The 1989 Phillips disaster in Texas killed 23 workers, but says Becky Allen, the death toll

might have been greatly reduced if the US had learned from Flixborough.

In the cemetery of Flixborough church, North Lincolnshire, ringed by two circles of granite
setts, stands a small stone bearing the names of the 28 victims of the 1974 Nypro disaster. In
Pasadena, Texas is a similar, albeit grander, memorial. Into a polished granite wall embedded
in a tree-planted mound are inscribed another 23 names, workers killed in the Phillips
disaster.

Though they are separated by 15 years and several thousand miles, the two memorials are
connected, because if the lessons of Flixborough had been better learned in the US, fewer
people might have died at Phillips 66.

Just after lunch on 23 October 1989 a series of massive explosions devastated the Phillips 66
Company’s Houston Chemical Complex (HCC), totally destroying two polyethylene
production plants. Almost a kilometre away at HCC’s administration building, windows were
shattered and bricks torn from the walls.

The first blast occurred around 1pm. It was so powerful — investigators later estimated its
force as equivalent to 2.4 tonnes of TNT or a 3.5 magnitude earthquake — that local
volunteer fire chief JS Goyer at work at GATX petrol storage terminal almost 1.5km away,
thought his own plant had blown up.

Some 10 to 15 minutes after the first, a second blast occurred. And as each caused further
damage, one eye witness reported hearing 10 explosions that afternoon.

Twisted like pretzels

Firefighters struggled to contain the blaze but found water pressure on site inadequate. HCC
had no dedicated fire water system; firefighting supplies shared the same water system as the

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chemical process. With the system heavily damaged by the explosions, which had sheared off
local fire hydrants, water pressure was insufficient to tackle the blaze.

Trapped by the fire, more than 100 workers were rescued by US Coast Guard fireboats and
evacuated across the Houston Ship Canal. Others were not so lucky. In all, 23 workers died
and another 130 were injured, making it one of the worst US industrial accidents for decades.

According to the US Department of Labor (DoL) report into the disaster: “Debris from the
plant was found six miles away from the explosion site. Structural steel beams were twisted
like pretzels by the extreme heat generated by the fire.”

Within a week of the disaster, DoL’s Elizabeth Dole promised President George Bush that
the Occupational Safety and Health Administration (OSHA) would conduct a complete and
comprehensive investigation.

The agency’s report, published in April 1990, distilled the testimony of 46 witnesses and
thousands of pages of documents into a explanation of why the disaster occurred and what
the petrochemical industry must learn from it.

Settling legs

Operating since 1956, the 6.5 hectare Phillips 66 complex produced high-density
polyethylene (HDPE) for milk bottles and other containers. By 1989 it was producing 20% of
the US HDPE supply, and employed 950 staff and some 600 daily contractors.

The manufacturing process involved reacting ethylene gas dissolved in isobutane in long
pipes under high temperature and pressure. The resulting polyethylene came to rest in settling
legs, from where it was removed via low-level valves.

At the top of each settling leg, where it joined the reactor pipes, was a single Demco ball
valve. This was kept open during production to allow the polyethylene particles to settle into
the leg.
In the Phillips 66 reactor the settling legs often became clogged with plastic. Removing the
block involved closing the valve for the blocked leg and disassembling the leg while the
reaction continued and the product settled in the remaining legs. As a result, if the valve
opened during a clean-out operation there would be nothing to stop large amounts of
flammable gas escaping into the atmosphere.

The investigation discovered that at the time of the disaster, one of the settling legs was
undergoing regular maintenance to remove a solidified polyethylene blockage.

Under Phillips 66’s written procedures for the job — which was usually carried out by
contractors — staff prepared the leg for maintenance by isolating it from the main reactor
loop.

On Sunday 22 October, the day before the disaster, contractors from Fish Engineering began
work on three of the settling legs on Reactor 6. All had been prepared, witnesses told OSHA,
by Phillips 66 staff with valves closed and air hoses disconnected.

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After completing work on the first leg, on Monday they began work on the second, but by
lunch had failed to fully remove the polyethylene blockage lodged below the valve. Shortly
after returning from lunch another witness reported that one of the contractors was sent to the
control room to ask a Phillips 66 operator for help.

