Page 31 - Serious Incident Prevention How to Achieve and Sustain Accident-Free Operations in Your Plant or Company
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The Improvement Challenge 13
More effective process for valve lockout and isolation of lines & vessels. More effective compliance audit system Additional training of operating and maintenance personnel, in- cluding contractors Provide redundancy for oxygen analyzers and other critical instru- mentation Modify nitrogen control to ensure adequate nit
Valve mistakenly opened, which dumped reactor contents The failure of an oxygen analyzer that inaccurately indicated low oxygen and inadequate redun- dancy in the nitrogen control system.
Fatalities: 23 Property damage: $675 M Business interruption: $700 M OSHA settlement: $4 M Approximately 1,000 legal claims reportedly filed. Fatalities: 17 Property damage: $12 M Business interruption: $200 M
the leak went undetected for some time because weep holes designed to detect leakage through the lam- inated reactor layers were not ade- quately checked on routine basis. During a maintenance shutdown, a large flow of ethylene was re- leased from a high-density poly- ethylene reactor. An explosion occurred that destroyed two pro- ductio
1989 (33-35) 1990 (36, 37)
Texas USA Texas USA
