor, Protection Neglected36.6. Several Poor Systems do not make a Good System36.7. “Failures in Management, Equipment, and Control Systems”36.8. Changes to Design and Operations36.9. The Irrelevance of Blame
37.1. An Explosion in a Coal Mine37.2. Marine Accidents37.3. Human Error37.4. Tests should be like Real Life37.5. Load and Strength too Close37.6. The Nineteenth Century
38.1. Accident Investigations often find only a Single Cause38.2. Accident Investigations are often Superficial38.3. Accident Investigations List Human Error as a Cause38.4. Accident Reports Look for People to Blame38.5. Accident Reports List Causes that are Difficult or Impossible to Remove38.6. We Change Procedures Rather than Designs38.7. We May go too Far38.8. We do not Let others Learn from our Experience38.9. We Read or Receive only Overviews38.10. We Forget the Les Sons Learned and Allow the Accident to Happen Again
39.1. Why did ICI, more so than other Companies, make these Changes?39.2. What Would Have Happened if ICI had not Existed?39.3. Why did ICI come to an End?39.4. What will we Miss in the Years to Come?
Primary CausesResponsibility
“It's Not Like That Today”
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Content preview from What Went Wrong?

Chapter 15. Static Electricity

We cannot carry on inspiration and make it consecutive. One day there is no electricity in the air, and the next the world bristles with sparks like a cat's back.—Ralph Waldo Emerson (1803-1882)

Static electricity (static for short) has been blamed for many fires and explosions, sometimes correctly. Sometimes, however, investigators have failed to find any other source of ignition. So they assume that it must have been static even though they are unable to show precisely how a static charge could have been formed and discharged.

A static charge is formed whenever two surfaces are in relative motion, for example, when a liquid flows past the walls of a pipeline, when liquid droplets or solid particles move through ...