PSM Standards & Safety Incidents

Introduction

The development of Process Safety Management (PSM) standards in the USA has been significantly influenced by past incidents. Process safety incidents pose significant risks, and the lessons learned from these historical disasters have played a pivotal role in shaping and refining PSM standards. This article unveils five critical incidents that have had a profound impact on the evolution of PSM standards, emphasizing the importance of continued vigilance and improvement in process safety.

“If you think SAFETY is expensive, try having an accident.” Trevor Kletz

These words by Trevor Kletz, the “Father of Process Safety,” resonate even more strongly as we delve into incidents that have led to the development and enhancement of Process Safety Management standards. Committing to safety is not just a regulatory requirement but a crucial aspect of preventing catastrophic events.

West Fertilizer Explosion and Fire, 2013

In the 2013 West Fertilizer Explosion and Fire, a significant explosion occurred at a fertilizer plant in West, Texas. The incident resulted in 15 fatalities, including first responders, and over 160 injuries. The explosion, triggered by the ignition of ammonium nitrate, caused extensive damage to nearby structures, including homes and schools.

The aftermath of the explosion included significant property damage, estimated at $320 million. As of the latest available information, the estimated current value of the damages stands at $349 million. The explosion underscored the critical importance of robust safety measures and regular maintenance in industrial facilities, particularly those dealing with volatile substances. 

The incident also highlighted the need for comprehensive risk assessments, thorough leak detection systems, and stringent adherence to safety standards to prevent catastrophic events in refineries and similar industrial settings.

Tesoro Anacortes Refinery Fatal Explosion and Fire, 2010

In a tragic incident at Tesoro Anacortes Refinery in 2010, a fatal explosion and fire occurred during the startup of the naphtha hydrotreater unit. The incident resulted in the loss of seven lives and severe injuries to others. Investigations revealed that a heat exchanger ruptured, causing a massive release of highly flammable hydrocarbons that ignited, leading to the explosion and subsequent fire.

Key issues surrounding this incident included deficiencies in equipment integrity, inadequate inspection and testing practices, shortcomings in process hazard analysis (PHA), and deficiencies in emergency response measures. The incident emphasized the critical need for robust inspection and testing protocols, thorough process hazard analyses, and effective emergency response systems to prevent similar incidents in the future.

BP Texas City Refinery Fire and Explosion, 2005

On March 23, 2005, the BP Texas City refinery suffered a devastating series of explosions during the restart of the hydrocarbon isomerization unit, resulting in 15 fatalities and 180 injuries. The incident was triggered by a flooding distillation tower, causing a geyser-like release from the vent stack and impacting nearby work trailers.

The causes of this tragic event were rooted in a lack of effective oversight, with the BP Group Board failing to adequately supervise safety culture and major accident prevention programs. Senior executives displayed inadequacies, emphasizing personal safety over process safety and providing insufficient resources. Managerial shortcomings included the absence of a reporting and learning culture, neglect of good practice design, and a failure to consider human factors in training and staffing.

Lessons learned from this catastrophe highlight the critical need to strengthen safety culture by balancing metrics, implementing effective oversight mechanisms, and prioritizing major hazard risks. Leadership commitment is paramount, requiring a focus on both personal and process safety, along with active involvement in safety culture initiatives. 

Encouraging a reporting and learning culture, conducting thorough investigations, and integrating human factor considerations into all aspects of an operation are imperative for preventing such incidents in the future. The continuous improvement of comprehensive process safety management remains crucial in mitigating major hazard risks within the petrochemical industry.

Phillips 66 Explosion, 1989

On October 23, 1989, Phillips 66’s chemical complex in Pasadena, near Houston, experienced a devastating chemical release on its polyethylene plant, leading to a catastrophic sequence of events. At around 1:00 PM, a flammable vapor cloud formed, eventually igniting and causing a massive vapor cloud explosion. Subsequent explosions and fires exacerbated the situation, resulting in severe consequences. The incident claimed 23 lives, with between 130 and 300 people sustaining injuries. The chemical complex also sustained extensive damage. 

The tragedy unfolded as scheduled maintenance work was underway to clear three of the six settling legs on a reactor. Despite established procedures for isolating the leg to be worked on, a portion of the plug remained lodged in the pipework during the clearing of the No. 2 settling leg. Seeking assistance in the control room, a team member witnessed the release occurring approximately two minutes later, followed by the ignition of the vapor cloud.

Key issues contributing to this tragic incident encompassed deficiencies in maintenance procedures, shortcomings in leak/gas detection systems, inadequacies in plant layout design, flaws in permit-to-work systems, gaps in active/passive fire protection measures, insufficient warning signs, and challenges in emergency response and spill control mechanisms. 

This incident underscored the imperative for robust maintenance protocols, effective leak detection, comprehensive plant layout planning, and enhanced emergency response capabilities in chemical complexes to prevent and mitigate such catastrophic events.

Bhopal Toxic Release, 1984

In the early hours of December 3, 1984, a catastrophic incident unfolded at a chemical plant involving the release of highly toxic methyl isocyanate (MIC). The disaster originated from a relief valve on a storage tank lifting, releasing a cloud of MIC gas that drifted onto nearby housing. The calamity had its precursors, as an operator had observed higher-than-normal pressure in the storage tank on December 2, accompanied by a MIC leak near the vent gas scrubber. Subsequent reports detailed a MIC release in the process area, with rapidly rising pressure inside the tank.

Efforts to mitigate the situation, including attempts to activate the vent gas scrubber, were hampered as it was not in operational mode. The unfolding events led to a series of devastating consequences, resulting in the death of approximately 2,000 people within a short period and causing tens of thousands of injuries. The severity of the incident, marked by the uncertainty surrounding the gas involved and its effects, rendered it the worst recorded within the chemical industry. Its impact made it one of the most significant process safety incidents that helped shape PSM standards in the USAand worldwide.

The key issues contributing to this tragic event encompassed plant modification/change procedures, shortcomings in reaction/product testing, design code inadequacies related to plant infrastructure, deficiencies in maintenance procedures, and challenges in emergency response and spill control measures. This incident underscored the critical importance of rigorous safety protocols, comprehensive testing, and robust emergency response mechanisms in chemical plants to prevent and mitigate catastrophic events.

Here is a table summary to distill the key learnings from these incidents:

PSM Standards & Safety Incidents chart

IncidentImpactCausesLessons Learned
West Fertilizer Explosion and Fire, 201315 Fatalities, Over 160 Injuries ($320 Million estimated property damage, $349 Million current)Ignition of ammonium nitrate, lack of safety measures, inadequate risk assessmentsRobust safety measures, regular maintenance, comprehensive risk assessments, stringent standards
Tesoro Anacortes Refinery Fatal Explosion and Fire, 20107 Fatalities, Severe InjuriesEquipment integrity deficiencies, inadequate inspection and testing practices, PHA shortcomings, emergency response deficienciesRobust inspection and testing protocols, thorough PHA, effective emergency response systems
BP Texas City Refinery Fire, 200515 Fatalities, 180 Injuries ($1.5 Billion estimated)Lack of oversight, resource inadequacy, reporting flaws, human factor neglectStrengthen safety culture, balance metrics, thorough investigations, human factor focus
Phillips 66 Explosion, 198923 Fatalities, Between 130 to 300 Injuries ($320 Million Property Damage)Maintenance issues, leak/gas detection flaws, layout, permit-to-work, fire protection gapsRobust maintenance, effective leak detection, comprehensive layout planning, enhanced emergency response
Bhopal Toxic Release, 1984Approximately 2,000 Deaths, Tens of Thousands InjuredPlant modification shortcomings, reaction testing inadequacies, design code flaws, emergency challengesRigorous safety protocols, comprehensive testing, robust emergency response

Advancements in Process Safety Management Standards

In response to these process safety incidents, the evolution of PSM standards in the USA has been continuous. Recognizing that safety is an ongoing journey, authorities have incorporated lessons learned, technological advancements, and a deeper understanding of potential hazards into current PSM standards.

From the Phillips 66 Explosion, insights emphasize the paramount importance of robust maintenance protocols, effective leak detection, comprehensive layout planning, and enhanced emergency response capabilities. The BP Texas City Refinery Fire and Explosion underscored the critical need for a strengthened safety culture, balancing metrics, conducting thorough investigations, and focusing on human factors. The Bhopal Toxic Release revealed the necessity of rigorous safety protocols, comprehensive testing, and robust emergency response mechanisms in chemical plants. 

The Tesoro Anacortes Refinery incident highlighted the imperative for constant vigilance, adherence to safety protocols, and continuous improvement in industrial practices. Lastly, the West Fertilizer Explosion emphasized the ongoing commitment to learning from past experiences, fostering a proactive safety culture, and ensuring continuous improvement in industrial safety standards, particularly in handling highly hazardous materials. 

These collective learnings underscore the crucial role of process safety management in preventing and mitigating catastrophic incidents across diverse industries

Conclusion

The development of Process Safety Management standards is intrinsically linked to the lessons learned from historical incidents. To prevent these incidents from happening again, let’s use the following as a guiding principle:

  • What could go wrong? 
  • How can we prevent these things from happening? 
  • How can we ensure that our safety systems are working effectively and won’t fail?

In the pursuit of continuous improvement, industries must remain vigilant, learn from the past, and integrate evolving standards to create workplaces resilient to the challenges posed by hazardous processes. A solution to these questions lies in comprehensive HAZOP facilitation, HAZOP training, and ensuring a skilled HAZOP leader guides risk assessments. Aside from being a regulatory obligation, robust Process Safety Management is a commitment to the well-being of workers, the community, and the environment.Contact Saltegra Consulting LLC today and allow us to assist you with your PSM needs.