Loss Prevention Bulletin

Improving process safety by sharing experience

Parallels between Beirut 2020 Issue 284, April 2022

and Texas City 1947

Port of Beirut – lessons

from the ammonium
nitrate explosion
Beirut – responding
to incidents
Texas City 1947 –
America’s worst
industrial accident
Hydrogen projects –
business as usual?
Beirut image: Diplomedia/Shutterstock.com

Reactive chemistry
case study
Accidents of the
future – part 6

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 Loss Prevention Bulletin 284 April 2022 | 1

Contents
2 Port of Beirut — lessons 16 Hydrogen projects –
Loss Prevention Bulletin from the ammonium business as usual?
nitrate explosion that Clare Dunkerley describes how by
Articles and case studies applying known and established
devasted the peninsula
from around the world Zoha Tariq discusses the events
techniques of hazard identification,
risk assessment, risk analysis
Issue 284, April 2022 leading to the 2020 Beirut
and best industry practice,
explosion, its impact and the
the hydrogen roadmap can be
Editor: Tracey Donaldson main issues in avoiding a future
achieved.
Publications Director: recurrence.
Claudia Flavell-While 23 Reactive chemistry case
Subscriptions: Hannah Rourke 7 Beirut — responding to
incidents study
Designer: Alex Revell Andrea Longley describes the
David Evans reviews the
Copyright: The Institution of Chemical findings from an investigation into
ammonium nitrate explosion
Engineers 2022. A Registered Charity in an explosion and fire at a batch
in Beirut in terms of whether
England and Wales and a charity registered processing facility when the wrong
organisations that handle
in Scotland (SCO39661) chemical was inadvertently added
dangerous substances
to a tank.
ISSN 0260-9576/22 should review their response
arrangements.
The information included in lpb is given in 27 Accidents of the future –
good faith but without any liability on the 11 Texas City 1947 — part 6
part of IChemE In the sixth part of this series, an
America’s worst industrial explosion in an hydrogen fuelling
Photocopying accident station and a fatal explosion in the
lpb and the individual articles are protected
by copyright. Users are permitted to Phillip Carson and Tony Fishwick small-scale distillery industry are
make single photocopies of single articles review the devastating chain of predicted.
for personal use as allowed by national events in 1947 that resulted in
copyright laws. For all other photocopying extensive damage and a huge loss
permission must be obtained and a fee of life, drawing parallels between
paid. Permissions may be sought directly this and the 2020 Beirut explosion.
from the Institution of Chemical Engineers,
or users may clear permissions and make
payments through their local Reproduction
Rights Organisation. In the UK apply
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 2 | Loss Prevention Bulletin 284 April 2022

Incident

Port of Beirut — lessons from the ammonium

nitrate explosion that devastated the peninsula
Zoha Tariq, University of Strathclyde, UK
What set the disaster in motion?
Summary
On 04 August 2020, Port Beirut saw what was to be one
Timeline
of the biggest ammonium nitrate explosions since 2000,
when 2,750 tonnes of stored NitroprilTM, equivalent to 1.3 Beirut blast – a timeline of events
kt of TNT1, was detonated. With a death toll of 207 people
and 7500 injured2,3 and $15 billions of reported property MV Rhosus sets sail
damage4, the disastrous incident ranks amongst the top carrying 2,750 tonnes
ten of the largest accidental explosions, and attracted of technical-grade
ammonium nitrate
the attention and scrutiny of political, humanitarian, and
scientific groups across the world. This was not the first MV Rhosus makes 27 September 2013
chemical hazard involving ammonium nitrate, and there port in Beirut
were significant failings to adopt the appropriate safety
protocols to prevent the resulting explosion. 21 November 2013

Keywords: Beirut, ammonium nitrate Beirut Port authorities

seize MV Rhosus; Nitrate
cargo is brought ashore
and stored at
Warehouse 12
Ammonium nitrate — the catalyst for disaster 4 February 2014
Ammonium nitrate is a chemical compound that is
MV Rhosus sinks in
manufactured when ammonia gas is reacted with liquid nitric the harbour
acid. Widely used in agricultural applications as a fertilizer along
with other applications in the manufacture of mining explosives, February 2018
ammonium nitrate is a highly combustible compound when A fire breaks out at
combined with oils or other fuels, or when exposed to Warehouse 12 Beirut Port
extremely high temperatures (temperatures should not exceed
4 August 2020 6pm
210°C); therefore, transport and storage should be planned (local time)
and implemented with these parameters in consideration.
Ammonium nitrate is considered an oxidiser, classified First explosion triggered
by the fireworks with
under the GHS of Classification and Labelling of Chemicals as the ammonium nitrate
a Class 5.1 oxidising substance5. This means that at an atomic cargo at Warehouse 12
level, it removes electrons from other substances in a chemical
4 August 2020 6:07pm
reaction. As an oxidiser, ammonium nitrate possesses the ability (local time) Final explosion devastates
to increase the burning of fuels by increasing the oxygen that central Beirut, sending
is available to those fuels, hence its applications in explosives up a massive orange-red
cloud of nitrogen dioxide
manufacture. into the air
Ammonium nitrate must encounter an open flame or other
ignition source to spark a reaction; once it does, it explodes 4 August 2020 6:07pm
violently6. NitroprilTM is a technical-grade, explosive variant of (local time)
– 33 seconds later
ammonium nitrate. Based on the manufacturer’s safety data
sheet7, NitroprilTM is specifically designed to be used as an
oxidiser in blasting agents. Storage requirements include that
it be kept dry, away from ignition/heat sources, and stored in
well-ventilated areas8. Figure 1 – A simplified timeline of events leading to the explosion

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 Loss Prevention Bulletin 284 April 2022 | 3

Even though the explosion took place in 2020, the events that Armed Forces, or sold to the private Lebanese Explosives
set the disaster in motion took place years prior. Company16. One of the letters sent in 2016 noted that judges had
In September 2013, Moldovan-flagged ship MV Rhosus set sail not replied to previous requests, and pleaded16:
from Batumi, Georgia enroute to Beira, Mozambique9, carrying
2,750 tonnes of technical-grade ammonium nitrate. When the
“In view of the serious danger of keeping these goods in
ship made port in Beirut, an inspection by the port state control
the hangar in unsuitable climatic conditions, we reaffirm our
deemed the ship unworthy and forbid it to set sail10. Due to unpaid request to please request the marine agency to re-export these
fines, the Beirut Port authority seized the ship, with the ammonium goods immediately to preserve the safety of the port and those
nitrate cargo being brought ashore and stored at Warehouse 12, working in it, or to look into agreeing to sell this amount.”
where it remained for the next six years. Warehouse interior
Disaster struck on 04 August 2020, at 6 p.m. local time, when
a fire broke out at Warehouse 12. A team of nine firefighters The interior of Warehouse 12, as mapped through examination
and one paramedic (Platoon 5)11 were sent to control the fire. of opensource information such as videos, photographs, and
However, the fire ignited some fireworks that were stored with documents, by Forensic Architecture17, a research agency based at
the ammonium nitrate cargo, triggering the first explosion and Goldsmiths, University of London, shows 2750 bags of ammonium
sending up a huge cloud of smoke12. Only 33 seconds later, the nitrate being stored on the floor. The reported stock of 23 tonnes
final explosion devastated central Beirut, sending up an orange- of fireworks and 1000 car tyres is not visible in the picture.
red cloud of nitrogen dioxide (a by-product of ammonium nitrate It is seen in Figures 2 and 3 that ammonium nitrate was not
decomposition) into the air. This explosion was destructive and stored in compliance with the Australian Standard AS 43263118 as
substantial, with shockwaves being felt in Turkey, Syria, Israel, advised by its safety data sheet7, but had been merely dumped on
parts of Europe, and Cyprus13. The detonation at Warehouse 12 the warehouse floor.
also caused a chain reaction, when a nearby ship, also carrying Gareth Collet, an explosives expert for the UN, worked with
ammonium nitrate, exploded, setting fire to chemical tanks and oil Forensic Architecture, and stated that from an engineering point of
refineries near the port. view, the arrangement of goods within the building was the spatial
layout of a makeshift bomb on the scale of a warehouse, awaiting
Appeals to government detonation. He further added “ammonium nitrate is extremely
The ammonium nitrate cargo was stored in a light-skinned difficult to detonate by fire alone. However, when confined
general cargo warehouse, which was inappropriate for the and contaminated, this… can lead to catastrophic detonation.
storage of dangerous products due to its location, construction It is sensitised by the presence of even the smallest quantity of
standard, environmental protection, and security measures7. additives and hence should be separated”17.
The port authorities, aware of the risks of storing technical-grade A comparison of the actual layout of the ammonium nitrate bags

