FLIXBOROUGH DISASTER

A CASE STUDY
 OVERVIEW

• THE CHEMICAL WORKS WAS OWNED BY NYPRO UK AND WAS ORIGINALLY A FERTILISER
PLANT.
• SINCE 1966 THE PLANT WAS PRODUCING CAPROLACTUM (USED FOR PRODUCING NYLON-6)
FROM CYCLOHEXANE.
• BY 1972 THE PLANT WAS PRODUCING ONLY 47000 TONS PER ANNUM OF CAPROLACTUM
WAY TOO LOW THAN THE TARGET OF 70000 TONS PER ANNUM LEADING TO LOSS.
THE CHEMICAL REACTION
 THE PROCESS

• THE PROCESS OPERATES BY INJECTING COMPRESSED AIR INTO LIQUID CYCLOHEXANE AT A

WORKING PRESSURE OF ABOUT 9 BAR AND TEMPERATURE OF 155°C.
• CONVERSION IS LOW AND IT IS NECESSARY TO RECIRCULATE THE CYCLOHEXANE
CONTINUOUSLY THROUGH A TRAIN OF SIX LARGE SS-LINED REACTORS.
SIMPLIFIED DIAGRAM OF THE PLANT
 • IN NOVEMBER 1973 THE GOVERNMENT PASSED THE
LEGISLATION TO RESTRICT THE USE OF ELECTRICITY BY
INDUSTRY TO 3 DAYS A WEEK.
EVENTS LEADING TO • THIS LEGISLATION RESULTED IN SHORTAGE OF POWER
THE ACCIDENT AND SO THE EMERGENCY POWER AVAILABLE ON THE
THE ELECTRICITY SITE WAS USED BUT IT WAS NOT SUFFICIENT.

LEGISLATION • THE 6 AGITATORS WERE THE CORE OF THE PLANT AND

ALSO THE MAJOR ELECTRICITY USERS, SO IT WAS
NECESSARY TO PROVIDE ALL THE POWER TO THEM.
• ALL THIS RESULTED IN LESS PRODUCTION AND SO
MORE LOSS.
 • IN JANUARY 1974 IT WAS FOUND THAT THE DRIVE
MECHANISM FOR THE STIRRER IN THE NO. 4 REACTOR
HAD BEEN SUBJECT TO SEVERE MECHANICAL DAMAGE.
EVENTS LEADING TO • EVEN AFTER LOTS OF INVESTIGATION NO REASON
THE ACCIDENT WAS FOUND FOR THIS.
REACTOR NO. 4 PROBLEM • DUE TO THE EFFECTS OF THE 3-DAY WEEK, THE PLANT
OWNERS WERE KEEN TO MAKE UP LOST PRODUCTION
AND IT WAS THEREFORE DECIDED TO CONTINUE TO
OPERATE THE PLANT WITH THE NO. 4 REACTOR STIRRER
SHUTDOWN.
 • IN MARCH,1974 CYCLOHEXANE FOUND LEAKING
FROM 6 FEET LONG VERTICAL CRACK IN THE MS SHELL
OF THE NO. 5 REACTOR.
EVENTS LEADING TO • DUE TO TECHNICAL PROBLEMS EXPERIENCED EARLIER
THE ACCIDENT AND THE EFFECTS OF THE 3-DAY WEEK, THE PLANT
REACTOR NO. 5 PROBLEM OWNERS WERE KEEN TO MAKE UP LOST PRODUCTION
AND THEREFORE THEY DECIDED TO REMOVE NO. 5
REACTOR FOR INSPECTION AND CONTINUE
OPERATION WITH THE REMAINING FIVE REACTORS.
 THE 20 INCH BYPASS PIPE