It was then that some 85,000 lbs of highly flammable gas escaped through the open valve. A
vapour cloud formed and rapidly moved downwind. Although the ignition source was not
identified, OSHA found several candidates, including welding and cutting operations, a gas-
fired catalyst activator with an open flame, and 11 vehicles parked near the plant office.

Triggered by the first blast, the second occurred in two 75,000-litre isobutane tanks, followed
25 to 45 minutes later by failure of a second polyethylene plant.

Wrong way

The FBI laboratory found that the valve was open at the time of the release because the air
hoses that supplied pressure to open or close it had been connected the wrong way round,
ensuring the valve would not shut.

This human error would not have been so disastrous had corporate safety procedures been
followed. These required backup protection in the form of a double valve or flange insert
when a process or chemical line in hydrocarbon service was opened. Local operating
procedures, however, ignored this requirement.

But this, OSHA found, was only one of a series of unsafe conditions at the plant: the valve’s
actuator mechanism had no lockout device; the air hose connectors on both the open and
closed side of the valve were identical, allowing the valve to be opened when the operator
might have intended to close it. Air supply valves for the actuator mechanism air hoses were
open, allowing the flow of air to rotate the valve when the hoses were connected; and the
valve lockout system for the maintenance operation was inadequate to prevent someone
deliberately or mistakenly opening the valve.

A series of other failings at the plant, while not the cause of the disaster, made it worse;
particularly the lack of a dedicated fire water system and siting office buildings too close to
large reactors and hydrocarbon storage vessels.

As at Nypro, the Phillips 66 blast destroyed the control room. “Overall, the US reaction to the
Flixborough event was minimal,” noted OSHA.

As a result — and because Phillips 66 failed to act on earlier reports by both company safety
personnel and safety consultants drawing attention to unsafe conditions at the plant — OSHA
fined Phillips 66 $4 million (£2.68 million at 1989 exchange rates). Fish Engineering was
fined $100,000 (£62,000).

Phillips 66’s failings

■ No process hazard analysis on the polyethylene plant; as a result serious safety issues
were ignored or overlooked.
■ Company safety procedures were not followed.

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Phillips 66’s failings

■ The valve on the settling leg was not designed to fail safe (closed).
■ No effective permit-to-work system for line operating, hot work or vehicle entry to areas
that might contain hazardous vapours.
■ Inadequate lockout/tagout procedures for equipment in hazardous areas.
■ No permanent combustible gas detection and alarm system.
■ Ignition sources sited near or downwind from large hydrocarbon stores, and ignition
sources were introduced into high-hazard areas without testing.
■ Inadequate firefighting capability.
■ Control rooms sited too near hazardous operations.

Repeat offenders

These was neither company’s first fine for safety violations. During the 10 years before the
disaster OSHA conducted 92 inspections at Phillips’ sites in the Dallas region, 24 of which
were in response to a major incident or fatal accident, and fined Phillips $52,595. Between
1972 and 1989 Fish Engineering was inspected 44 times, seven in response to a fatality or
major incident, and fined $12.760.

As well as the fines, the economic impact of the disaster is reckoned to have topped $1.4 bn
(£868 million), including $715.5 million (£443.3 million) in property damage and a further
$700 million (£434 million) as a result of disruption to business.

The effects of the disaster were felt throughout the industry, and within OSHA.

“The primary causes of the accident were failures in the management of safety systems at the
Houston Chemical Complex,” said its report. “[But] the investigation of the Phillips
catastrophe has caused OSHA to take stock and consider a strong cause of action to prevent
such disasters or mitigate their consequences.”

Following Phillips 66, OSHA accelerated work on its Process Safety Management standard
(legislation that had been announced but had yet to be enacted), revised the way it prioritised
work in the petrochemical sector, set up a catastrophe investigation protocol and — together
with the US Environmental Protection Agency — developed a joint strategy for investigating
chemical incidents.

And, as after Flixborough, politicians and regulators said it should never happen again.

“Accidents such as this can and must be prevented through better chemical process safety
management, better training of workers, and better emergency response procedures,” Dole
told Bush.

“[We] grieve the loss of these workers. We are committed to taking the necessary steps to
prevent such a loss of life in the future.”