Major industrial accidents

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1 Major industrial accidents Eric Marsden Learning from the gift of failure

2 Learning objectives These slides contain brief descriptions of a number of major industrial accidents together with the lessons learned from the investigation Learning from experience is a major source for safety improvement the gift of failure [B. Wilpert] We focus on accidents where the technical/technological contribution was significant many major accidents have causal factors that are primarily organizational (not the focus of this module) 2 / 26

3 Manufacturing gunpowder Gunpowder ( black powder ) is the oldest known explosive mixture of sulfur, charcoal, and potassium nitrate (saltpeter) invented in China in 9 th century Its production and storage are perhaps the first hazardous industrial activity 3 / 26

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6 Hazardous! A very hazardous product! many accidents during production, transport, storage Lessons learned: locate production and storage far from urbanized areas use multiple small facilities so that fewer workers killed in each explosion 6 / 26

7 7 / 26 Toulouse in 1680

8 A gunpowder factory in Toulouse 8 / 26

9 Île du Ramier, Toulouse 9 / 26

10 Grenelle (Paris): a large gunpowder factory with 2000 workers production pressure from revolutionary government: new production methods, manufacturing sites located near urban Paris new management increases production density 1794: 1000 people killed by explosion 10 / 26

11 1906: Courrières mine disaster (France) 1099 miners killed by a coal dust explosion worst industrial accident in French history Lessons learned: introduction of explosion barriers use of safety lamps creation of specially trained emergency teams 11 / 26

Titanic (1912) Queenstown Southampton Cherbourg British passenger liner that sank in the Atlantic after colliding with iceberg largest ship in the world at the time New York Titanic More than 1500

12 Titanic (1912) Queenstown Southampton Cherbourg British passenger liner that sank in the Atlantic after colliding with iceberg largest ship in the world at the time New York Titanic More than 1500 passengers and crew killed RMS Titanic Person Car Bus Airbus A380 Many died due to lack of sufficient lifeboats and lifeboats launched before they were full (706 people saved, 1200 person capacity) 12 / 26

Titanic: contributing factors Designer hubris ship described as practically unsinkable hull with 16 watertight compartments with remotely controllable doors in fact, water could flow in via the roof

13 Titanic: contributing factors Designer hubris ship described as practically unsinkable hull with 16 watertight compartments with remotely controllable doors in fact, water could flow in via the roof of each compartment Operator hubris ship did not slow down after being warned of presence of icebergs lifeboat capacity for only one third of ship s capacity (outdated regulations) inadequate training on evacuationh u b r i s : e x c e s s i v e p r i d e & c o n f i d e n c e 13 / 26

Titanic: contributing factors Badly built with low quality rivets iron rivets instead of steel in some sections many large ships under construction simultaneously: shortage of quality rivets pressure

14 Titanic: contributing factors Badly built with low quality rivets iron rivets instead of steel in some sections many large ships under construction simultaneously: shortage of quality rivets pressure to finish the ship on time Inadequate regulations very large ships: number of lifeboats required not a function of passenger capacity no requirement to build double hull Poor organization of emergency response 14 / 26

Titanic: lessons (re)learned Defence in depth prevention does not eliminate the need for mitigation Regulations must be updated to follow technological progress Improved emergency communication

15 Titanic: lessons (re)learned Defence in depth prevention does not eliminate the need for mitigation Regulations must be updated to follow technological progress Improved emergency communication creation of International Convention for the Safety of Life at Sea (SOLAS) 24-hour radio watch on ships, secondary power supply for radios Addition of double hulls Titanic had a double bottom but no side protection (heavy, expensive) 15 / 26

BLEVE at Feyzin (1966) Operator was sampling from a pressurized propane sphere (quality control) Mistake in order of valve opening leads to frozen valve and

16 BLEVE at Feyzin (1966) Operator was sampling from a pressurized propane sphere (quality control) Mistake in order of valve opening leads to frozen valve and propane leak Car passing on nearby road ignited cloud Leak from sampling line ignited BLEVE of the tank Domino effect to other nearby spheres and oil tanks 16 / 26

