1 Introduction :

A series of large explosions destroyed the Pacific Engineering Company plant

(PEPCON) in Henderson, Nevada, which manufactures ammonium perchlorate (AP)
for rocket fuel, beginning about 1151 PDT (1851 UT, Universal Time) on May 4, 1988
when workers in the facilitys batch house noticed a small fire. The workers
attempted to suppress the fire but it rapidly grew out of control. Soon after, three
massive explosions occurred that levelled the entire PEPCON facility and the
neighboring plant. The explosion was so powerful that it registered 3.2 on the Richter
scale on seismographs in California. The flames, which grew out of control, soon
engulfed PEPCONs massive stock of oxidizer, creating the largest domestic, non-
nuclear explosion in recorded history. The explosion affected structures in a 10-mile
radius, accrued damages estimated at $100 million [1], injured approximately 372
people, and ended the lives of 2 plant employees.
Several buildings including schools within or close to the industrial complex, in
which the PEPCON facility was located, experienced substantial structural and non-
structural damage. Damages to the surrounding community were surveyed and
interpreted as air blast over pressures versus distances, which allowed an estimate
of 1-kiloton nuclear free-air-burst for the equivalent explosion yield. This could be
reproduced by 250-tons TNT burst on the ground surface [2]. Several seismic
recordings in Las Vegas showed the greatest ground motion resulted from the air
blast wave passage, traveling at near acoustic speed.Of the 4000 tons of AP
apparently stored in and around the plant, it appears that about 1500 tons detonated
in the largest explosion

This case study summarises the causes and effects of the disaster and its
implications to industrial safety and risk analysis . It is divided as follows : section 2
gives a brief background to the disaster , section 3 details the incident including the
causes of the explosion through assessment reports and explores social and political
amplification of risk , section 4 provides details on the effect of the disaster both on
principles of industrial safety as well as risk analysis and suggests changes to
existing methods , section 5 gives a conclusion to the case study .

2 Background :

Ammonium perchlorate was the only product manufactured at the PEPCON

facility. The process of manufacturing uses several hazardous materials, including
anhydrous ammonia, hydrochloric acid, nitric acid, and various chlorate compounds.
These chemicals were shipped to the site primarily by rail and were present in bulk
quantities. In 1988, all NASA launch activities had been indefinitely halted by the
Challenger disaster on January 28, 1986 and subsequent investigative activities of
the Rogers Commission. The stand down froze PEPCONs AP shipping, yet had no
effect on PEPCONs AP contract orders with Space Shuttle Solid Rocket Booster
(SRB) manufacturer Morton Thiokol. Over the next 15 months following the
Challenger disaster, PEPCON had accumulated a stockpile of over 4,000 tons of the
oxidiser [1].

The AP involved in this explosion was being produced at Pepcon by a batch process
that included combining electrolytically produced sodium perchlorate and ammonium
chloride. The resulting AP was blended to customer specifications in several stages
involving blending, evaporative drying, and kiln drying using a steam heated batch
dryer. The dryer was located in a dual use building situated in the southwestern
quadrant of the facility.AP is normally shipped in large aluminium "tote" containers,
each holding
several thousand pounds of the white granular material. At the time of the explosion ,
Several hundred of the aluminium "totes" were stored in one area of the plant
awaiting shipment, along with a smaller number of fiber drums. Another storage area
at the plant contained several thousand 55-gallon plastic drums of the product
awaiting final blending . In addition to the chemicals at the plant, a 16-inch, high-
pressure (300
psi) natural gas transmission line ran underneath the plant and also supplied
the plant through a pressure reducing assembly.

The product (ammonium perchlorate) apparently had not been tested for mass(large
quantity) detonation prior to this fire and the precautions for ammonium perchlorate
are somewhat different depending on its particle
sizes. There are different Guide numbers, hazardous materials numbers, and
instructions for particle size under 45 microns and over 45 microns. A
firefighter approaching a vehicle or plant might well not know which
instructions to follow without detailed knowledge gained in pre-fire planning. The
product size range at the Henderson plant was from 90 microns to 400 microns with
most storage inventory averaging 200 microns [3]. For either particle size, the
firefighters are warned of the explosion
potential ,but bulk quantities as large as those normally stored in a plant or fixed site
are not covered by the manual . The Guidebook
did not make it clear enough that even large particle size ammonium perchlorate
can explode catastrophically.

According to the Occupational Safety and Health Administration (OSHA) of the U. S.