• THIS DOG-LEG SHAPED PIPE CONNECTED TOGETHER THE EXISTING 28 INCH BELLOWS ON THE
OUTLET OF REACTOR NO. 4 AND THE INLET OF REACTOR NO. 6.
• THE COMPANY DID NOT HAVE QUALIFIED MECHANICAL ENGINEER ON SITE TO OVERSEE
DESIGN AND CONSTRUCTION.
• NO HYDRAULIC PRESSURE TESTING OF PIPE WAS CARRIED OUT, EXCEPT FOR A LEAKAGE
TEST USING COMPRESSED AIR.
SIMPLIFIED DIAGRAM OF PLANT AFTER MODIFICATIONS
 THE DAY OF ACCIDENT (PART-1)

• THE PLANT RESTARTED AND OPERATED NORMALLY, WITH OCCASIONAL STOPPAGES, UP UNTIL
THE AFTERNOON OF SATURDAY, 1 JUNE 1974.
• THE START-UP INVOLVED CHARGING SYSTEM WITH LIQUID CYCLOHEXANE TO NORMAL LEVEL
AND THEN RECIRCULATING THIS LIQUID THROUGH A HEAT EXCHANGER TO RAISE THE
TEMPERATURE.
• THE PRESSURE IN THE SYSTEM WAS MAINTAINED WITH NITROGEN AT ABOUT 4 BAR UNTIL THE
HEATING PROCESS BEGAN TO RAISE THE PRESSURE DUE TO EVAPORATION OF CYCLOHEXANE.
• THE PRESSURE WAS THEN ALLOWED TO RISE TO ABOUT 8 OR 9 BAR, VENTING OFF NITROGEN
TO RELIEVE ANY EXCESS PRESSURE. THE TEMPERATURE IN THE REACTORS BY THEN WAS ABOUT
150°C.
 THE DAY OF ACCIDENT (PART-2)

• ON 1 JUNE THIS PROCEDURE WAS FOLLOWED EXCEPT IT WAS NOTED BY THE MORNING SHIFT
THAT BY 0600 HOURS THE PRESSURE HAD REACHED 8.5 BAR EVEN THOUGH THE TEMPERATURE
IN THE NO. 1 REACTOR HAD ONLY REACHED 110°C.
• IT WAS NOT REALIZED AT THE TIME THAT THIS DISCREPANCY MIGHT HAVE INDICATED THE
PRESENCE OF WATER IN THE SYSTEM.
• THE START-UP CONTINUED UNTIL, AT ABOUT 1650 HOURS, A SHIFT CHEMIST WORKING IN THE
LABORATORY CLOSE TO THE REACTORS HEARD THE SOUND OF ESCAPING GAS AND SAW A
HAZE TYPICALLY ASSOCIATED WITH A HYDROCARBON VAPOR CLOUD.
 THE ACCIDENT
• 1653 HOURS ON 1 JUNE 1974, MASSIVE AERIAL EXPLOSION OCCURRED WITH A FORCE LATER
ESTIMATED TO BE ABOUT 35 TO 45 TONS OF TNT EQUIVALENT.
• EXPLOSION WAS HEARD UP TO 30 MILES AWAY AND DAMAGE SUSTAINED TO PROPERTY
OVER A RADIUS OF ABOUT 6 MILES AROUND THE PLANT.
• 28 PLANT WORKERS KILLED WITH NO SURVIVORS FROM THE CONTROL ROOM AND ALL
RECORDS AND CHARTS FOR THE START-UP WERE DESTROYED.
• FOLLOWING THE EXPLOSION, 20 INCH BYPASS ASSEMBLY WAS FOUND IN A RUPTURED
CONDITION.
ORIGINAL 1974 FOOTAGE OF ACCIDENT
 THE PUBLIC INQUIRY

