Accident Anniversaries: Honoring Lives and Learning Lessons

Welcome to Process Safety with Trish and Traci, the podcast that aims to share insights from past incidents to help avoid future events. This podcast and its transcript can be found at chemicalprocessing.com. I'm Traci Purdum, editor-in-chief of Chemical Processing. And as always, I'm joined by Trish Kerin, the director of the IChemE Safety Centre. Happy New Year, Trish.

Trish: Happy New Year to you, too, Traci, and all the listeners out there.

Traci: Yeah. We're winter, you're summer, but it's a new year, and we're ready to go. As with any start to a new year, it's always good to get a glimpse of what to expect. I wanted to dedicate this podcast to highlight some of the episodes we'll focus on this year.

Each year we record podcasts highlighting anniversaries of incidents. And as always, a lot of great lessons learned. But are there other reasons why it's important to commemorate these anniversaries?

Trish: Yeah. I think, for me personally, there are two really important reasons to continue to reflect back and commemorate the things that have happened in the past.

One of them obviously is what can we learn? What happened in that event that we can take, and change and do differently in the future so hopefully we never see that sort of event again? That's one reason.

But the second reason I think is really important as well. That's that I think we owe it to the people that were involved to just take a moment to remember them. There's often a saying that legislation and standards is written in blood, and it is. It's written in the blood of the people that were killed, that led to the changes in rules and laws that we have today. I think it's really important to just take that moment and reflect that this is not a theoretical exercise. This is about people's lives. This is about we do or fail to do, every day that potentially leads to someone surviving or not surviving at work. I think we owe it to those that we've lost to take a moment and reflect on their legacy.

Traci: I think that's very important and very honorable to hopefully give some sort of reasoning that they didn't perish in vain, that they can go on. The lessons learned from it can really help others so I think that's very important.

But some of these incidents, they're very old now. Haven't we already learned from them?

Trish: Well, you'd like to think we have. Ultimately, we're still seeing the same sorts of incidents take place. We're still seeing incidents related to poor management of change. We're still seeing poor maintenance, corrosion, isolation incidents. We're seeing all of these things occur again and again and again.

Now, fundamentally, the physics and chemistry of what we do hasn't changed, so we're bound by the laws of physics and chemistry. Unfortunately, we can't just change those laws or break them. We're stuck with them. They are what they are. That means that the hazards are actually all still there and all the same. So we need to make sure that we do try and continue to learn those lessons because, as generations move on, sometimes the lessons of the past are forgotten. We slip in, and that same hazard is still there. If we fail to manage it adequately this time, we're going to have the incident again.

I see repeat incidents occur, time and time again, all over the world. Unfortunately, there's nothing new. We're not learning any new ways to have these incidents. They're all the same standard hazards that are still causing incidents today.

Traci: There are a lot of significant anniversaries coming up here in 2024. I wanted to talk a little bit about a few of them, on a high level, as sort of a teaser for what we're going to discuss throughout the year, all those lessons learned from these topics and these anniversaries.

First off is a congratulatory one. 10 years for the IChemE Safety Centre, congratulations. Can you talk a little bit about how the ISC came to fruition and what the goals are for the next 10 years?

Trish: Yeah. 10 years ago, on the 6th of January, the ISC officially started its operations. It started in Melbourne, Australia, where I live, as the director and the person that started it, that's where its officially headquartered. It was an idea that was born out of some conversations that our IChemE president at the time, Dame Judith Hackitt, had been having, where she wanted to see IChemE do something that really brought together groups of people in process safety. We had an ambition to become this global hub of best practice, and learning, and sharing in process safety. That's where it started, with an idea and six initial upstream oil and gas companies that said, "That sounds like a good idea, we'll fund that for three years."

10 years later, we have over 100 organizations that are a part of our center. We cover a wide range of industry sectors. We've moved beyond just upstream oil and gas to all sorts of different sectors, from mining and minerals, to pulp and paper, to water treatment, energy generation, as well as upstream, downstream, midstream. A whole range of different organizations that we engage with. Even the aviation sector now as well. We're looking at how we can create those best practices for sharing and learning. It's been a very exciting ride.

Over the last 10 years, some of the things that I've looked back and things that I've achieved, and things that the center has achieved over that time, to be honest, 10 years ago I never thought they were possible. I didn't even imagine them. I'm really excited about the next 10 years. I think the center has a great future. We're still continually growing. We grew by over 14% in membership last year. I'm looking at maintaining fairly high membership growth so that we can continue to spread to different sectors. Because we can learn a lot from talking to people in our own industry sector, but we can learn even more from talking to people outside our industry sector because they challenge our thinking. Some of them still face identical hazards, but they challenge how they manage them versus how you might manage them. That creates another level, another dimension of learning.

