DEPARTMENT OF CHEMICAL ENGINEERING,

UNIVERSITY OF BENIN,
BENIN CITY,
EDO STATE, NIGERIA

LECTURE NOTE ON THE CAUSES OF ACCIDENTS IN PROCESS

PLANTS.
PREPARED BY GROUP 3 MEMBER (2013/2014 SESSION) FOR THE
COURSE SAFETY AND LOSS PREVENTION WITH COURSE CODE
CHE 522
COURSE LECTURER: PROFESSOR KESSINGTON OBAHIAGBON
DATE PREPARED: 22ND OF SEPTEMBER, 2014.
SN
1.
2.
3.
4.
5.
6.

NAME
SALE NGBEDE SUNDAY
ALA CAROLINE
OHIENMHEM DAMIAN
ADUBIAGBE OLANREWAJU
OMOYAKHI TUNDE JUSTUS
EKPETI UCHE ISREAL

MATRIC NUMBER
ENG0902148
ENG0902075
ENG0802031
ENG0902068
ENG0902136
ENG0902

INTRODUCTION
A study of past accidents in the chemical process industry (CPI) has been carried out. It is
found that the majority (73%) of the accidents were caused by technical and engineering
failures. Based on the causes of accident and types of equipment failures, five common
features of accident in the CPI were identified. The analysis reveals that the contribution of
the design to accidents is significant and the advancement of knowledge/technology is not
shared effectively by practitioners. Dependency on the add-on control strategy should be
reduced and inherently safer or passive engineered must be considered as premier risk
reduction strategy to lessen the safety load, for better design and to prevent accident
effectively.
Analysing the past accident cases is very important for continuous improvement of process
safety. It gives useful information on how accidents arise in practice. There are many studies
related to accidents, which have been carried out worldwide and majority of them concentrate
on identifying the root causes of accident and lesson learnt from it. Most of them classified
causes of accident into the technical/physical and human/organizational failures. The
contribution of the organizational/human aspect to accident is well discussed and accepted by
the CPI. However, analysis on the technical aspect of the accident is still lacking. This may
relate to the quality issue of accident reports. Majority of the accident reports are not
complete or poorly written due to inadequate investigation and competency (Kletz, 2009). To
minimize this issue, the Failure Knowledge Database (JST, 2009) was selected. The database
covers the most significant accidents all over the world and is managed by experienced
academia from Japan under close monitoring of Japan & Science Technology (JST) Agency.
The accident report is carefully reviewed by the nominated committee and contains almost
complete information of the accident. Some of them contain detailed technical drawing,
process flow diagram, plant layout, fault tree analysis, and proper comment on the
background of the accident.
Some definitions of accident

1. An unfortunate incident that happens unexpectedly and unintentionally, typically

resulting in damage or injury.
2. An event that happens by chance or that is without apparent or deliberate cause.
3. An accident is a sequence of events that produce unintended injury, death or property
damage.
4. An accident or a mishap is an unforeseen and unplanned event or circumstance, often
with lack of intention or necessity (en.wikipedia.org/wiki/accident).
5. An accident is an unplanned and unexpected event often with lack of intention or
necessity which occurs suddenly and results in injury to persons and/or loss of
property, leading to a decrease in the value of resources and undesirable increase in
liability.
6. An accident is when there is no intention to cause damage or injury, the damage or
injury happens, in part due to chance (answers.com/Q/What_are_accidents).
TYPES OF ACCIDENTS
There are so many numerous types of accident, but only three (3) will be highlighted:
1. Physical accident: these are accidents that have effect directly on the five physical
senses (eye, ear, nose, tongue, and skin) of the human body and can have direct
degradation of these senses, this type of accidents include; being injured by touching
something sharp, hot, or electrical (flow of electron) in nature with your skin, or the
ingestion of poison, etc.
2. Non-physical accident: non-physical accidents are accidents that do not have direct
adverse effect/impact on the five physical senses. These types of accidents include;
un-intentionally revealing a secret, saying something incorrectly, forgetting an
appointment, etc.
3. Accident by activity: this is like the duty call word, where an individual or group of
persons actually forget what they are to do next since they are totally engrossed with
what they are doing at the moment. In other words, accidents by activity include
accidents that occur during the execution of work or arise at the execution of work.
Accidents in process plants
Accidents in process industries are relatively common. They occur in various forms and to
various degrees, from minor near-misses such as trips to major catastrophes involving
all the significant hazards in process industries (Fire, Explosion, and Toxic Releases).
Regardless of their degree, accidents have potential to bring about unwanted loss with

