Coursework Enm302 Salim-g

School of Engineering

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All sections except the “LATE DATE” section must be completed and the declaration signed, for the submission to be accepted. Any request for a coursework extension must be submitted on the appropriate form (please refer to http://www.rgu.ac.uk/academicaffairs/quality_assurance/page.cfm?pge=44250), prior to the due date.

Due Date Date Submitted For official use only

July 17th,2014

July 17th,2014 LATE DATE

MATRIC No. 1310028

SURNAME GADDA

FIRST NAME(S) SALIM

COURSE & STAGE

Eg MSc Oil & Gas Engineering MSc Drilling & Well Engineering

Full Time

MODULE NUMBER & TITLE ENM302 / SHERA

ASSIGNMENT TITLE Case Study of DuPont Explosion

discussion of the explosion as an accident waiting to happen

LECTURER ISSUING COURSEWORK Mr. Mohammed Kishk

I confirm: (a) That the work undertaken for this assignment is entirely my own and that I have not made use of any unauthorised assistance.

(b) That the sources of all reference material have been properly acknowledged. [NB: For information on Academic Misconduct, refer to

http://www.rgu.ac.uk/academicaffairs/assessment/page.cfm?pge=7088]

Signed ….. .....SALIM GADDA........................ Date........... July 17th,2014..................

Marker’s Comments

Marker

Grade

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ENM302/SHERA Coursework

By: SALIM GADDA

1310028

July 2014

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Table of contents

1. Introduction................................................................... 1

2. Safety Management System & Industrial Disasters........ 1

3. Accidents Causation…………………………………………………. 2

4. Case Study: DuPont Explosion…..………………………………. 2

4.1 Accident Date & Site............................................................ 2

4.2 Sequence of Events Description............................................. 3 4.3 Accident Results................................................................. 4 4.4 Root Causes of the Explosion................................................ 5

4.5 Was DuPont Explosion an Accident Waiting to Happen? Could it have been avoided?...............................................

6

4.6 Lessons Learned from DuPont Explosion................................ 7 4.7 Recommandations................................................................ 7

5. Conclusion..................................................................... 8

References........................................................................... 9

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List of figures

List of abbreviations

CSB U.S. Chemical Safety and Hazard Investigation Board

U.S United State of America

VF Vinyl Fluoride

SMS Safety Management System

Figure 1: Storage tanks.............................................................. 3

Figure 2: The two contractors began the repair activity on tank 1.... 3

Figure 3: During the welding activity; Vinyl fluoride was flowing

inside tank 1 (a), and welding sparks were falling into the same tank

(b)..............................................................................................

4

Figure 4: A sudden explosion occurred......................................... 4

Figure 5: Work place before and after the explosion…………………..….... 5

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Executive summary

This short paper deals with a case study proposal about an industrial

disaster which is discussed as an accident waiting to happen. The

discussed disaster is ‘‘DuPont Explosion’’; this is an explosion of a

flammable vapour in DuPont plant near Buffalo in New York that

happened on the morning of November 9th, 2010 when a hot work

activity was taking place (welding operation). The explosion involved

death and injuries.

The case study is developed and discussed in the context of an industrial

accident(s) in such a way that the report first covers; a safety

management system, its key elements, what should it do, and then

followed by developing accidents causation. Next, this report covers the

proposed case study in terms of explosion date & site, events description,

root causes, was DuPont explosion an accident waiting to happen?, could

it have been avoided?. At the end, some recommendations are covered

including those made by the CSB (U.S. Chemical Safety and Hazard

Investigation Board) are covered.

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1. Introduction

Safety Management System can be established for all sorts of sectors

(business and/or industry) and the safe functioning of each organisation

from these sectors is based upon its overall management. A good Safety

Management System cannot stop the accidents from happening because

it is not perfect. However, learning from previews accidents and then

reviewing the safety management system itself can at least minimize the

accidents from happening. Most of these accidents are caused by the

human being who is not perfect as well, most of the investigations have

proved that human errors were the root causes.

In this report, a proposal of case study will be discussed highlighting the

causes making the explosion as accidents waiting to happen leading to

accidents, and if so how could these accidents have been avoided.

2. Safety Management System & Industrial Disasters

The SMS(s) term stands for Safety Management System(s), which refers

to a comprehensive integrated system which ensures that all work can be

performed safely (i.e. considering the safety of people, equipment,

environment…etc.) based upon its key elements which are as follows:

Policy: set a clear directions to be followed by the organisation.

