제 목 : £48m explosion and fire at Taxco's Milford Haven
일 자 : 1997년 10월
제공처 : SAFETY MANAGEMENT
£48m explosion and fire at Taxco's Milford Haven
site was caused by management failures, says HSE
The explosion at Texaco's Mil-ford Haven refinery in July 1994
was caused by 'a combination of management, equipment and
control systems frilures', according to a damning Health and
Safety Executive (HSE) report.
As well as blaming management frilings for the explosion at the
Texaco site, the report outlines 14 lessons for industry to learn
from the incident.
The accident happened at the Pembroke Cracking Company (PCC) at
the Milford Haven refinery on 24 July 1994 after a severe electrical
storm caused plant disturbances.
Lightning strike
------------------
The report concludes that the electrical storm and a lightning
strike that caused a fire an a distillation unit, 'though signif-
cant in initiating a plant upset, were not the cause of the
release and explosion that occurred five hours later. These
consequences resulted age the plant safely.'
At 7am on the day of the incident, the crude distillation unit
was shut down as a result of`a fire caused by a lightning strike.
During the course of the morning, all the PCC units were shut
down, with the exception of thef luidised catalytic cracking unit
(FCCU), which breaks down oil. During HSE's prosecution of
Texaco Limmited and Gulf Oil Limmited - joint owners of the
Pembroke Cracking Company - Swansea Crown Court heard that
flammable hydrocarbon liquid continued to be pumped into
process plant causing a flare drum of the FCCU to overfill.
Vapour cloud
-------------
The excess was vented into a discharge pipe which was known
to be corroded. The force of `the liquid an the pipe caused it
to break, releasing 20 tonnes of `hydrocarbons which formed a
drifting vapour cloud.
Some 110 metres from the flare drum, the cloud found an igni-
tron source causing an explosion which was heard up to 30 miles
away. 26 people working on the site were injured as a result of the
million worth of plant damage and damage to property in Milford
Haven town, two miles away.
Subsequently, Texaco and Shell were fined a total of £200,000 and
ordered to pay £143,700 costs by Swansea Crown Court in November 1996
following HSE's prosecution. The report slams the joint ven-
ture's safety management system pointing out that 'all the key ele-
ments of the incident have been seen and publicised before in
major accidents around to world.Those who are responsible
for operating hazardous plant must have systems in place that
bring to their attention the lessons of history.'
Furthermore, HSE's incide investigation 'demonstrated that
some of the company's crucial. safety management systems were
not adequately performing their function. The company was
unaware of` these defects in safety management systems because
its monitoring of their performance did not effectively
highlight the problems.
These conclusions form the first two of the report's overall
recommendations: That safety management systems should include
means of storing, retrieving and reviewing incident history
of similar plant; and that safety management systems should have a
component that moni-
component their own effectiveness. The report also makes recommenda-
tions regarding plant design, staff training and emergency planning.
In one final indictment of the causes of the accident, the report
says: 'In their attempts to restore the plant to normal operation on
the day, the company failed to take the necessary overall per-
spective, concentrating instead on the local, immediate symptoms
rather than looking for the underlying causes.'
Emergency planning
--------------------
The Health and Safety Executive(HSE) has produced a new infor-
mation sheet that details the lessons that have been learnt on
emergency planning from major accidents such as the Allied Col-
loids fire in 1992, Hickson and Welsh in 1992 and Associated
OCtel in 1994 Copies of Chemical Information Sheet No.1,
Recent Major Accidents : Lessons on Emergency Planning, are
available free from HSE Books on (Tel) 01787881165
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