The Flixborough Disaster.

5/6/2014
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A brief look from de control system failures point of view.
The Flixborough Works of Nypro (UK) Ltd. was a plant designed to
produce 70,000 tons per year of Caprolactam, a basic raw material
for the production of Nylon.
In one almighty explosion the overall complex was demolished at
about 4:53 p.m, on Saturday June 1st. 1974. The explosion, of warlike
dimensions, was the equivalent of 15 tonnes of TNT and let 28 men
dead.
All of this, largely due to negligence on the use of control systems
and performing changes in the plant process design without take into
account the necessary modifications in the control system.
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The process where the accident occurred consisted of six reactors in
series. In these reactors Cyclohexane, highly flammable, was oxidized
with air to a mixture of Cyclohexanone and Cyclohexanol.
The reaction was slow and the conversion had to be kept low to avoid the
production of unwanted by-products, so the inventory in the plant was
large, about 400 tonnes.
The reaction took place in the liquid phase and each reactor used to
hold about 20 tonnes.
The reaction was highly exotermic. The temperature was controlled
trough evaporation of cyclohexane and the pressure by nitrogen
injection.
One of the reactors developed a crack and
was removed for repair. In order to maintain
production a temporary bypass pipe was
installed in its place.
The bypass (the only one available at the
plant) consisted of a dog-leg pipe from 20in
and this was used although the vessel
apertures were of 28-inch diameter.
Calculation showed that this size would be
adequate for the flow rates required,
however the pipe was not design by
personal professionally qualified or under
appropriate security settings.
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The pipe, which was supposed to be temporary, performed for two
months until a slight rise in pressure occurred. The nitrogen stock for
purging was found to be deficient, so there was insufficient provision for
the venting of off-gas as a method of pressure control.
A fresh delivery of Nitrogen was not expected before midnight. However,
the production was not stopped.
The slight rise in pressure perhaps did not cause damage in the reactors,
however it was enough to make the pipe to twist. The bending moment
was strong enough to tear the bellows and two 28 inch holes appeared in
the plant.
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As a result, a massive vapor cloud was formed by the escape of
cyclohexane from the holes of the ruptured.
It was estimated that about 3050 tonnes escaped in the 50 seconds that
elapsed before ignition occurred. The source of ignition was probably a
furnace some distance away.
In addition to this, the plant site contained excessively large inventories
of dangerous compounds. This included 330,000 gallons of cyclohexane,
66,000 gallons of naphtha, 11,000 gallons of toluene, 26,400 gallons of
benzene, and 450 gallons of gasoline.
The resulting explosion, one of the worst vapour cloud explosions that
has ever occurred, destroyed the oxidation unit and neighbouring units
and caused extensive damage to the rest of the site.
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In all 54 casualties, 28 workers were killed and a further 36 suffered
serious injuries. 18 of these fatalities occurred in the main control when
no one escaped from the control room before the ceiling collapsed.
In the surroundings, 1,821 houses and 167 shops and factories suffered
damage, adding more economic losses to the ones had from the plant.
Loss of life would have been substantially greater if the accident had
occurred on a weekday when the administrative offices were filled with
employees
In the UK, the government set up an Advisory Committee on Major
Hazards, which had a huge influence on accidents regulation and
dangerous compounds management.
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1. Performing changes in the plant process design without take into
account the necessary modifications in the control system. The
bypass was never closely inspected; it was attached to the process
and no pressure-testing was carried out on it in order to resettle new
set points. Due to the fact that there was not pressure control in the
bypass, this was easily damaged by the pressure increase.
2. Negligence and improper use of the existing control system. The
slight rise in pressure must have been controlled by nitrogen
injection. Despite the lack of this compound, they decided to continue
with the process instead of shutting down the plant. If the pressure had
been controlled, the accident had not been happened.
1. The importance of understanding and managing the potential
conflict of priorities between safety and production.
2. The importance not only of a good process control implemented in
the plant, but also of accepting and take in consideration the
information given by this.
3. The need to take steps to limit exposure of personnel to potential
hazards, for instance, protecting the control room and building it
blast-proof.
4. The importance of reducing the inventory, mainly when hazardous
chemical area used. If we set out to reduce inventories, the
resulting plants will be cheaper as well as safer.
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Kletz, Trevor A., Learning from accidents, 3rd edition, Butterworth-Heinemann,
Oxford, UK, 2001, Chapter 8.
Cox, S., Tait, R., Safety, Reliability and Risk Management: an integrated approach,
2nd edition, Butterworth-Heinemann, Oxford, UK, 1998, Chapter 16, p. 300-303.
Health and Safety Executive, The Flixborough Disaster : Report of the Court of
Inquiry, HMSO, ISBN 0113610750, 1975.
Kletz, Trevor A., What Went Wrong? Case Histories of Process Plant Disasters,
4th edition,Gulf, Houston, Texas, 1998, Sections 9 and12.
Video links:
https://www.youtube.com/watch?v=8A1xSCUtB-M
https://www.youtube.com/watch?v=tCsTlvCQmBY

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5/6/2014

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