Page 17 - Serious Incident Prevention How to Achieve and Sustain Accident-Free Operations in Your Plant or Company

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The Improvement Challenge 3

15 Oct. 1976 . . . Longview, Texas . . . Ethyl alcohol facility . . . ethylene
. . . $26.1M Property Damage (1991 Value) . . . 1 Dead

Failure of mixing nozzle led to jet of ethylene directed into courtyard
between control room, process structure and pipe rack. Ignition by heaters
45 m away. Control room destroyed. Pipe breakage led to ensuing fire
damage. 2

During my years as safety director, major changes occurred in the chemi-
cal industry. The Bhopal, India, incident in 1984 triggered numerous initia-
tives, including OSHA special emphasis programs targeted for chemical
facilities (ultimately leading to the OSHA Process Safety Management stan-
dard), the establishment of Chemical Manufacturers Association Responsible
Care initiatives, and more active EPA involvement in process safety issues.
Despite the many opportunities to learn from past incidents and additional reg-
ulatory actions, serious injuries continue to occur on a much-too-frequent
basis.

Serious Incidents of the Past

News reports of failures to sustain safe operations have a special impact
on individuals with responsibilities for preventing serious incidents.
Reactions to the initial reports can vary from disdain to empathy, depend-
ing upon the initial details provided.

After experiencing a major incident resulting in multiple fatalities
and property damage in excess of $200 million, a facility spokesper-
son made the following statement: “It’s been a relatively safe plant.
We’ve had numerous safety awards over the years. This is just dev-
astating.” 3
A press release following the occurrence of an explosion at another
company emphasized that OSHA had conducted seven facility in-
spections, all with zero violations, in the months preceding the inci-
dent. 4
A report from the National Transportation Safety Board indicated
that the crash of a commercial plane departing from a Houston air-
port was caused by failure to reinstall 47 screws in the plane’s tail
5
section following maintenance. One year later, another flight by the
airline required an emergency landing due to excessive vibration.