grand consequences. Examples of major hazards recorded in recent times include: The
emission of radiations (gamma rays and neutron radiation) from the Tokaimura plant in
Japan 1999, the partial power outage of the Tesoro Golden Eagle Refinery due to
damage its substation which led to excess flaring of light hydrocarbons and some unit
shut down, Macondo blow out in the Gulf of Mexico, etc.
CLASSIFICATION OF ACCIDNETS
There are two main classifications of the cause of accidents in process plants namely;
1. Organisational or Human cause: Under this classification they are several causes of
accident which occur as a result of human error or faulty organisational policies.
Some these causes include;
i.

Operators error: this occurs as a result of an operators inexperience in the

operation of the given process or wrong judgement of the conditions which
eventually leads to an accident.

ii.

Lack of training and staff assessment: every organisation should invest in

the training of its employees (operational personnel), in other to ensure they
acquire the required skills necessary to carry out their job(s) efficiently and
safely. Lack of this form of training could result to huge consequences due to
employees ignorance.

iii.

Lack of integrated management system: when an organisation runs a system

of management that lacks integration, this could lead to conflicting others and
decisions that could bring about confusion on the part of employees which can
invariably affect his performance and in turn lead to the event of accidents.

iv.

Poor incidence and near miss investigation/follow ups: usually in operation

of plants, there are near miss events, that is events that had the possibility of
leading to an accident, if this event are not well investigated, there are high
possibilities that this event occur again and this time they might actually lead
to an accident.

v.

Bad management decision: bad management decisions can cause accidents;

it is the duty of every organisational management to ensure operations are safe
before considering profits that can be made from such operations. Therefore,
irrespective of the profits that can be to unsafe operations; they should be
avoided or eliminated completely from organisational operations, etc.

2. Technical or Engineered cause: accidents can occur as a result of faulty design and
other technical and engineering related matters. Some of the technical and engineering
causes are listed below:
i.

Use of defective equipment: Use of defective equipment can occur as a

result of wrong specification during the design stage of a plant
process/operations, it can also occur as a result of not incorporate a design
factor (factor of safety) while designing process equipment. Defective
equipments are equipment that fall below the norm in either structure or
functions, which in turn can lead to the event of an accident.

ii.

Use of wrong tools: every operation has a tool required to carry out carry out
the operation safely and efficiently, using a wrong tool can lead to the damage
to parts of a process equipment or machine, which in the long run can result in
the event of an accident occurring.

iii.

Non-existence or poorly developed work standard: every organisation

should have a high standard work practice, which is meant to guarantee the
safe operation of the plant. If the standard is poor, then theres a high risk of
accident occurring.

iv.

Substandard equipment design: this occurs when the standard of materials

used in the production/design process are being compromised for low quality
ones and this falls below the required specified design standards and
regulations. In the course of operation, these materials can fail leading to
events which have the likelihood of resulting to in an accident.

v.

Improper or unorganised plant layout: this is a result of poor positioning of

machines and equipments within a workplace. Arrangement of machines
haphazardly along a line or within a department is likely to cause accident.

vi.

Maintenance: this is a result of improper maintenance culture or lack of

preventive and predictive maintenance programs. Manufacturers do publish a
recommended maintenance schedule for equipment, but the failure of the
maintenance personnel to follow this schedule leads to the unnecessary stress
on the equipment. This can lead to equipment failure which can inturn lead to
the event of an accident.

