Page 16 - Serious Incident Prevention How to Achieve and Sustain Accident-Free Operations in Your Plant or Company

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2 Serious Incident Prevention

known as “Eastman luck” were mitigated without significant consequences.
Having heard the stories of past near misses, I immediately thought of the
polyethylene unit when my apartment shook in the early morning of
February 25, 1971. It was the day “Eastman luck” ended. To researchers the
event is now simply a line item on a long list of worldwide vapor cloud ex-
plosions in the past half-century:

25 Feb. 1971 . . . Longview, Texas . . . Polyethylene facility . . . ethylene
(450 kg) . . . 0.5 tonnes TNT . . . 10% Yield . . . $17.5M Property Damage
(1991 Value) . . . 3 Dead

Leak from 12mm pipe connection to large pipe at 275 Mpa. Three
explosions occurred. Second was worse.
Some confinement by barricades and building around alleyway.
Explosion felt 9.6 km away. 1

To those directly involved, the magnitude of this 1971 incident was
sobering, and its occurrence, despite the vigilance of a committed manage-
ment team, made a lifelong impression. Such events raise doubts about
human capabilities to successfully control technology. With improved man-
agement processes, however, Eastman’s polyethylene manufacturing units
have now completed more than a quarter century without a major incident.
Rather than “war stories,” new employees now hear success stories of im-
provements in product quality, equipment reliability, customer satisfaction,
and safety.
After completing three years as a process improvement engineer, I
began a supervisory assignment with responsibilities for the polyethylene
warehousing and shipping functions. The assignment served as an intro-
duction to the challenges of sustaining manual handling operations in an in-
jury-free manner. The experience continually reinforced the inadequacy of
simply exhorting workers to “be more careful.” I quickly developed and
have continued to maintain a favorable bias towards minimizing hazards
through improving the process.
I was later transferred to Eastman’s polypropylene manufacturing facil-
ity as manager of the polypropylene processing unit. During this assign-
ment, another major incident occurred at the Texas Division site—further
reinforcing the need for more effective incident prevention processes. This
time, the incident involved an ethylene release from the ethyl alcohol man-
ufacturing unit: