Explosion accident investigations

Kuchta, J. M. 1985. Investigation of fire and explosion accidents in the chemical, mining, and fuel-related industries-A manual. Bureau of Mines Bulletin 680. 

In addition to these formal studies of human error in the CPI, almost all the major accident investigations in recent years, for example, Texas City, Piper Alpha, the Phillips 66 explosion, Feyzin, Mexico City, have shown that human error was a significant causal factor at the level of design, operations, maintenance or the management of the process. 

The accident investigation evidence showed that this safe procedure was not followed specifically, the product takeoff valve was removed, the DEMCO valve was in the open position, and the lockout device was removed. This scenario was a serious violation of well-established and well-understood procedures and created the conditions that permitted the release and subsequent explosion. 

Figure 6-5 Maximum pressure for methane combustion in a 20-L sphere. The flammability limits are defined at 1 psig maximum pressure. Data from C. V. Mashuga and D. A. Crowl, Process Safety Progress (1998), 17(3) 176-183 and J. M. Kuchta, Investigation of Fire and Explosion Accidents in the Chemical, Mining, and Fuel-Related Industries A Manual, US Bureau of Mines Report 680 (Washington, DC US Bureau of Mines, 1985).

The classification of the explosion as either a deflagration or a detonation and the magnitude of the explosion may be useful for developing causes and recommendations during accident investigations. 

The accident investigation indicated that the explosion was caused by a static spark that jumped from the steel nozzle to the tank car. The nozzle was not bonded to the tank car to prevent static accumulation. The use of a nonmetallic hose probably also contributed. 

Based on the accident investigation, the explosive energy was equivalent to 0.3 ton TNT. Therefore the fraction of energy manifested in the explosion is 0.3/2.69 = 11.2%. This 11.2% is considerably higher than the 2% normally observed (see section 6-13) for unconfined vapor cloud explosions. The higher energy conversion is a result of the explosion occurring in a partially confined area. 

Illustrate the layered accident investigation process, using Example 13-1 as a guide, to develop the underlying causes of the duct system explosion described in section 13-1. 13-2. Repeat Problem 13-1 for the bottle of isopropyl ether accident described in section 13-2. 13-3. Repeat Problem 13-1 for the nitrobenzene sulfonic acid decomposition accident described in section 13-2. 

It is common for crash investigators to undertake reconstruction of the aircraft wreckage, and this can be exceptionaUy useful in estabhshing the seat of an explosion, if that is what in fact took place. The National Transportation Safety Board in the United States and the United Kingdom Air Accident Investigation Branch have both done some exceptionaUy fine work of this type. 

NFPA 422M—Manual for Aircraft Fire and Explosion Investigators. Chapter 5 Evidence, Chapter 6—Determining Incident Sequence. Quincy, MA NFPA, 1989. Kuhlman, R. Professional Accident Investigation. Loganville, GA Institute Press-International Loss Control Institute. 

Baker, Q. A., Pierorazio, A. J., Ketchnm, D. E., Investigation of Explosion Accidents, Center for Chemical Process Safety International Conference and Workshop on Process Indnstry Incidents, October 2000, Orlando Florida. New York AIChE, 2000. 

Investigation of Explosion Accidents, Quentin A. Baker, Adrian J. Pierorazio, Donald E. Ketchum... 

Special Investigation Team for the Explosion Accident in Sakai Factory of Daicel... 

Kuchta, J. M., Investigation of Fire and Explosion Accidents in the Chemical, Mining, and Fuel-Related Industries — A Manual, Bulletin 680, U.S. Department of the Interior, Bureau of Mines, 1985. 

ABSTRACT Four hundred and sixty seven coal gas explosion accidents that occurred in China between the years of 1950 and 2000 were investigated through statistical methods so as to review the overall situation and provide quantitative information on coal gas explosion accidents. Statistical characteristics about accident-related factors such as space, time, gas accumulation reasons, gas grade, ignition sources, accidents categories, and accident economic loss were analyzed. Some special conclusions have been achieved. For example, most gas explosion accidents were found to have concentricity on the space-time and hazard characteristics. Such results may be helpful to prevent coal gas explosion accidents. Moreover, comments were made on APS (Accident Prevention System) and safety culture. In conclusion, countermeasures were proposed in accordance with the results of statistical studies, including the change of safety check time. 

The article select 100 coal mine accident cases from all the accidents happened in 2001-2009 according to the reason type of coal mine accidents, including mine roof accident, gas accident, water disaster accident, transportation accident, mechanical and electrical accident, explosion accident, fire accident and other accidents. Though analysis the accidents process, acquainting accident investigation and handling, the accident reasons were found out. The reason of coal mine accidents in our country mainly includes the following four areas ... 

In order to carry out the review of accident investigation reports into machinery space fires and explosions on board merchant ships, the HFACS framework had to be slightly adapted. The adapted framework is shown in Fig. 2. More detailed explanation with regard to the adaptations can be formd in Ghirxi (2008). 

The paper reported the findings of a review of 41 accident investigation reports of machinery space fires and explosions. The investigations were carried out during a period of time before and after the ISM Code implementation or the provision of IMO guidance for HF investigation in maritime casualties. 

Fatal Accident Investigation Report - isomerization unit explosion, interim report Texas City, Texas, Incident March 23, 2005. Date of Report May 12, 2005, http //www.root-causelive.com/Files/Past%20Investigations/BP%20Explosion/texas city investigation report.pdf [accessed 17.09.14]. 

On March 23,2005, at a BP Products North America-owned and -operated refinery, a fire and explosion resulted in 15 deaths, 170 injuries, and extensive property damage. An investigation team led by BP employee J. Mogford released a report titled Fatal Accident Investigation Report, Isomerization Unit Explosion Final Report, Texas City, Texas, USA. The 192 page report may be accessed at the website listed in the end-of-chapter references. 

It is easier to write about a culture that includes safety as a core value than it is to factually describe a situation in which the culture deteriorates over time, the effect the deterioration has on increasing risk and the position in which such deterioration places a safety professional. The following are excerpts taken from a report that was internally produced by BP Products North America (2005) pertaining to a fire and explosion that occurred on March 23,2005, at an owned and operated refinery in Texas City, Texas. As a result of that incident, 15 people were killed and over 170 were harmed. It is important to note that these excerpts, taken from the Executive Summary— Fatal Accident Investigation Report, represent a self-evaluation. 

Unfortunately, today, we are still making very similar mistakes that we saw at Flixborough decades ago and other disasters. For example, the accident investigation into the BP Texas City Refinery explosion and fire in 2005 found eerily similar accident causes and precursors ... 

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