knowledge and
competence
ammonium nitrate at the warehouse that was not adapted to at the port warehouse was conducted with the internationally
the storage conditions required by ammonium nitrate7, lacked recognised standards such as INDG23019 and AS 43263118
the resources and court approval required to move it to a more standards
suitable facility more in-line with the safety guidance.
According to an investigation conducted by the General
Causes

engineering
and design
Directorate of State Security14, port officials had warned of the Through Figure 3, it is observed that fireworks and tyres were
dangers of storing enormous amounts of explosive chemicals stored in close proximity to a cargo of potentially explosive
at the port through several letters, including a private letter to ammonium nitrate, going against recommended storage
President Aoun and PM Hassan Diab on July 20, 202014, warning instructions. The entire 2750 tonnes cargo of this explosive
of the dangers of security risk and requesting its removal at least chemical was stored in one place, rather than being divided up

systems and
six times15, but this advice was not heeded. and sent off to separate storage facilities to reduce the risk

procedures
It had been repeatedly advised by Lebanese customs officials associated with containment.
in letters regarding the issue of the confiscated cargo, that the Furthermore, there was no segregation — the entire cargo
ammonium nitrate be either exported, given to the Lebanese was kept in a single restricted stack. Stacked bags or sacks apply
assurance

Figure 2 – Layout of ammonium nitrate bags as recreated by Forensic Architecture17

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 4 | Loss Prevention Bulletin 284 April 2022

Figure 3 – A comparison of the layout of the elements stored inside Warehouse 12, and how they are required to be laid out
according to the British and Australian standards17

static pressure to the AN, which might cause changes in the window for disaster.
crystal structure and hence increase chemical sensitivity which Therefore, the definitive cause was oversight; oversight by the
would have hindered firefighting even if the fire service had timely government officials and inspection authorities, as they failed to
access to the storage site in the event of a fire breaking out. understand the extent of the danger posed by mismanagement
The ammonium nitrate was also directly exposed to the
of safety protocols regarding storage of 2,750 tonnes of
atmosphere during its storage, where it would have become
ammonium nitrate at one of the biggest commercial ports in
progressively more contaminated with dust and other organic
matter and would have absorbed moisture from the humid the country bordering densely populated civilian areas. All the
maritime atmosphere. other causes branch out from this one crucial failure in regulating
The failure to remove ammonium nitrate cargo from the the ammonium nitrate properly. The storage of technical-grade
warehouse to a more suitable storage location, combined with ammonium nitrate at Beirut Port was not part of its regular
the inappropriate conditions in which this ammonium nitrate operations, though many appeals by the port authorities to move
was stored at the warehouse, was what ultimately provided the the cargo were over-ruled15, 16.

Businesses and The blast created a 400 ft (120m) wide crater where the port used to be30 causing an astounding $15 billion in property damage, leaving
infrastructure about 300,000 people homeless and 50% of businesses and service sectors damaged.
ruined

Healthcare The healthcare sector was amongst the most critically affected, with 292 healthcare facilities damaged in the aftermath of the explosion
(equating to about 36% of the healthcare facilities in the region), reducing the access and quality of medical care available20.

Environmental The blast produced enormous white and orange-red clouds8 containing white ammonia mist (NH3), HNO3, H2O vapours, and hazardous
impact and toxic NOX compounds nitrous oxide (N2O), nitric oxide (NO), and nitrogen dioxide (NO2).
Nitrogen dioxide was particularly dangerous during the COVID-19 crisis, as it is known to damage respiratory systems in several ways.
In fact COVID-19 cases rose from 177 on 3 August to 334 on 14 August8.
Toxic plumes from the explosion were dispersed within 24 hours, but the long-term environmental repercussions currently remain
unexplored.

Commercial panic Concerns were raised regionally and beyond about the storage of ammonium nitrate and other similar chemicals at ports across the
world21. Despite its dangers, ammonium nitrate demand continues to grow in the chemical industry, with an estimated 3% increase in
market size by 202621, which makes it more imperative than ever to enforce proper safety, handling, and storage regulations.

Table 1 – Impact analysis of the Beirut explosion

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 Loss Prevention Bulletin 284 April 2022 | 5

Impact analysis of Beirut explosion (see Table 1) surrounding conditions.