Department of Labor [4], AP is stable in pure form at normal temperatures, and the
threshold of decomposition is T>150o C, where the decomposition products are
Chlorine, Hydrogen Chloride, and Nitrogen Oxides. Moreover, it is powerful oxide
and can be explosive when contaminated with organic materials. Without
contamination, it can be as sensitive to shock as a typical class-A explosive, and it
may explode when involved in fire. The Pacific Engineering Production plant Pepcon
safety rules [5] prior to the explosions stated that Chlorates and Perchlorates,
themselves, will not burn, but when Mixed with wood, paper, cloth, or and other
organic matter, a highly flammable mixture is produced. Kerr McGee Chemical
corporation, another major AP producer, informed in a product bulletin [6] that AP is
stable below 65.5 C but decomposes exothermically at 275- and 470- C
respectively. This bulletin also indicates that pure AP will deflagrate at 349 C.

3 The Incident

3.1 Causes
When preparing AP for different customers, the practice at Pepcon was to load the
dryer and monitor the temperature at unspecified intervals. In between checking the
temperature, the dryer was left unattended for as long as 60 minutes [8]. Loading
and unloading the dryer created much dust that deposited on walls and layered on
horizontal surfaces of the structure. Housekeeping was casual and only performed
well when inspections were scheduled. Dust along with dirt from the floor was swept
and collected in poly drums for reprocessing [9]. Previous fire incidents in the batch
dryer building were initiated by various causes including; belt and break friction,
electrical sparks, undefined ignition of insulation on the dryer, overheated electrical
motors and welding or flame cutting sparks. Each of these fires either burned out or
were extinguished by water. The prime candidate for fire initiation on the day of the
explosions was from welding or flame cutting sparks. Most of the process buildings
on the site were constructed with steel framework to which fibreglass panels were
attached as siding and roof structure, The welding and flame cutting operation was
being done in close to the batch drying facility to repair damage caused by high
winds.

The fire is reported to have originated in or around a drying process

structure in the PEPCON plant between 1130 and 1140. The fire spread rapidly in
the fibreglass material, accelerated by ammonium perchlorate residue in the area. As
employees attempted to fight the fire
with hose-lines, the flames spread to 55-gallon plastic drums containing the
product that were stored next to the building. The fire continued to spread in the
stacks of filled 55-gallon plastic drums and created an extremely intense fireball. The
first of two major explosions then occurred in the drum storage area. The fire
continued to
spread and reached the storage area for the filled aluminium shipping
containers.This resulted in an even larger, second major explosion, approximately
four minutes later. Witnesses reported that this explosion created a
visible shock wave coming toward them across the ground. Very little fuel remained
after the second
explosion and the flame diminished rapidly except for the flame plume
created when the high pressure natural gas-line beneath the plant was
ruptured in one of the explosions. The gas-line was shut off at 1259 hours
by the gas company, at a valve about a mile away, eliminating the fuel for
this fire. A huge column of smoke rose from the plant and was carried downwind to
the east, over most of the residential and business areas of Henderson.
The smoke rose on the thermal column to an altitude of several thousand
feet and was spotted almost 100 miles away . Over
eight million pounds of the product were consumed in the fire and
explosions. A crater estimated at 15 feet deep and over 200 feet long was
left in the storage area. These two explosions were measured at
3.0 and 3.5 on the Richter scale at an observatory in California!

3.2 Disaster Response

Regulations and codes in force at the time of this explosion mandated that facilities
of combustible construction that store or process Class 4 oxidisers or explosives
required automatic fire detection and deluge sprinkler protection. In addition, each
facility was required to have an emergency plan and periodic training exercises
conducted in cooperation with local emergency organisations. At Pepcon, there was
none of the above. In fact the plant manager in charge of safety testified that he did
not recall any specific requirements with respect to storage and handling of AP. The
only fire alarm system at the plant was installed in the administration building and a
warehouse used for equipment assembly.

One of the major challenges faced by the Clark County Fire Department
in this incident was the management of information. The Department itself
had an urgent need for information on what had happened, was happening, and
could happen, in order to formulate a plan for operations and evacuation.
This required consultation with Fire Department personnel, plant
management, and experts from other agencies, under extremes of stress and
uncertainty.
While the process of planning and evaluation was taking place, there
were immediate and constant pressures from the local news media for details
and for information to broadcast to the public concerning the dangers and
actions that should be taken. The time required to gather and analyse
information resulted in some incorrect information being broadcast and
caused widespread public confusion. At the same time the national news
media were calling for more details. The Clark County Fire Department's
Public Information Officer responded and established an official source of
media information within an hour after the explosion.
Many residents were in near panic from rumours of several different
scenarios and dangers. Radio and television stations quickly devoted their
air time to the situation, but lacked a source of accurate information
during the first hour. Conflicting information was broadcast and, as a result, people in
the area reported confusion about whether to stay indoors
to avoid the smoke, evacuate, go to shelters, or take some other action.
The confusion extended to schools in the area, with some keeping children
inside and others sending students home. This emphasises the need to establish
working lines of communication with the news media.