I think there's an exciting 10 years ahead. We'll be writing and producing more guidance documents, more case studies. Obviously, looking at some of the emerging technologies and what the hazards are in there, and how we can manage those more effectively. What can we learn from some of the older industries, so that the new emerging industries don't have to learn them the hard way? We've already had these incidents, we don't have to learn them again. We need to get smarter about it. I'm really excited about taking that forward.

Traci: Well, congratulations once again. And again, not learning the hard way is hopefully what we're trying to do here as well with this podcast, is giving those lessons as well.

This year marks the 20th anniversary of the LNG explosion in Algeria. I know we're probably going to talk about that this year, as a lessons learned. Can you give us a little bit of a high level of that?

Trish: Yeah. That incident killed 27 people when it occurred. There was a release of LNG out of one of the trains. That was then ingested into a boiler. It's around understanding the management of, if there is a release of a flammable substance, how are you managing possible ignition sources? That LNG was able to get into the boiler, which then caused the explosion. So focusing on things like understanding how you're going to manage potential ignition sources when a loss of containment does occur. Unfortunately, we can't assume a loss of containment won't occur. We need to manage so it doesn't. But when it does, we need to be able to respond.

Traci: Another anniversary, 105 years since the Boston molasses spill. I was in Boston five years ago, so the 100th anniversary, and you couldn't go anywhere without hearing the folklore of smelling molasses on hot summer days. Can you give us a little bit of insight there?

Trish: Yeah. That one also, apparently, it prompted the saying of, "Slow as molasses in January." But in fact, molasses in January in Boston 105 years ago didn't move slowly. It was estimated that when a tank of molasses actually burst, a wave of molasses flowed down the streets at up to 25 miles an hour. Think about how fast that is, when you think about it being molasses.

Now, that killed 21 people in that particular incident. There were issues with inappropriate design of the tank, and then inspection and maintenance. The tank was not fit for purpose. It should not have been storing molasses. And then, it was not being maintained either, which further weakened it's ability to store the molasses. How we design our facilities is critically important. And then, how we make sure that maintain and inspect them adequately.

Traci: 45 years ago, the flour dust explosion at The Roland Mill in Bremen, Germany. Was this one of the first major incidents that brought combustible dust into focus?

Trish: Yeah, I believe it actually was. Quite some time ago, when we started to see this, dust had always been exploding but this was one that particularly created a lot of interest and focus. It killed 14 people. Again, it's around understanding that dust is combustible, even if it's food. We can't just assume that because we eat that substance, it's safe.

Now, flour mills, sugar mills, grain mills, they all have the potential for dust explosions and we do see those occur around the world, even today. Managing your combustible dust so that it doesn't build up, managing your ignition sources in the area so that you don't ignite it. Because one of the challenges with dust explosions is usually the first one is little. It's a small, little fire. But that liberates the dust that's built up on surfaces, that creates a much bigger dust cloud, so usually the subsequent explosions are much more violent and significant.

Traci: This next one is making me feel old. 35 years since Valdez. A friend of mine left when that happened, to go out and help with the cleanup for that. Obviously, this is ingrained in our history. But what are we still learning from this one?

Trish: Well, one of the key things that we went to after this was the requirement for double-hulled tankers. So that if an oil tanker does ground, it doesn't put a hole immediately in the oil tank. The Valdez was a single-hulled tanker.

There's also a lot around making sure that we really are clearly understanding the navigation requirements, having the use of pilots in treacherous areas. And just making sure, in general, that we've got good operating processes and procedures with what we're doing. And again, then response capability. If we're going to be working in areas that potentially can have quite a significant impact in an incident, we need to make sure we can adequately respond to them.

Obviously, everybody that was alive at the time, I'm sure, will remember some of the images of the birds and the sea life, covered in oil. We always see a lot of those when it comes to an environmental impact that like. So how we can actually minimize the impact, if something happens.

Traci: Flixborough, we're coming up on that 50-year anniversary. Flixborough is in text books, right? This is something that we study all the time. Hasty equipment modification was to blame here, is that correct?

Trish: Yeah. Some changes were made to the plant to keep it running whilst they did some repair work on other parts of the plant. It wasn't adequately designed. It also was a situation where the people that were in charge of doing that work weren't actually competent in that particular activity either. There's a few different elements that do come out in Flixborough, and it is one of the classic ones that we talk about, we still teach about quite a lot. It killed 28 people, not only in the facility but also in the neighboring town. And really, a landmark event. It changed the legislative framework in the UK at the time, which has followed on elsewhere.

