Beruflich Dokumente
Kultur Dokumente
1994
Incident
Flixborough: 20 years on
Robin D Turney, Eutech Engineering Solutions Limited ICI Brunner House, Winnington, England
Introduction
Looking back at Flixborough after 20 years provides the process industries with important lessons which are still valid today. We have only to look at the photographs or videos to remind ourselves that this was the worst onshore disaster the process industries have known in the UK. Photographs 2.1, 2.2 & 2.3 show the devastation both on and off site. Many aspects of the incident were clear even before the court of inquiry started its work. It was quite clear from early on that the explosion, which killed 28 people, 18 of whom were in the control room, was caused by the escape and ignition of a massive cloud of cyclohexane. What events lead up to this? 4 outlet and reactor 6 inlet the temporary pipe had a dog-leg construction, see Figure 2.1. Once installed the temporary pipe was supported by scaffolding and was tested at operating pressure with nitrogen. All seemed to have gone well and the plant was returned to service on the 1 April (a quick turnaround considering the amount of work which had been carried out). On the 29 May it was noticed that the isolating valve on one of the vessels was leaking and the plant was once again shutdown for repair. The leak was repaired and the plant start-up commenced at 04.00 on the 1 June. The start-up seems to have been troublesome and it is likely that the pressure in the reactors rose to values between the normal value of 8.6 bar and the relief valve pressure of 11.3 bar. Exact details of this could not be determined since the control room with all the records was destroyed and all the relevant shift staff killed by the explosion.
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not be used out of line in the same pipe without adequate support. To quote the official report the instructions on this point are clear and explicit and there are helpful diagrams. It is plain that if the engineers at Nypro had read the Designers Guide they would have realised that their pipe and bellows assembly was unsafe. Similar advice was available in the relevant British Standard. The Specific Lessons of the official report state: The disaster was caused by the introduction into a well designed and constructed plant a modification which destroyed its integrity. The immediate lesson to be learned is that measures must be taken to ensure that the technical integrity of the plant is not violated. We recommend:
1)
that any modifications should be designed, constructed, tested and maintained to the same standards as the original plant...
Figure 2.2 Organisation Chart: Those reporting to the General Works Manager
Each of these sections is illustrated in the training module by two or more case studies. There are also a number of supplementary case studies covering situations where either incomplete information or errors in the way a modification was made lead to serious accidents. In addition, the modification control procedures from two leading companies are included.
Organisational change
The consideration of changes to manning and organisation leads us back to Flixborough. Changes in the organisation at Flixborough produced a situation where the engineering errors which caused the accident could arise. These were due to failure by the management to adequately respond to changes which were forced upon them. To understand these we need to appreciate the organisation of the site shown on Figure 2.2. Of these positions the only manager/engineer with professional mechanical engineering training was the Works Engineer (Chartered Mechanical Engineer). The Works
Engineer had, however, left early in 1974 and although attempts had been made to replace him these had been unsuccessful. Below the Works Engineer were a number of other engineering positions shown in Figure 2.3. None of these engineers had any professional engineering qualifications although the Services Engineer had an ONC in Electrical Engineering (a Further Education College qualification) and was acting as co-ordinator for the engineering function. The management recognised the weakness of this situation and had established links with the Assistant Chief Engineer of a National Coal Board subsidiary. This man was, however, very busy and only able to make sporadic visits to site. As we can see, in making a change to a part of the plant which required careful professional consideration, those on site were being asked to do work outside of the areas in which they were trained and competent They did not know what they did not know. This lead the court of inquiry to some further recommendations. That the training of engineers should be broadly based. Although it may well be that the occasion to use such knowledge will not arise in an acute form until an engineer has to take executive responsibilities it is impossible at the training stage to know who will achieve such a position. All engineers should,
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therefore, learn at least the elements of other branches of engineering than their own in both academic and practical training. Also it is essential that: a) persons given certain responsibilities are competent to carry out those responsibilities, b) top management has a clear knowledge and understanding of individuals and the magnitude and type of demand made upon them, and c) top management has a clear knowledge and understanding of the total workload placed on each individual in relation to his capacity. Even good and competent individuals have increased potential for errors of judgement when overworked. Also in times of crisis and extreme demand it is easy to overwork the willing horses some of whom may not know their own limitations. At a time when re-organisations are taking place in so many businesses the lessons outlined above are just as relevant today as they were in 1974.
References
The Flixborough Disaster. Report of the Court of Inquiry, HMSO 1975, ISBN 011 361075 0 Modifications: The Management of Change, IChemE slide training package 025, June 1994, R D Turney, S J Burge and S R Jones
The views expressed by the author are his own and do not necessarily reflect those of ICI or of any of its subsidiaries.