CAUSES OF ACCIDENTS

Figure 1 shows the general (pie chart) and immediate (bar chart) causes of accidents in CPI
based on Failure Knowledge Database. It clearly indicates that majority of the accidents are
caused by technical failures (73%), followed by organizational (23%) and unknown (4%). In
this work, special attention on human engineering error is given for the accidents caused by
human failures by asking questions such as why did the operator make a mistake; why the
operator did not follow the instruction/procedure; why the operator repeat the same
mistake etc. As a result, majority of the human errors (under management/procedural
category) are shifted to technical causes due to design error of work unit. Among typical
examples related to the human engineering error include wrong equipment/component
labelling, confusing control panel display, wrong work instruction and standard operating
procedure, wrong colour-coding, and poor visibility and accessibility to the equipment.

Figure 1: The general (pie chart) and immediate (bar chart) causes of accidents

Technical causes
The bar chart from Figure 1 shows the root causes of accidents in CPI. The most frequent
cause of accidents in the Failure Knowledge Database is the piping system failures (16%
from 364 cases). Accidents related to the piping systems involved loss of containments or
leakages that leads to toxic dispersion, fire and explosion. From the analysis, typical

problems associated with the piping system are poor layout, wrong specification, dead end or
no flow arrangement, poor installation and finishing work, inadequate hot bolting, and
blockage. Technically, the piping system is complex due to multiple interactions between
process equipment. The demand for higher process flexibility increases the complexity of the
system. The likelihood of the piping failure is a function of failure rate of its components. If
the number of the components increases, the probability of the system failure will increase.
Thus, designing a simpler piping system is the best way to prevent accidents in the CPI.
The second largest cause of accidents is contamination of the process stream with 36cases
(10%). In this category, impurities, by-product and in-direct or external contaminations are
also considered. The basic problem of the contaminations is related to insufficient process
hazard analysis at the process development and plant design. Contaminations also occur due
to incomplete draining/cleaning/purging, reverse flow, pressure difference, blockage,
leakages and condensation due to weather changes. In chemistry term, the contaminant
changes the quality of process stream and creates a lot of operational problems such as
increase the corrosion rate, partial/full flow blockage, wall sticking, depositing or scaling,
disturbed/delayed chemical reactions, etc. If unstable or reactive material presents and the
conditions are right (i.e. temperature and concentration), an unwanted reaction (i.e.
polymerisation and decomposition) may occur, resulting unwanted events such as fire and
explosion.
Inappropriate selection of construction material (29 cases or 8%) is the third contributor of
accidents in CPI. This is a design related error and normally connected to the physical and
mechanical problems of process equipment such as cracking, corrosion, erosion, creep,
fatigue and shock. For example, selecting mechanically robust construction material as well
increasing the wall thickness of process equipment can eliminate wall failures. Meanwhile
selecting a chemically resistant construction material such as stainless steel or teflon can
minimise the corrosion issue.
The contribution of mass transfer and corrosion/erosion are also significant (26 cases or 7%
each). Accidents resulting from poor or no mixing, excessive charging, and varied feed
conditions are common factors related to the mass transfer category and consequently lead to
uncontrolled reactions. Meanwhile, corrosion/erosion may be resulted following operational
scenarios, such as flow restriction, process condition deviations, and raw material variation.
Among the factors that accelerate corrosion rates are changes in process conditions i.e. higher
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temperature and pressure, high pH value, and contaminations by specific materials from other
process streams or from outside.
Heat transfer is also a very usual contributor of chemical plant accidents, causing 20
accidents. Loss of cooling, wrong heating method, hot spots, and scaling in the piping system
and process equipment are among the problems associated with heat transfer related
accidents. Special attention should be given to thermal expansion phenomena and the
reactivity hazard of heat transfer media to the process fluid.
The low fraction of accident causes should also be noted i.e. substandard equipment (5%),
fabrication (4%), flow related (4%), layout (3%), and control system (2%). Still, even the
small percentage cause, may generate big problems if not managed properly.
Organizational causes
Out of the 364 accidents analyzed, 23% are classified as organizational causes which is
categorized

as

management/procedural

faults

(15%),

knowledge-based

(4%)

and

storage/handling of chemicals (4%) Almost all of the organizational failures are causes by
poor human performance. Majority of the faults are caused by the managerial level due to
wrong policies/directions, inadequate hazard recognition, wrong/inadequate instructions, as
well as personal factors e.g. incompetence and risk taking. At the operators level, the main
factors that contribute to accidents are mistakes, short cut, not following instructions, missjudgement, and under estimation chemical safety. The contribution of knowledge based and
chemical handling related accidents are also explored. It is found that the basic reason for
knowledge-based accident is due to ignorance of technology advancement and knowledge
sharing (Kletz, 1993). Many organizations do not update their operations to the current code
of practice based on technical guidelines as provided by the authorities. For the chemical
handling related accidents, the majority of the accidents are classified under wrong valve
setting, operator doing short-cut and not following work instructions.

