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Flixborough Disaster

What?
The Flixborough disaster was
an explosion at a chemical plant close to
the village of Flixborough,England on 1
June 1974.
How?
The chemical works, owned by Nypro UK
(a joint venture between Dutch State
Mines (DSM) and the British National
Coal Board (NCB)) had originally
produced fertiliser from by-products of
the coke ovens of a nearby steelworks.
Since 1967, it had instead
produced caprolactam, a chemical used
in the manufacture of nylon 6. The
caprolactam was produced from
cyclohexanone. This was originally
produced by hydrogenation of phenol,
but in 1972 additional capacity was
added built to a DSM design in which hot
liquid cyclohexane was partially oxidised
by compressed air. The plant was
intended to produce 70,000 tpa (tons per
annum) of caprolactam but was reaching
a rate of only 47,000 tpa in early 1974.
Government controls on the price of
caprolactam put further financial
pressure on the plant.
It was a failure of this plant that led to
the disaster. A major leak of liquid from
the reactor circuit caused the rapid
formation of a large cloud of flammable
hydrocarbon. When this met
an ignition source (probably a furnace at
a nearby hydrogenproduction plant)
there was a massive fuel-air explosion.
The plant control room collapsed, killing
all 18 occupants. Nine other site workers
were killed, and a delivery driver died of
a heart attack in his cab. Fires were
started on-site which were still burning
10 days later.
Lessons

Plant where possible should be


designed so that failure does not
lead to disaster on a timescale too
short to permit corrective action.

Plant should be designed and run


to minimise the rate at which critical
management decisions arise
(particularly those in which
production and safety conflict).

Feedback within the management


structure should ensure that top
management understand the
responsibilities of individuals and can
ensure that their workload, capacity
and competence allow them to
effectively deal with those
responsibilities.

Bhopal Disaster
What?
The Bhopal disaster, also referred to as
the Bhopal gas tragedy, was a gas
leak incident in India, considered the
world's worst industrial disaster. It
occurred on the night of 23 December
1984 at the Union Carbide India
Limited (UCIL) pesticide plant in Bhopal,
Madhya Pradesh. Over 500,000 people
were exposed to methyl isocyanate
(MIC) gas and other chemicals. The toxic
substance made its way in and around
the shanty towns located near the plant.

How?

In November 1984, most of the safety


systems were not functioning and many
valves and lines were in poor condition.
In addition, several vent gas scrubbers
had been out of service as well as the
steam boiler, intended to clean the
pipes. Another issue was that Tank 610
contained 42 tons of MIC, more than
safety rules allowed for.[5] During the
night of 23 December 1984, water
entered a side pipe that was missing its
slip-blind plate and entered Tank E610
which contained 42 tons of MIC.
A runaway reaction started, which was
accelerated by contaminants, high
temperatures and other factors. The
reaction was sped up by the presence of
iron from corroding non-stainless steel
pipelines. The resulting exothermic

reaction increased the temperature


inside the tank to over 200 C (392 F)
and raised the pressure. This forced the
emergency venting of pressure from the
MIC holding tank, releasing a large
volume of toxic gases. About 30 metric
tons of methyl isocyanate (MIC) escaped
from the tank into the atmosphere in 45
to 60 minutes.

Piper Alpha Disaster (1988)


Oil was discovered at the Piper field in
1973 and was brought on stream three
years later. By 1980 the steel platform
was modified to also take gas and was

connected by pipeline to the Orkney


Islands.
The original modules on the structure
were carefully located, with the staff
quarters kept well away from the most
dangerous production parts of the
platform. But this safety feature was
diluted when the gas compression units
were installed next to the central control
room. Further dangers arose when
Occidental decided to keep the platform
producing oil and gas as it set about a
series of construction, maintenance and
upgrade works.
A lack of communication at a shift
change meant staff were not aware that
they should not use a key piece of
pipework which had been sealed with a
temporary cover and no safety valve.
Gas leaked out and ignited while
firewalls that would have resisted fire on
an oil platform failed to cope with the
ensuing gas explosion.