The explosion in Beirut, was a combination of inappropriate
Lebanon was undergoing a huge economic crisis (caused by
storage conditions, and a lack of oversight by the government
local civil wars and a refugee crisis due to wars in neighbouring
and intransigence by the courts towards addressing the safety
Syria), causing a rise in poverty and unemployment rates and
concerns which had been raised.
massive inflation. This crisis was already worsened by the
Therefore, in legislative drafting, a priority should be given
COVID-19 pandemic, and combined with the aftermath of
to developing policies that enforce application of recognised
the explosion, there is considerable strain on the government,
standards and regulations, along with good governance and
healthcare systems, banks, and individuals.
responsibility, in storing ammonium nitrate. Port areas should
be developed and prepared to manage hazardous cargoes
Hazard prevention and risk control which they are required to store but are not part of their normal
Most of the time, the root cause of a chemical accident or planned operations.
disaster is lack of awareness of the hazards and inappropriate The key lesson here is that disaster prevention is not just
measures to control the risks, rather than equipment failure. about preventing importers and distributors from storing large
It is obvious that Lebanon has a chemical storage problem, amounts of chemicals improperly; hazards and risks are now
not only looking at the Beirut explosion, but also the fire at present throughout the industrial supply chain.
Beirut Port on 10 September 202222, 23 caused by the ignition of There should be an effective organisational structure
a tyre and oil store, injuring at least 14 people, along with the and communication in place at the site to ensure all safety
hazardous chemical clean-up operation that led to the discovery procedures are being followed. There is an also essential need
of at least 59 containers of dangerous chemicals24,25 abandoned of good leadership and effective government policies along
at warehouses like the ammonium nitrate cargo. There is a with detailed chemical safety procedures, to attain world-
desperate need for a national Chemical Regulatory Agency in class safety performance. Organisations should augment their
Lebanon to oversee and implement chemical safety measures systematic risk-based policies with pragmatic measures. The
and adopt preventive strategies for chemical industries across goal should be to design a system that is resilient and does not
the entire country. collapse due to human error.
Lebanon does not currently have legislation specific to The only way to prevent chemical incidents such as the Beirut
ammonium nitrate handling and storage. The handling and explosion is to take a rigorous, collaborative approach to safety.
storage of hazardous chemicals is regulated by Decree No. It is necessary for government officials and policymakers to
11802 of 2008 on Occupational Health and Safety26, which take a proactive and collaborative approach to develop national
provides the standard Health & Safety measures for any legislation and regulations to implement chemical safety
workplace, covering ventilation, passageways, storage building measures, including their storage, handling, and transport,
specifications, warning signs, and training. Ammonium nitrate along emergency preparation in response to any small- or large-
is categorised as an explosive under the Legislative Decree scale incidents.
No.137 regarding weapons and ammunition27. Chapter 5 of
this decree prohibits possession or sale of explosives without References
proper licenses, with Article 53 instructing special warehouses
to be established to store explosive materials. Additionally, Law 1. Ang, C. (2020, August 6). The Biggest Ammonium Nitrate
No. 444 of 2002 on Protection of the Environment (Part VII) explosions since 2000. Retrieved from Visual Capitalist:
requires a permit to be obtained for the import and storage of https://www.visualcapitalist.com/biggest-ammonium-
dangerous materials or chemicals28. nitrate-explosions/
Legislation can, however, only be drafted and enforced 2. Khoury, J., & Landau, N. (2020, August 5). Massive Beirut
properly through organised governmental action: The Port blast kills over 100, leaves thousands wounded.
prevention and control steps identified will offer an essential Retrieved from Haaretz: https://www.haaretz.com/
point of discussion for government officials and policymakers middle-east-news/massive-explosion-shakes-lebanese-
to build and implement an effective chemical safety framework capital-buildings-near-beirut-port-damaged-1.9046138
that not only includes regulation and storage protocols, but also 3. Nasrallah, H., & Rose, S. (2020, August 4). Many injured as
guidance on emergency services and disaster preparedness, large blast rocks Beirut. Retrieved from BBC News: https://
which will prevent such disastrous incidents from taking place www.bbc.com/news/world-middle-east-53656220
in the future, but top-down management with connectivity and 4. Hussain, N. Z., & Cohn, C. (2020, August 7). Insured losses
efficient information-flows should be implemented to monitor from Beirut blast seen around $3 billion. Retrieved from
industrial and chemical operations. Co-ordination between Reuters: https://www.reuters.com/article/us-lebanon-
private-sector and industries should be strengthened to avoid security-blast-insurance/insured-losses-from-beirut-blast-
gaps in national regulatory frameworks. seen-around-3-billion-sources-idINKCN2532IF?edition-
redirect=in
Conclusion 5. Seddon, B., & Shiotani, H. (2020). The Beirut Port
Past incidents have shown that ammonium nitrate is not Explosion: Understanding its impact and how to reduce
always stored appropriately, and amongst accidents involving risks from explosive precursors. Geneva, Switzerland:
ammonium nitrate, the leading cause has been uncontrolled fire UNIDIR.
due to ignition of the stockpile8. But ammonium nitrate cannot 6. Staff, L. S. (2020, August 5). Beirut Blast: How does
be ignited by itself, and its trigger usually lies in storage and Ammonium Nitrate create such devastatting explosions?