4 Effects and implications

Both the PEPCON facility

and the neighbouring marshmallow plant had been destroyed in the explosions
prior to the arrival of fire fighters . The magnitude of the fire in the PEPCON facility
was beyond any fire suppression capability, and flames also were visible in
the rubble of the marshmallow plant. The only hydrants were in the
immediate area of the two involved plants, but there was no water supply
due to the loss of electrical power to the pumps. Recognising the danger
and futility of operations, no attempt was made to approach or to fight it . During the
overhaul process the remains of one plant employee were
located. No trace of the second victim was ever found.

4.1 Implications on risk analysis and assessment:

Based on the events of the PEPCON disaster , risk assessment and analysis must
include the following points [1] :

1. Land development decisions must consider risks of disasters.

The potential destructive power from an incident of this type needs to be evaluated in
land use decisions. The encroachment of residential and commercial development
into the area around the PEPCON plant contributed significantly to the injuries and
damage. The magnitude of the incident was much greater than had been
contemplated by urban planners or in pre- incident planning.
2. Need for triage outside hospitals: Large numbers of even minor injuries can
overwhelm a medical facility once inside.
Damage and injuries spread over a large area present unusual
challenges to emergency services, which are accustomed to incidents occurring in a
well-defined area. Large numbers of injured presented themselves to hospitals.
Triage centres need to be set up outside
hospitals to prevent overloads within the hospitals when the emergency medical
service cannot "capture" most victims at the site of the
i n c i d e n t . Fortunately in this incident there were not large numbers of seriously
injured waiting for assistance and relying on public agencies for treatment and
transportation. This potential needs to be considered more than it has been by local
communities.

3. Disaster mutual aid plans should be established, practiced, and kept

up to date.
The value of established mutual aid and interagency coordination
procedures was demonstrated once again. Many of these relationships came
as a result of Las Vegas's experience from major fires at the MGM Grand and
Hilton Hotels in 1980 and 1981. Communities should review their disaster
coordination plans and make sure they are up to date.

4. Hazardous materials incidents require size-up from a safe distance.

The need for a "stand back and assess the situation" strategy for some
hazardous materials incidents was well demonstrated. Had fire units
continued at full speed to the scene they probably would have been
destroyed.

5. Public information needs to be accurate and timely in a disaster.

In spite of a good relationship and established procedures, dealing
effectively with the media was a major problem in the early stages of the
incident. Misinformation by the media and rumours among the public created
near panic. Since the aftermath was not dangerous, it did not matter much
here whether people stayed indoors or not. But in an environmentally
serious incident, clear information should be given to the public as soon
as possible on what to do, even if that must be changed as conditions
change. The departments did a good job in providing information to the
media as it became available, but the media did not wait for good
information

7. The problem of assessing the immediate risk of hazardous materials

releases and products of combustion on the surrounding area needs
additional research and development.
Determining the risk of explosion and the risk of toxic fumes to the
public and to their firefighters can be extremely difficult. Some aspects
of risk assessment are too specialised to be covered in general hazardous
materials training courses. Special expertise needs to be called into play
when unusual or exotic hazardous materials are known to be present in a plant
or other location. The "worst case" situation needs to be anticipated.
Local fire departments also need to know who to call for quick assistance
in air sampling. Whatever the designated agency -- most often it is the state
environmental protection agency -- its personnel need to be equipped, trained,
and prepared to respond quickly to locations throughout their state if they
are to be of real assistance. (In the Nanticoke, Pennsylvania, chemical plant
fire, which occurred in March of 1987 and was also investigated by the U.S.
Fire Administration, getting assistance in air sampling was a major problem.)'
Sampling devices to identify gases need to be improved and put into
greater use. Improved methods need to be developed to make a more rapid
assessment of risk.

8. Industrial safety plans need to be established, kept up to date, and

understood by all employees.
The employees in the chemical plant averted a life loss catastrophe by
fleeing immediately after the first ("small') explosion and fireball system.
There was no alarm system and no evacuation plan, according to the
employees. Plants such as this should have explicit emergency plans, and all
employees should be trained.