17 gas phase Fuels such as butane and propane are generally stored as pressurized liquids at a temperature higher than their boiling point. Typical pressures: 17 bar (1700 kpa). liquid phase 17 / 26

18 An initial event (often a jet fire) leads to heat impinging on the storage vessel. Pressure inside the tank increases. The liquid in the tank cools down the metal in the lower part of the vessel, but the upper part of the tank may become weaker due to heat. 17 / 26

19 The vessel fails, initially with only a small hole. Gas leaks from the hole, rapidly lowering the pressure inside the tank. The liquefied gas boils violently (its boiling point is pressure-dependent). 17 / 26

20 BLEVE: Boiling Liquid Expanding Vapour Explosion The boiling liquid vapourizes, increasing pressure in the vessel and ripping it open. A huge volume of gas is ejected into the atmosphere. Massive blast. If material is flammable, a huge fireball forms with massive heat radiation. 17 / 26

21 18 / 26 BLEVE after train derailment in Casselton, North Dakota (2013)

22 BLEVE: explanatory video Explanatory video: youtu.be/um0jtd_owlu 19 / 26

23 Feyzin: BLEVE effects 18 people killed, extensive damage 48 hours to put out blaze Missiles ejected 700 m away One 48 tonne element ejected 325 m 20 / 26

BLEVE at Feyzin: lessons Protect tanks from impinging heat insulation, sprinklers Site layout to avoid domino effects B1 B2 R1 R2 R3 R4 r1 Protect

toxique_tf+ R1 toxique_f+ r1 toxique_m+ B2 surpression_fai, toxique_m+ B1 toxique_m b1 Emprise HERAKLES SAFRAN Périmètre d'étude 100 200 Mètres Plan

24 BLEVE at Feyzin: lessons Protect tanks from impinging heat insulation, sprinklers Site layout to avoid domino effects B1 B2 R1 R2 R3 R4 r1 Protect firefighters 0 b1 Légende : Manage urbanization around high-hazard industrial sites toxique_tf+ R4 toxique_tf+ R3 toxique_tf+ R2 surpression_fai, toxique_tf+ R1 toxique_f+ r1 toxique_m+ B2 surpression_fai, toxique_m+ B1 toxique_m b1 Emprise HERAKLES SAFRAN Périmètre d'étude Mètres Plan de Prévention des Risques Technologiques Société HERAKLES SAFRAN à Toulouse (31) ZONAGE BRUT Affaire n : /2012 Réalisation : KTl Contrôle : Avn

25 Piper Alpha Watch the video: youtu.be/tpa_6oegc1s 22 / 26

26 Explosion at Caribbean Petroleum, Puerto Rico us csb safety video Filling blind, 2015 Watch the video: youtu.be/41qmajqxqio 23 / 26

27 Lac Mégantic derailment Canadian TSB animation on the 2013 derailment and fire Watch the video: youtu.be/wvmnsppc8zc 24 / 26

28 Image credits Gunpowder (slide 2): Mondebleu, public domain, via Wikimedia Commons Illustration of Courrières accident (slide 10): public domain, via Wikimedia Commons Titanic to scale (slide 11): CC BY-SA licence, via Wikimedia Commons For more free course materials on risk engineering, visit risk-engineering.org 25 / 26

some of the content unclear? Which parts were most useful to you? Your comments to feedback@risk-engineering.

29 Feedback welcome! This presentation is distributed under the terms of the Creative Commons Attribution Share Alike Was some of the content unclear? Which parts were most useful to you? Your comments to ( ) (Twitter) will help us to improve these course materials. Thanks! fb.me/riskengineering google.com/+riskengineeringorgcourseware For more free course materials on risk engineering, visit risk-engineering.org 26 / 26

Hazard Prevention Fires & Explosions. Buncefield, England, 2005

Hazard Prevention Fires & Explosions Buncefield, England, 2005 Brief Summary of Buncefield Incident 10 December 2005 Approx 17.00 Tank starts to receive product from pipeline Flow rate 550 m 3 /hr 11 December