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 6 | Loss Prevention Bulletin 284 April 2022

Retrieved from Live Science: https://www.livescience. SAI GLOBAL: Standard Legislation: https://www.saiglobal.
com/28841-fertilizer-explosions-ammonium-nitrate.html com/pdftemp/previews/osh/as/as4000/4300/4326.pdf
7. Orica. (2021, November 9). Safety Data Sheet. Melbourne, 19. HSE: Health and Safety Executive. (1996). Storing and
Australia. Handling Ammonium Nitrate. Retrieved from HSE: Health
8. Al-Hajj, S., Dhaini, H. R., Mondello, S., Kaafarani, and Safety Executive: https://www.hse.gov.uk/pubns/
H., Kobeissy, F., & DePalma, R. G. (2021, June 4). indg230.pdf
Beirut Ammnium Nitarte Blast: Analysis, Review, and 20. International Medical Corps. (2021). Beirut Explsion:
Recommendations. Retrieved from Frontiers in Public Situation Report 9. International Medical Corps .
Health: Pilicy and Practice reviews: DOI: 10.3389/ 21. Taylor, A. (2020, August 21). After Beirut, ports around the
fpubh.2021.657996 world searched for dangerous chemicals. Some didn’t like
9. BBC News. (2020, August 7). Beirut explosion: How ship’s what they found. . Retrieved from The Washington Post:
deadly cargo ended up at port. Retrieved from BBC News: https://www.washingtonpost.com/world/2020/08/21/
https://www.bbc.com/news/world-middle-east-53683082 after-beirut-ports-around-world-searched-dangerous-
10. Dagher , C., & Maksoud, C. (2015, October). MV Rhosus chemicals-some-didnt-like-what-they-found/
- Arrest and Personal Freedom of the crew. Retrieved from 22. Abueish, T. (2020, September 10). Fire erupts in Beirut
shiparrested: https://shiparrested.com/wp-content/ Port over a month after deadly explosion. Retrieved from
uploads/2016/02/The-Arrest-News-11th-issue. Al-Arabiya News: https://english.alarabiya.net/News/
pdf#page=3 middle-east/2020/09/10/Fire-erupts-in-Beirut-port-over-a-
month-after-deadly-explosion
11. Kohnavard, N. (2020, August 16). Beirut Explosion: the
story of Platoon 5. Retrieved from BBC News: https:// 23. Tidey, A. (2020, September 10). Large fire in Beirut Port
www.bbc.com/news/av/world-middle-east-53797998 weeks after huge explsoion. Retrieved from Euronews:
https://www.euronews.com/2020/09/10/watch-live-
12. BBC News. (2020, August 11). Beirut explosion: what we
large-fire-in-beruit-port-weeks-after-huge-explosion
know so far. Retrieved from BBC News: https://www.bbc.
com/news/world-middle-east-53668493 24. DW. (2021). Lebanon: Beirut ship carrying hazardous
materials to soon depart for Germany. Retrieved from
13. Sarah El Deeb, & Bassem Mroue. (2020, August 5). In
DW: https://www.dw.com/en/lebanon-beirut-ship-
a horrific instant, a burst of power that ravaged Beirut.
carrying-hazardous-materials-to-soon-depart-for-
Retrieved from AP News: https://apnews.com/article/
germany/a-57394538
ap-top-news-international-news-middle-east-lebanon-fires-
7a104960789d9b25e89a889fbbc125e7 25. TRT World. (2020, August 11). More dangerous chemicals
found at Lebanon’s Beirut Port. Retrieved from TRT World:
14. Nakhoul, S., & Bassam, L. (2020, August 11). Lebanon’s https://www.trtworld.com/middle-east/more-dangerous-
leaders were warned in July about the explosives at chemicals-found-at-lebanon-s-beirut-port-38807
port. Retrieved from Reuters: https://www.reuters.
26. The President of Republic, L. (2008, June 6). Decree No.
com/article/us-lebanon-security-blast-documents-excl-
11802- Regulating Occupational Prevention, Safety and
idUSKCN2562L7
Health in all Enterprises subject to the Code of Labour.
15. Walsh, D., & Higgins, A. (2020, August 5). Blame for Retrieved from International Labour Organistaion (ILO):
Beirut Explosion begins with a leaky, troubled ship. https://www.ilo.org/dyn/travail/docs/713/Decree%20
Retrieved from New York Times: https://www.nytimes. No.11802.pdf
com/2020/08/05/world/middleeast/beirut-explosion-
27. President of the Republic, L. (1959, June 12). Weapons
ship.html
and Ammunition: Legislative Decree No.137.
16. Azhari, T. (2020). Beirut Blast: Tracing the explosives that Retrieved from http://77.42.251.205/LawView.
tore the capital apart. Al Jazeera. aspx?opt=view&LawID=180890
17. Forensic Architecture. (n.d.). The Beirut Port Explosion. 28. Food and Agricultural Organistaion of the United Nations.
Retrieved from Forensic Architecture: https://forensic- (2002). Law No.44 of 2002 on Environmental Protection.
architecture.org/investigation/beirut-port-explosion Retrieved from Food and Agricultural Organistaion of the
18. SAI GLOBAL. (1995). Australian Standard AS 4326: The United Nations: https://www.fao.org/faolex/results/
storage and handling of oxidizing agents. Retrieved from details/en/c/LEX-FAOC037678/

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Incident

Beirut — responding to incidents

David Evans, Director Corporate Resilience Solutions Ltd, Chair of the IOSH
Hazardous Industries Group, UK
submitted by global organisations, media and NGOs2,3. This
Summary paper examines the issues associated with the incident from
Do we expect too much of emergency responders? The a responder’s perspective and focuses on the early stages of
impacts of the ammonium nitrate explosion in Beirut may the emergency. It considers the event from the perspective of
be considered extreme but they raise uncomfortable issues challenging the way that emergency response procedures are
for those charged with the preparation and maintenance of developed.
emergency plans and arrangements. It would be too easy to simply dismiss the event as extreme,
This article compares the ammonium nitrate explosion with poor control of a dangerous substance and a lack of corporate
in Beruit with the West, Texas explosion some seven years governance of the responsible organisations — there is after all
earlier to consider if organisations that handle dangerous a history of large-scale incidents involving ammonium nitrate. To
substances should review their response arrangements. show that the events of Beirut with regards to incident response
are not unique, the situation has been compared with the 2013
Keywords: Incident response, emergency management explosion in West, Texas to identify common issues; the intention
being to highlight areas which could lead to improvements in the
response arrangements for any incident involving the potential of
Introduction a major accident hazard.
On 04 August 2020 an ammonium nitrate explosion at the Port of
Beirut created headline news around the world, such was the scale Major Accident Hazard: A source of danger that has

knowledge and
competence
of the devastation, the loss of life and the widespread damage the potential to cause a major incident, whether that
to the area. It was a national disaster for a country ill prepared to involves multiple fatalities and/or significant damage to
manage such a significant event. plant, equipment or the environment.
The explosion could be felt many kilometres away and reports
in the media refer to a death toll ranging from 190 to 220 deaths
and thousands of injuries. The promised judicial inquiry has been
Port of Beirut explosion
suspended (and recently restarted) owing to political intervention. The following details of the incident are extracted from a range of
With refusals of leaders to be questioned, or to vote in favour of media sources and there is no one set of agreed timings, but the
lifting immunity that protects them from prosecution, it seems sequence appears to be:
unlikely that a full analysis of the situation will be available soon. At approximately 17:30 (some reports suggest 17:40) hours on
The sequence of events can be pieced together from reports 04 August 2020 an alarm was raised, via a call from the port to the

systems and
procedures

Figure 1 – August 2020 at 5.55pm (initial explosion) and at 6:08pm (orange and mushroom cloud) at the Port of Beirut1 (Source:
Al-Hajj S, Dhaini HR, Mondello S, Kaafarani H, Kobeissy F and DePalma RG (2021) Beirut Ammonium Nitrate Blast: Analysis,
Review, and Recommendations. Front. Public Health 9:657996. doi: 10.3389/fpubh.2021.657996)