EQUIPMENT FAILURE
Based on the information available in 364 accident reports, the frequency of the equipment
failures are examined and classified into 12 main categories. The resulting categories of
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equipment failures and their respective percentage are: piping (25%), reactors (15%), storage
tanks (14%), process vessel (10%), heat exchanger (8%), separator (7%), general machinery
(5%), other equipment (5%), drum (4%), warehouse (3%), control system (3%), and cylinder
(2%).
The result shows that piping is the most fragile component of chemical plant operations. In
general, piping failures are caused by design error (i.e. unsuitable construction material);
corrosion and erosion issues; poor operations and project implementation (i.e. fabrication/
installation). They can be eliminated or minimized by proper design and operation within
safety limits. Meanwhile, reactor is the heart of chemical processes and has a risky task.
Chemical contaminations are the common contributing factor associated with reactor failures.
Abnormal reactor operations also caused by uncontrolled mass transfer phenomena (i.e. poor
mixing, more reactant, and diffusion issues); flow related problems, and heat transfer issues.
These problems increase the risk of unwanted chemical reaction in the reactor that result to
toxic release, fire and explosion. Storage tanks should be safer equipment if compared to
others but statistically the accident rates are high. Operational problems associated with the
storage tanks are related to poor management practice (i.e. hot work and confined space
entry) and improper operations (contamination, heating, and static electricity).
Similar results have been published by Marsh & McLennan Inc. (1987). It is interesting to
notice that the CPI has been aware of these facts for more than 20 years but the same types of
equipment failures still occur. The reason for this may be due to lack of technical analysis,
wrong interpretation of the evidence and inadequate knowledge sharing (Kletz, 1993; 2003).
On inherent safety point of view, it seems that the current control strategy used by the CPI,
i.e. add-on control systems is ineffective to prevent accidents. Logically, the add-on systems
may fail and their reliability reduces if not properly maintained.
OPERATIONAL STATUS
Based on Failure Knowledge Database, the operational status of the equipment failures is also
studied. 49% of the accidents occur during normal operations (178 out of 364 cases),
followed by charging/chemical transfer (18% or 66 cases) and maintenance work (12% or 42
cases). Other operational status with their respective percentage are cleaning activity (7%),
start-up (4%), inspection/testing (4%), emergency (4%), environmental factor (1%), and
shutdown (1%). Half of the accidents occur during normal daily operations and occur without
any sign, such as piping failure due to corrosion and runaway reaction due to chemical
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contamination. Briefly, plant owner/operators were not aware what went wrong, resulting
panic situation. This sometime worsened the consequences of accident. Based on the accident
reports, the basis of the equipment failure and the root cause of the accidents are related to
design error, which only appeared after an accident. Accidents related to chemical handling,
maintenance and cleaning work are significant and directly caused by poor management of
plant operations. Meanwhile, the analysis shows that the plant start-up is more risky if
compared to the plant shutdown. However, both activities require good planning and
technical knowledge.
COMMON FEATURES OF ACCIDENT AND LESSONS LEARNED
From the accident cases reported in Failure Knowledge Database, a number of similarities
appear. These can be summarized as following:
Majority of the accidents are caused by failure of auxiliary systems and its
components, not the main equipment. Typical example is piping system. The integrity
and reliability of the piping system depend on many factors including design,
complexity and management. The integrity and reliability of the piping system can be
achieved by selecting robust material of construction and through simpler design.
Well-structured pipes inspection and replacement is a good element of piping
management system.
Almost half of accidents occur during normal operations and are directly related to the
design error. Typical examples of design error in the CPI are unsuitable construction
material for equipment, incorrect design capacity and design rating/specification, poor
layout, and physical arrangements. Proper process analysis is needed especially on
identification of inherent physical and chemical properties of substances; stability and
incompatibility of process fluids with construction material; and runaway reaction
hazards. In addition, detail risk analysis based on worst-case scenario should be
conducted and the result should be used to design the equipments protective and
mitigation system.
Lack of process analysis in respect to chemical reactivity and incompatibility.
Identification of hazards associated with reactive materials and the potential of the
process contamination as well as material accumulation in process stream should be
made known as early as possible, i.e. in research and development stage. The data can
be used as criteria for raw material selection during process screening or process