Planning: an effective arrangements to deliver the Policy key

element.

Implementing: policies & procedures are put in place.

Assigning: measurement of performance & improvement.

Management Review: lessons learned and apply them.

All these aim to identify, prevent, deal with and mitigate risks before,

while and after doing any activity. So, the SMS should do:

Define safety roles and responsibilities;

Ensure adequate skills;

Maintain awareness of hazards and risks;

Plan, implement and evaluate;

Develop performance requirement and set targets for improvement;

Manage changes;

Manage and maintain knowledge; and

Review and improve the SMS itself.

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3. Accidents Causation

Different causes can contribute to accidents, some can be considered as

primary causes which are known as Root Causes, and others can be

considered as secondary causes. This does not mean that only the root

causes are sufficient for the accident to happen, but any cause, a root

cause is or not, can be sufficient to cause the accident alone or

contributing with other causes together.

The causes of accidents can be categorized into three main groups; these

can be a technical failure, human errors or organizational failure and all of

them can lead to dangerous situations. Among the causes within these

groups the following:

Technical failure: poorly designed equipment, poor preventive and

systematic maintenance and whatever is the equipment, service

companies try to makes it reliable and last as long as possible, but it

is like the human being, it might break down and no one know

when.

Human errors: these can be divided into be intended or

unintended actions:

Within the intended actions violations and mistakes, and within the

unintended actions lapses and slips. Within all these; work under

pressure, overwork (doing too much), lack of training, violation of

legal requirement, communication problems, intention, conflicts,

exhaustion, memory lapses, noisy work place, ignorance,…etc.

Organizational failure: bad safety management system, poor

management of change, lack of leadership competence within

groups….etc.

4. Case Study: DuPont Explosion

4.1 Accident Date & Site

On the morning of November 9th, 2010, a flammable vapour explosion

took place at an E.I. DuPont de Nemours and Co. Inc., Yerkes chemical

facility near Buffalo in New York. The explosion happened when a welding

activity was being performed on the top of one of the storage tanks

(10,000 gallon) containing flammable Vinyl fluoride (VF). Two contractors

were involved in the welding activity, when they were so doing welding

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Figure 1: Storage tanks

Figure 2: The two contractors began the repair activity on tank 1

sparks entered into the tank, ignited the contained flammable vapour and

caused the explosion.

4.2 Sequence of Events Description

On the morning of November 9th, 2010, at around 9 am two contractors

(a welder and a foreman) began the repair activity; the welder started

the grinding and welding repair work on the top of tank 1 and the

foreman was looking at him from the nearby catwalk. At approximately

11 am when the welder was working, (using an electric arc welder)

sparks were falling inside the tank and suddenly the flammable vapour

ignited and exploded. The explosion blew the tank cover 100 feet away.

Minutes later, the fire self-extinguished after consuming all the

flammable vapour.

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(a) (b)

Figure 3: During the welding activity; Vinyl fluoride was flowing inside

tank 1 (a), and welding sparks were falling into the same tank (b)

Figure 4: A sudden explosion occurred

4.3 Accident Results

The explosion was tragic; firstly, it involved death and serious injuries

(killing of a contract worker and injuring another). The welder was killed

instantly and the foreman was seriously injured; his arms and head were

burned, one of his eardrum was burst and one of his eyes was scratched.

In addition to the death and injuries the vinyl fluoride tank destroyed and

the DuPont plant stopped producing for a period of time.

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Figure 5: Work place before and after the explosion

4.4 Root Causes of the Explosion

- The DuPont technician only monitored the atmosphere around and

above the tank and did not monitor its interior. Therefore the failure to

monitor the interior of the tank was the main root cause that lead to the

explosion as said CSB.

- The vinyl fluoride was leaking from the U- shaped pipe existing inside

tank 2 and found the pathway to reach tank 1. This can be considered

as an equipment failure and poor maintenance cause leading to the

explosion.

- The compressor used for scripting vinyl fluoride was not functioning

properly, the amount of slurry was much more than that of gas. The

personnel were not aware about the improperly functioning of the

compressor.

- Poor maintenance and checking of the equipment according to DuPont

safety procedures.

- A poor safety management system related to hot works was used at

DuPont facility, because the system was not amended learning from

other similar hot works which caused explosions.

- Non rigorous training and permitting procedures were applied by DuPont

plants.