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Beirut police, of a fire in a storage hangar at the docks. The local event, again an ammonium nitrate explosion, as explained in the
fire station was informed and a team of responders mobilised. The following section.
team of ten – nine fire-fighters and a paramedic – took a fire truck
and an ambulance to the port, which was a short drive from their West Texas explosion
location in the city’s Karantina neighbourhood.
Some nine years ago in April 2013, an ammonium nitrate explosion
It is likely that the initial call reporting an incident related to a
at the West Fertilizer Company (WFC) in the city of West, Texas
fire in an area where fireworks were being stored. This seems to
resulted in 15 fatalities, including 12 emergency responders who
be backed up by social media reports and photographs1 but, with
were called to the incident at a warehouse and office.
no inquiry to confirm the facts, details are sketchy. The fire in the
warehouse prompted the Beirut Fire Department to respond to CSB (Chemical Safety Board) in its report4 on the incident
the incident site with first responders, probably unaware of the identified the following seven key factors that contributed to the
presence of ammonium nitrate in hangar 12. There are reports of fatalities of fire-fighters and other emergency responders:
dockworkers also responding to the incident and working with • lack of incident command system
the fire fighters. Photographs are available online which show fire-
• lack of established incident management system
fighters attempting to enter hangar 12 together with a member
from the port workforce who is assisting them. Global news • lack of hazardous materials (HAZMAT) and dangerous
reports that evening showed many people filming the event from goods training
areas outside of the port and that there are pictures shared from • lack of knowledge and understanding of the detonation
phones within the port area. What is known is that prior to the hazards of FGAN (Fertilizer Grade Ammonium Nitrate)
blast, there was no notification to the public, or to other agencies, • lack of situational awareness and risk assessment
to allow for population protection in terms of rapid evacuation or knowledge on the scene of an FGAN-related fire
sheltering in place. • lack of pre-incident planning at the WFC facility
From online copies of footage filmed of the event, the initial fire
• limited and conflicting technical guidance on ammonium
and a series of explosions (timed around 17:50) can be identified
nitrate.
before the main catastrophic explosion occurred at 18:08. The
scale of the explosion immediately overwhelmed the ability of These recommendations largely focus on aspects of the response
Beirut hospitals, emergency medical services (EMS) agencies, first from a structural and organisational perspective of the emergency
responder agencies, and other responding agencies to mount an responders. In both incidents, West city and Beirut, the American
effective response. Casualties flooded the hospitals — several of Incident Command System formed the basis of the management
which had been directly impacted by the blast. In the immediate structure for handling emergencies, but whatever arrangements
response the Lebanese Army formed an incident command are in place for establishing command and control, the knowledge
structure to oversee the disaster response activities, including and experience of the responders and their access to information
operations, logistics, planning, and finance and administration. and good decision making are key attributes. The CSB report
The basis of the training and procedures for the offsite response highlights the importance of situational awareness, knowledge and
appears to have been the American ICS system. information being considered as core elements for a successful
Several issues can be considered when examining the incident response.
from the perspective of the responders: The WFC site consisted of two buildings and a number of
• what information did they hold about the nature of the storage tanks. One building served as a chemical warehouse,
incident as they mobilised? shop area, and office space, the second provided storage for dry
fertilizer. On site were two 12,000-gallon anhydrous ammonia
• how were they met on arrival at site?
storage vessels, located to the south of the fertilizer building.
• could they and those working at site have been aware of Adjacent to the site were schools, a nursing home and residential
the risks? areas. The explosion projected many pieces of the process
Apart from a series of photographs on social media, which were building and a substantial amount of material ejected from the
taken close to the incident and media reports post explosion crater. The explosion also generated a blast wave that swept
there is limited information available regarding the location across the surrounding area causing significant structural damage
and conditions that the Beirut responders were working under. to homes and community structures.
However there are several striking similarities to a separate CSB report that the emergency responders were notified and