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concept development. Selection of safer, stable and compatible raw material can
eliminate or reduce the overall risk of the chemical process plant operations.
Operational fault as a result of operating beyond the equipment design limits. The real
issue here is the record keeping and technological updates. Some of the companies did
not maintain the original technical specification of the process equipment or update
the current technology/chemistry knowledge of the process employed. These
situations lead to use of sub-standard or unsuitable equipment in normal operation.
Similar issue is related to the management of change especially on plant
modifications.
Under estimating the problem related to thermal expansion phenomena. Many of the
heat exchanger and piping system failed due to these phenomena. The origin of the
problems is somehow related to design error and poor plant operations such as
material miss-match, uneven tightening and support arrangements. Mechanically,
metals expand at different rate and create gap between them. For the high temperature
services, hot bolting and heating/cooling rate are very important for this issue. Special
considerations on piping movement are also required during structural or support
installation of major equipment.
REAL LIFE SCENARIO OF ACCIDENTS

1. Calpine Los Moedanos Energy Center: While overseeing the unloading of

a bulk delivery of corrosion inhibitor, approximately 300 gallons of Nalco
Trasar 3DT177 (phosphoric acid) was inadvertently unloaded into a storage
tank containing about 378 gallons of 12.5% Sodium Hypochlorite solution.
The chemical reaction of the two products resulted in a chlorine gas release
in which the Field Operator and two other plant employees were exposed to.
The three employees were transported via ambulance to the Mt. Diablo
Medical Center for observation. Time of injury was reported to be 8:30 a.m.
24th of May, 2007.
CONCLUSION
Based on the accident report in the Failure Knowledge Database, the technical and
engineering aspects of plant operation are found to be important causes of accident in the
CPI. 73% of accident cases were caused by technical and engineering failures. Furthermore,
the study found five common features of accidents, which are related to the auxiliary
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equipment, design error, chemical reactivity and incompatibility, operational fault, and
thermal expansion issues. It is evident that the contribution of design to the accidents is
significant and current knowledge of science and technology in the CPI is not shared and
used effectively to combat design and operational error. Effort to share the latest knowledge
and technology should be enhanced for healthy plant design and operation. In general, the
result of the analysis point out that the add-on control strategy is inefficient to prevent
accidents. As a control system is subject to failures, the dependency on add-on control
systems should be reduced. To increase the reliability and availability of the chemical process
plant, the inherently safer approach should be considered as a premier strategy for risk
reductions in the CPI.

REFERENCES
1) JST, 2009, Failure Knowledge Database, Japan & Science Technology Agency, Japan.
http://shippai.jst.go.jp/en/Search, Online available on 29th October 2009.
2) Kletz, T. A., 1993, Lessons from Disaster: How Organizations Have No Memory and
Accidents Recur. IChemE, Rugby.
3) Kletz, T. A., 2003, Still Going Wrong! Case Histories of Process Plant Disasters and
How They Could Have Been Avoided, Gulf Butterworth Heinemann, Burlington.
4) Kletz, T. A., 2009, Accident reports may not tell us everything we need to know,
Journal of Loss Prevention. in the Proc. Ind., doi: 10.1016/j.jlp.2009.08.017
5) Marsh Inc., 1987, A Thirty-Year Review Of One Hundred Of The Largest Property
Damage Losses In The Hydrocarbon-Chemical Industries. Marsh Inc., New York.
6) http://www.answers.com/Q/What_are_accidents
7) http://www. en.wikipedia.org/wiki/accident

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