Dr. S. Maruthappa – 4.12.

2009

Vice President, Safety Engineers Association of India.

President Institution Fire Engineers (UK) Chennai Br

Case study on Major Chemical Disasters-One day Symposium on

“Prevention of Industrial/Chemical Disasters at Bangaloru

Accidents in Chemical process industries constitute major threat to property and

population because of the magnitude. With the rapid development in science and
technology, several new innovations have come up and Chemical process industries deal
with thousands of new chemicals and several processes. Nevertheless, there are
innumerable causes that lead to disasters of major or minor in nature. So it would be of
great use if we could collate and categorize all the disasters, which occurred in the past,
so that the analysis results of these disasters are not only a useful lesson but also is
helpful to prevent their recurrence.
Disaster is an accident / event that can lead to tremendous destruction to the
environment, equipment, plant and people. The consequences of the chemical disaster in
the chemical toxic gas release and dispersion. The various accidents due to these
consequences are well known and gives prominent caution to prepare, practice and
amend the / Toxic Disaster Management plans for each and every hazardous process
industries and their material storage / Handling location. As per amended factory act in
1985 after Bhopal incidents. Each chemical industry aims to achieve totally zero
accidents potential. Therefore prevention, protection and suppression techniques have
been applied to reduce the probability disaster.
Some of the worst disasters of toxic releases have occurred in toxic chemicals like MIC,
Ammonia, and Chlorine cyclohexane etc. Some data’s on past planning in details which
explains the various stages of Disaster Management plan. The various stages of Disaster
Management are, Planning, Prevention, Preparedness, Response and Recovery.
We learn best through our own experiences in different phases of our life. Mistakes could
be catastrophic in a chemical plant, but it is a great opportunity to learn and design a
safer plant in the future. We must learn from previous incidents and develop design a
safer plant in the future. We must learn from previous incidents and develop new
procedures, practices and management systems.
These incidents have much learning which reveal many hidden facts about safety and
provide efficient tools for prevention of similar incidents in the future. In spite of these
lessons Indian industry continues to suffer.

Let us take up the case of major disasters that had happened in our country. Ammomia &
Chlorine are the toxic gases used in our industries, by many fertilizer plant and water
treatment, chlore alkali plants bleaching in paper industries
Let us take up the toxic gas release of Ammonia & Chlorine resulted in Fatal accidents.

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Dr. S. Maruthappa – 4.12.2009
BHOPAL TRAGEDY
If we see the history of worst chemical disasters, in industries the first thing that comes to
our memory is one at Bhopal
On the night of Dec. 2nd and 3rd, 1984, a Union Carbide plant in Bhopal, began leaking.
due to run-away reactions, temperature and pressure rise and the safety valve lifted to
the atmosphere. About 25-27 tons of the deadly gas methyl isocyanate spread through
the city of Bhopal.
Half a million people were exposed to the gas. Protective systems that should have
prevented or minimized discharge were out of service. Refrigeration system to cool the
reactor was down. Scrubbing system to absorb the released vapour was not immediately
available. Flare system to burn vapours getting past the scrubber was out of service.
Lessons we learned form Bhopal Tragedy
1)Reduce inventory of hazardous material (MIC)
2)Keep all the safety related equipment in order
3)Keep residential areas away from the plant
4) Proper Management

Another worst chemical disaster: that comes to our mind was;

Flixborough Disaster – A CASE SYUDY.

On 1st June 1974 the Nypro (UK) site at Flixborough was severely damaged by a large
explosion. Twenty-eight workers were killed and a further 36 suffered injuries. Offsite
consequences resulted in fifty-three reported injuries. Property in the surrounding area
was damaged to a varying degree.
A 20 inch bypass system ruptured, which may have been caused by a fire on a nearby 8
inch pipe. This resulted in the escape of a large quantity of cyclohexane. The
cyclohexane formed a flammable mixture and subsequently found a source of ignition. At
about 16:53 hours there was a massive vapour cloud explosion, which caused extensive
damage and started numerous fires on the site.
Eighteen fatalities occurred in the control room as a result of the windows shattering and
the collapse of the roof. No one escaped from the control room.
The fires burned for several days and after ten days those that still raged were
hampering the rescue work.

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Dr. S. Maruthappa – 4.12.2009
CASE STUDY 1
Mangalore Chemicals and Fertilizers Limited
There was a chemical accident in the Urea Plant at M/s. Mangalore Chemicals and
Fertilizers Limited, Panambur, Mangalore on 9.2.2000. An 8" dia high-pressure pipeline
housing a weldolet was connected between autoclave (urea reactor) of 108MT capacity
and the stripper to carry ammonium carbamate (Urea Solution). The pressure of pipe line
was of the order of 141kg/cm2 and the temperature of 180 C. The Solution had contained
29% of ammonia, 18% carbon di oxide and 32% of urea..
On 9th February 2000, a substantial quantity of ammonium carbamate solution leakage
was noticed at the weldolet joint of the pipeline. A maintenance manager along with two
operators, an engineer and two contract workmen were trying to plug the leakage by
providing a proper clamping. In the process, the weldolet joint gave way resulting in
sudden release of pressurized hot ammonium carbamate solution. As a result, the
personnel on the job were exposed to hot solution and toxic gas. Consequent to which, 8
persons were affected amongst them 2 died on the spot and the other two at the hospital
amounting to death of 4 persons including the maintenance manager and an engineer.
Investigation conducted by the department under the guidance of an expert committee
revealed that the weldolet used in the high pressure pipe line had high carbon content
which is not suggested for that kind of a process, maintenance Repair works was
undertaken on line even after noticing the hazardous solution which amounts of non
implementation of shutting down procedures. Further the high-pressure pipeline was not
subjected to hydrostatic test, ultrasonic tests and examinations as required under
relevant provisions of law for its soundness. The personnel who were on the job were not
wearing any personal protective equipment in addition to non-adherence to work to
permit system.
The expert committee investigated made the following recommendations to prevent any
incident in future.
The pipeline, connected equipment and the accessories must be subjected to hydrostatic
test as required under the relevant provision of law;
Weldolet must be subjected to 100% examination to detect corrosion and the soundness;
Maintenance/repair works shall not be undertaken on line, it shall be done only as per
standard maintenance procedure drawn up before hand;
Permit to work system shall be strictly adhered to along with suitable personal protective
equipment;
The on site emergency plan rehearsals shall be put to rigorous tests and practiced by
updating the weaknesses noticed from time to time;
The personnel including the contract workmen shall be put to rigorous training in handling
chemical emergencies particularly to bring a change in their attitudinal behaviour of over
confidence;