• FOLLOWING THE DISASTER, PUBLIC INQUIRY CONDUCTED TO ESTABLISH THE CAUSES AND
CIRCUMSTANCES OF THE DISASTER AND TO IDENTIFY LESSONS TO BE LEARNT FROM THE
DISASTER.
• THE IMMEDIATE CAUSE OF THE MAIN EXPLOSION WAS CONCLUDED TO BE THE RUPTURE OF
THE 20 INCH BYPASS ASSEMBLY BETWEEN THE NO. 4 AND NO. 6 REACTOR.
• ALSO THERE WERE 2 THEORIES TO EXPLAIN.
 THE 20 INCH PIPE THEORY (PART-1)
• THE 20 INCH BYPASS ASSEMBLY FAILED DUE TO ITS UNSATISFACTORY DESIGN FEATURES.
HOWEVER, THE ASSEMBLY HAD SURVIVED 2 MONTHS OF NORMAL OPERATION.
• A NUMBER OF INDEPENDENT PRESSURE TESTS WERE COMMISSIONED TO DETERMINE UNUSUAL
CONDITIONS BUT THE PIPE SURVIVED THOSE.
• THE NORMAL WORKING PRESSURE WAS 8 BAR BUT PRACTICE DURING START-UP TO ALLOW
THE PRESSURE TO BUILD UP TO ABOUT 9 BAR.
• THE SAFETY VALVES FOR THE SYSTEM, WERE SET TO DISCHARGE AT A PRESSURE OF 11 BAR, AT
PRESSURE ABOVE 11 BAR, SQUIRMING MOTION STARTS WHICH DISTORTED THE BELLOWS.
 THE 20 INCH PIPE THEORY (PART-2)

• THE SAFETY VALVES FOR THE SYSTEM, WERE SET TO DISCHARGE AT A PRESSURE OF 11 BAR, AT
PRESSURE ABOVE 11 BAR SQUIRMING MOTION STARTS WHICH DISTORTED THE BELLOWS.
• EVEN WHEN THE ASSEMBLY SQUIRMED, NO RUPTURE WAS OBSERVED UNTIL PRESSURE
CROSSED 14.5 BAR, A PRESSURE NOT ACHIEVABLE IN REACTORS.
• SIMULATION TESTS WERE NOT ABLE TO REPLICATE FAILURE AT SIMILAR CONDITIONS.
• REPORT CONCEDED AMBIGUITY IN THE HYPOTHESIS.
 THE WATER THEORY (PART-1)

• IT EXAMINED THE EFFECTS OF NOT OPERATING THE NO. 4 REACTOR STIRRER DURING THE
START-UP AT A TIME WHEN WATER MAY BE PRESENT.
• CYCLOHEXANE AND WATER ARE NORMALLY IMMISCIBLE, AN AZEOTROPE FORMS DUE TO THE
LIMITED SOLUBILITY OF WATER IN CYCLOHEXANE.
• THIS AZEOTROPE HAS LOWER BOILING POINT THAN EITHER WATER OR CYCLOHEXANE, UNDER
CERTAIN CONDITIONS IT CAN BOIL AND ERUPT VIOLENTLY EJECTING CYCLOHEXANE AND
SUPERHEATED WATER FROM THE REACTOR.
 THE WATER THEORY (PART-2)

• IT IS NORMALLY IMPOSSIBLE FOR WATER LAYER TO FORM DUE TO DISPERSION OF WATER BY

AIR DISTRIBUTION.
• AS THE STIRRERS ARE RUNNING DURING START-UP NO WATER LAYER FORMS, BUT IF STIRRER
STOPS, A LAYER OF WATER COULD FORM TOGETHER WITH THE UNSTABLE AZEOTROPE.
• AS TEMPERATURE OF REACTOR INCREASES, BOILING POINT OF AZEOTROPE IS REACHED AN
THERE IS A POSSIBILITY OF A SUDDEN VIOLENT ERUPTION FROM THE REACTOR AND EJECTION
OF SLUGS OF LIQUID REACTANT.
• SLUGS EXERT HIGH MECHANICAL FORCES ON THE BYPASS ASSEMBLY, LOOSELY SUPPORTED BY
SCAFFOLDING, IT CAUSES BYPASS ASSEMBLY TO FAIL WITHOUT THE HIGH STATIC PRESSURE IN
THE REACTORS.
 THE QUESTION

WHICH THEORY IS MOST PROBABLE, THE 20-INCH PIPE THEORY OR THE WATER
THEORY AND WHY?