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