9. Safety of the handicapped needs to be considered in high-hazard

occupancies.
One of the two fatalities in this fire was a wheelchair-bound employee
who obviously could not just run across the desert or jump in his car, as most
others did. Society now encourages and assists the handicapped to visit and
work in a much wider range of occupancies, which exposes them to new risks.
The handicapped need to be given realistic appraisal of their risks in a
potential emergency and their alternatives for escape or refuge, even though
the probability of the event occurring is low. Volunteers might be assigned
to handicapped individuals to help them to escape by car or truck, or by being
wheeled or carried to a safe distance. This may suffice for most emergencies,
but in the face of a catastrophic explosion the value of such assignments may
be moot.

4.2 Practices that should have been incorporated

Based upon the risk assessment and good engineering practices, the following
procedures and systems should have been incorporated at PEPCON [3]:
1. Better fire watch training
2. Better housekeeping
3. Ventilation system
4. Elimination of fuel sources
5. Sprinkler/deluge systems
6. Elimination of combustible building products
7. Alarm and fire sensing systems
8. Storage spacing and separation
9. Evacuation procedures
10. Standpipes that use gravity flow
These procedures would cost more initially, but the risk analysis that should precede
their implementation would clearly show the cost benefit of the fire protection
countermeasures and training.

5 Conclusion

The cast study shows that the most significant factors involving ignition in the plant
included (1) high sensitivity ofAP and other chlorate compounds,
(2) the quality of housekeeping, (3) possible open drums of product wastes, (4)
inadequate welding procedures in high hazard areas, and (5) the high wind
conditions.

Today, an accident in such a plant may be

less likely due to requirements imposed by
OSHA in its new 29 CFR 1910.119, &dquo;Process
Safety Management of Highly Hazardous
Chemicals.&dquo; A complete process safety
management program is now required including
various levels of training, operating
procedures, emergency response plan
and a process hazards analysis to identify
any unreasonable hazards.

Nevertheless this case study points to the need to integrate land-use planning with
disaster management. The situation whereby a dense urban development, the City
of Henderson surrounds existing major hazardous industrial facilities is a disaster
waiting to happen. Avoiding the juxtaposition of heavy resi- dential development and
major hazard facilities can minimize the off-site consequences of a technological
hazard event by reducing the number of citizens exposed to a hazard event [7]. The
need to maintain appropriate separation distances between industrial facilities and
residential development has to be emphasised. Another implication of the PEPCON
explosion for land- use planning and disaster management is the adverse effect of
locating sensitive land uses such as schools, day care cen- ters and hospitals close
to major hazardous facilities. The location of schools within the same complex as
PEPCON and other industrial facilities led to convergence as parents flocked to the
schools to pick up their children, and jammed the schools telephone lines in order to
obtain information about the welfare of the children.Also, Hendersons lack of
political jurisdiction over the island ignores the fact that lo- cal communities are the
ones most at risk and therefore should be involved in decisions that affect their lives.
The prevailing arrangement precludes the city emergency management per- sonnel
that could conceivably respond faster than the county unit from responding to any
hazard event on the island. The issue of prompt response is critical because in an
emergency a swift response may avert more dangerous consequences.
References

[1]J. Gordon Routley, "Fire and Explosions at Rocket Fuel Plant

Henderson, Nevada". United States Fire Administration - National Fire Data Center

[2] Reed, J. W. (1992),"Analysis of the Accidental Explosion at PEPCON,

Henderson, Nevada, on May 4, 1988". Propellants, Explosives, Pyrotechnics, 17:
8895. doi:10.1002/prep.19920170208

[3]Lambert, H. E., and N. J. Alvares. July 25, 2003. The PEPCON

DisasterCausative Factors and Potential Preventive and
Mitigative Measures. Fourth International Seminar Fire
and Exposion Hazards, Londonderry, Nothern Ireland, UK,
Spetember 8-12, 2003. U.S. Department of Energy, Lawrence
Livermore National Laboratory.

[4] Shepich, T.J. OSHA Hazards Information Bulletin, Classification of Ammonium

Perchlorate. Memorandum for Regional Administrators. Directorate of Technical
Support. September 25, 1991. http://www.osha.gov

[5] Fire Hazards and Fire Prevention. Safety Rules, Pacific Engineering and
Products CO. March 1, 1985.

[6]AP Bulletin 1111, Kerr-McGee Chemical CO. December 1983.

[7]Ibitayo, Olurominiyi O., Alvin Mushkatel, and K. David Pijawka. "Social and
political amplification of technological hazards: The case of the PEPCON explosion."
Journal of hazardous materials 114.1 (2004): 15-25.

[8] The PEPCON Disaster. A Report by The United Steelworkers of America. March
1989.

[9] Pepcon Workers Depositions. Case No. A264974. Department XIV-Docket T. In

the District Court, Clark
County, Nevada.