It also led to the development ... Or, it coincides with the development, sorry, of IChemE's Loss Prevention Bulletin, which is our lessons learned document that we produce. That's a really positive that's come out of it, that we've been publishing the Loss Prevention Bulletin now for 50 years, following the Flixborough incident as well. That continues to go strong, too.

Traci: Now, in the beginning, we were talking about being able to honor those that lost their lives during these incidents. We're coming up on the 35-year anniversary of the Phillips Petroleum incident in Pasadena, Texas. This is where Mary Kay O'Connor lost her life, and the MKO Process Safety Center was named after her to bring attention to these types of incidents, and to try and mitigate future incidents. Can you talk a little bit about it?

Trish: Yeah. That particular incident, it did kill 23 people. Obviously, Mary Kay O'Connor was one of those that we know of. It was related to some isolations not being adequately done, that then led to a leak and a subsequent explosion that occurred. Coming out of that, Mary Kay O'Connor's husband, T. Michael O'Connor, decided that he wanted to change how safety was taught to engineers so that nothing like this ever happened again. I think that's an incredibly noble gesture and action that Mike took.

Sadly, we lost Mike a couple of years ago. He passed. But, the Mary Kay O'Connor Process Safety Center is still going strong with its aim of making safety second nature. To help educate engineers into the future in process safety, so that we don't see another incident like this happen again.

Traci: One of the other big anniversaries that we're going to be commemorating this year via single source podcast is 40-years since Bhopal. What are we still learning here?

Trish: Bhopal was and is still the worst industrial disaster the world has ever seen. It also had significant environmental impacts, too. The Bhopal incident killed an estimated at least 5000 people. We don't know how many people it actually killed, though. It also made hundreds of thousands of people ill, ongoing birth defects, related chronic illnesses in that area in Bhopal. So the release of a toxic gas cloud.

Now, there were issues with the plant design and construction. In fact, the design was identical to a plant that was operating in the US at the time. The design was good. The issue that occurred was it wasn't built to design. There were changes made. It was built with some concepts of inherently safer design principles, but they were then stripped out. It wasn't maintained adequately. In the end, there wasn't competence to operate it. There's a range of different things that we need to focus on. The inherently safer design, looking at how we maintain and operate, looking at making sure we have the right competence for people in the workplace as well, so they can adequately operate the facility.

For me, one of the worst things about Bhopal is the fact that the facility is still there, in ruins. It is still contaminated. It is still currently contaminating the environment in that city. It's a very large city in India, where people are still living. Peoples today are still being made sick because of that Bhopal incident. I think from an industry perspective, it's a terrible blight on all of us as professional engineers, that Bhopal is still physically sitting there as a contaminated site. Hopefully, we can get something done about that into the future, but it's been 40 years and we still haven't seen it fixed.

Traci: Is there anything that you'd like to add?

Trish: I think, really, just encourage people to be curious about why things happen and the sorts of incidents that have occurred. Asking questions, thinking about, "Well, why is that? Why do we do something a particular way? Or this incident that I noticed, what caused it? What can I do to make sure that doesn't happen again?" I think there's some really important things, attributes, as professionals, and as leaders, and as engineers that we need to think about. We need to be more curious, we need to ask questions.

If any of these incidents that we've very briefly touched on today, if any of them you think, "I'd like to know a little bit more about that," take the next step, and go and look it up. There's an enormous amount of information on the internet on any one of these incidents that we've discussed today. Go check them out. Check out our Minute To Learn incident anniversary videos that the Safety Center puts out. Check out our podcasts. Go and read Loss Prevention Bulletin. Or go and read Process Safety Progress. Both of those two publications produce really high quality process safety lessons learned and case studies. Go have a read of them, see what's in them. Be curious, find out why and make sure that you embed that learning in your mind so you don't make that same mistake again at some point in the future.

Traci: Well, as always, Trish, you are a champion of safety and of disseminating great information and lessons learned. Unfortunately events happen all over the world, and we will be here to discuss and learn from them, including all of the anniversaries that we've highlighted today. Subscribe to this free podcast so you can stay on top of best practices. You can also visit us at chemicalprocessing.com for more tools and resources aimed at helping you run efficient and safe facilities.

On behalf of Trish, I'm Traci and this is Process Safety with Trish and Traci.

Trish: Stay safe.