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Dr. S. Maruthappa – 4.12.2009

CASE STUDY 2
National Fertilisers Limited (NFL) at Panipat.
The Panipat tragedy: what went wrong?
Liquid ammonia burst out at the high pressure of 23 kg per sq cm, vaporising within
seconds to form suffocating clouds of deadly gas. This hit and choked to death
eleven persons and injured ten even as their colleagues sprung into action to diffuse
the gas with water sprays.
Liquid ammonia hit workers Coughing and choking, with lungs bursting, scrambled
for fresh air.
It is a Freak accident? This was the first major incident in any of the NFL plants. When
working on the ammonia pipelines. It was admitted to down to earth that for such work
"Need to take extra precautions to ensure that workers other than those doing the
hazardous task, are not present in the vicinity,"

CASE STUDY 3
The Chlorine Gas Leak at Jamshedpur
People of Jamshedpur were caught unaware when they were exposed to a dense, pale
green, pungent and poisonous gas, Chlorine. This gas had leaked from an unused
cylinder lying in the Tata Motor’s water treatment plant for the past 10 years. By the next
day, around 150 to 200 people had been hospitalised. The affected people also included
company employees and their family members. So far no deaths have been reported.
Later, in a statement, Tata Motors claimed that the chlorine leak has been plugged and
about 60 to 70 residents who reported breathing difficulty were admitted to the Tata
Motors hospital in Jamshedpur. The Chief Minister of Jharkahnd, Madhu Koda, alleged
that negligence by Tata Motors had led to the leakage of chlorine gas.

.As we know Chlorine gas has strong oxidising properties. Its toxicity irritates the
respiratory system. Severe exposure to the gas may cause pulmonary edema within 30
to 60 minutes and die´. There is no available prophylactic or post exposure therapy for
chlorine.

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Dr. S. Maruthappa – 4.12.2009
CASE STUDY 4
SPIC ammonia unit shut due to leakage problem
Southern Petrochemical Industries Corporation (SPIC) at Tuticorin has been shut down
due to a leakage in the pipeline. When the repair works were going on, a fatal accident
occurred on October 1, company sources told Business Line.
Sources said that after the southern grid failure last month, technical problems arose in
SPIC's plant, causing a leakage in the pipeline. The plant has been shut down since
September 27.
While trying to do the repair work, Mr Thiraviyaraj, Joint Manager (Operations) slipped
and fell. The gas mask he was wearing came off and he died of asphyxiation, it is learnt.
It is understood that it would take at least another 10 days to restart the plant.
None of the senior officials of the company was available for comment, and therefore, no
estimate of the value of loss in production is readily available.
Only last year, the Tuticorin plant of SPIC had been shut down between May 1 and June
22 for a "routine turnaround maintenance", which caused a loss of production of 1.03
lakh tonnes of urea.

CONCLUSIONS
We learn best through our own experiences in different phases of our life.
Mistakes could be catastrophic in a chemical plant, but it is a great opportunity to learn
and design a safer plant in the future.
We must learn from previous incidents and develop new procedures, practices and
management systems.
These incidents have much learning which reveal many hidden facts about safety and
provide efficient tools for prevention of similar incidents in the future.

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 Dr. S. Maruthappa – 4.12.2009
MAJOR CHEMICAL DISASTERS IN INDIA
Number of
Origin of accident Year Date Location Products involved
Evacuate
Deaths Injured
d

Explosion (warehouse) 1992 29.04 New Delhi Chemicals 43 20

Fire at a chemical store 1994 13.11 New Delhi Toxiccloud (chemicals) 500

Leakage 1984 03.12 Bhopal* Methyl isocyanate 2800 50 000 200 000

Britannia
Leakage 1989 05.05 Chlorine - 200 ..
Chowk

Leakage 1989 17.01 Bhatinda Ammonia - 500 ..

Leakage 1987 24.06 Bhopal Ammonia 200 000

leakage (transport
1997 21.01 Bhopal Ammonia 400
accident)

Leakage from a pipeline 1991 00.12 Calcutta Chlorine. 200

Leakage in an Ice Factory 1990 00.07 Lucknow Ammonia gas 200

Release 1985 14.05 Cochin Hexacyclo-pentadiene - 200 ..

Thane
Transport accident 1994 00.01 Chlorine gas 4 298
District

New
Transport accident 1991 00.01 Ammonia gas 1 150
Bombay

Maharash
Transport accident 1995 00.12 Ammonia gas 2 000
tra

1985 India Chlorine 1 150 -