- Use of welding spark producing methods during performing a hot work

activity.

Before, Everything is OK

After, Death, injury and tank destruction

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4.5 Was DuPont Explosion an Accident Waiting to Happen?

Could it have been avoided?

According to CSB investigation on DuPont explosion, all the elements

necessary to cause the explosion were present and the accident was

expected to occur (i.e. the explosion was an accident waiting to happen)

if the preventive measures were not considered at the right time.

Therefore the DuPont explosion could have been avoided if:

- DuPont technician had monitored all the atmosphere around, above,

inside and outside the tank before and even during performing such hot

works. Therefore the failure to monitor the interior of the tank would

not have been the main root cause that lead to the explosion.

- Good maintenance and checking of the equipment had been included

within DuPont safety procedures, there would have been no vinyl

fluoride leaking from the U- shaped pipe existing inside tank 2. Also, the

compressor used for scripting vinyl fluoride would have been functioning

properly; there would have been no much more amount vinyl fluoride

than that of the gas. The personnel would have been aware about the

properly functioning of all the equipment at the DuPont facility

particularly those equipment that have links with the hot work.

- A good safety management system related to hot works had been used

at DuPont facility, analysis and assessment of all potential risks would

have been performed before starting the concerned hot work.

- All process connections, outlets and inlets, on tank1 had been

disconnected and/or completely isolated by closing the adequate valves

before tackling such hot work activities, thus all known and/or possible

sources of flammable materials would have been prevented from

entering the slurry container.

- Enforcing rigorous training and permitting procedures had been

ensured.

- A welding spark producing method had not been used.

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4.6 Lessons Learned from DuPont Explosion

While performing any hot work activity that involves welding, cutting, or

grinding on surface of flammables containers, heat and sparks will be

generated and these can ignite flammables present inside these

containers. Also, before authorizing such activities, a continuous

atmosphere monitoring inside any container previously containing

flammables should be performed regardless to its size.

Any process connection on flammable materials containers or similar

containers can let these materials enter the container at any time if it is

not completely isolated by installing blanks, closing valves and

disconnecting pipes.

4.7 Recommendations

Here we try to give one recommendation or more correspondent to each

cause of the accident (the given recommendations include those made by

CSB to DuPont facilities);

- Atmospheric monitoring is required inside tanks before and while

performing any hot work activity.

- All process piping on tanks are required to be totally isolated before

authorizing and permitting any hot work activity.

- Enforcing rigorous training and permitting procedures.

- Analysis and assessment of all potential risks and hazards should be

performed before starting any hot work.

- Constantly monitoring of the atmosphere for flammables while

performing any activity that involves welding, cutting, or grinding on the

flammable substances containers.

- Create a policy which determines criteria and factors that require a

continuous or periodic testing for the duration of hot work activity.

- Avoiding the use of welding spark producing methods when performing

any hot work.

- Auditing of the whole hot work process including hot work permitting

systems should be ensured before initiating any hot work by

establishing and enforcing corporate-directed policies and procedures.

- High quality maintenance procedures should be established

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5. Conclusion

Based upon the case study (DuPont explosion) which has been discussed

in this report we can conclude that a high efficiency safety management

system can ensure high prevention level of industrial disasters including

hot work activities. And this should include high quality trainings for all

the personnel members including motivations and free work spaces at

acceptable levels in order to minimise and why not to prevent human

errors which are always involved in such disasters.

Overall, although the SMS can be established for all sorts of sectors

(business and/or industry) and it has the importance of reviewing the

accidents and the contributing causes, but having it is not enough even if

it has a high prevention level because it is not perfect and it will never

cover everything. Thus, all of us are responsible for safety, with different

levels of course, we should put in our mind the saying ‘‘prevention is

better than cure’’ and we should not let and/or ignore anything that can

lead to accidents or make them just as accidents waiting for us to

interfere and prevent them, but in lots of cases it is too late as the case

of DuPont explosion and other similar accidents.

Word-Count: 1746 words.

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References

CSB Safety video, http://www.csb.gov/e-i-dupont-de-nemours-co-fatal-

hotwork-explosion/, accessed on July 05st, 2014.

CSB E.I. DuPont de Nemours & Co Inc. Case Study, January 2011,

Chemical Safety and Hazard Investigation Board (CSB), report No.

2011-01-I-NY.

RGU ENM302 courses with tutor instructions (Mr. Mohammed Kishk).