Detection Initial explosions Main explosion

Fire Devastation
17:30? Alarm raised and fire Fire teams attempt to 18:08
teams respond gain entry to hangar 12

Figure 2 – Timeline of the Beirut explosion, 4 August 2020

1
Beirut firefighters hailed as heroes after tragic final picture emerges of them entering warehouse; Daily Telegraph 6 August 2020

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 Loss Prevention Bulletin 284 April 2022 | 9

dispatched to the scene at about 7:29 pm. The fire-fighters arrived process operations or dangerous substances; they cannot be
on scene over a span of about 14 minutes. They concentrated their expected to know the layout and hazards of sites or the particular
efforts initially on the incident scene, preparing to suppress flames characteristics of storage or transport arrangements. They have
that were visible at the northeast portion of the storage structure. an expertise in their equipment and its capability, they work well
Just as in Beirut, there was no official warning issued to the public. as teams, and they are generally excellent at problem solving
Witness testimonies for the WFC incident revealed that emergency and have access to databases of information. But in preparing
alert systems for the public were not activated before the emergency response plans do we factor in assumptions relating
explosion. However, when the fire was first detected by a police to the capability of the responders and then consider what they
officer, he ordered people in the parks near the facility to evacuate, need in terms of support and protection?
and he blocked off roads. In addition, employees from a nursing Operating companies have a duty of care to responders to
home close to the site took the initiative, as part of their company ensure the risks they face are minimised and that they are fully
emergency response policy, to move occupants to the back of the aware of the hazards and escalation potential of any incident. This
building for fear of smoke or an ammonia release. There appears duty covers people working at the site as well as the responders
to have been little awareness of the potential for a significant from external organisations and agencies. Even under emergency
explosion, instead evidence recorded in the CSB report suggests conditions, responders have a right to expect that a safe system
that the attention of the fire-fighters was on the escalation potential of work can be established.
of the anhydrous ammonia storage and not the ammonium nitrate. In terms of developing the response arrangements, it is
common to ensure, where possible, good liaison between site
Discussion personnel and the emergency services incident commander
Both examples focus on the actions of the fire and rescue services (in UK terminology this is the nominated competent officer
and in each case the teams involved part time, volunteer personnel. having overall responsibility for dictating tactics and resource
In Lebanon, fire-fighting as an emergency response forms management). Where a senior manager acts to brief the
part of the General Directorate of the Lebanese Civil Defense, emergency services on the hazards and provides specific
which is part of the ministry of the Interior and Municipalities. A information on the process and materials present in the affected
regulatory framework for safety falls within Decree No. 11802 areas, some jurisdictions refer to this as a forward/site controller.
on occupational, safety and health. In addition, as the incident Good practice would also suggest that staging areas are identified
occurred within the area of the Port of Beirut, the Port should which are safe locations to meet and brief vehicles as they arrive.
also have had knowledge of the IMO (International Maritime In addition both site personnel and the responders would share
Organisation) maritime codes for Dangerous Goods (IMDG) and a common understanding of the need for cordons and zoning
security (ISPS; International Ship and Port Security Code). (hot, warm and cold) around the incident, in which the control
In West Texas, the regulatory requirements included a mix of movement of personnel and the activities are driven by the
at Federal, State and regional/county levels. With OSHA incident risk assessment. But not all sites may be manned at the
(Occupational Safety and Health Administration), the EPA time of the incident and alternative arrangements need to be in
(Environmental Protection Agency) risk management programme, place to protect the responders.
NIMS (National Incident Management Standards) together with All of this does not happen without a high degree of planning
NFPA (National Fire Protection Standards) standards playing and testing. It requires a professionalism that recognises how
an important role. Under OSHA, the PSM (Process Safety important the issues are and one in which an organisation accepts
Management) standard states that it applies, in part, to a process its responsibility for ensuring they take the lead in protecting
which involves a chemical at or above the specified threshold emergency responders.
quantities for “highly hazardous chemicals, toxics and reactives”. As a result, should we be challenging organisations to
Notably, ammonium nitrate is not listed. continually improve how they prepare and test emergency
Timelines for both incidents, from discovery of the incident response arrangements and to ensure that during pre-incident
through to explosion, show that responders had very little planning responders are placed at the heart of the arrangements?
opportunity between the alarm being raised and the explosion in Often emergency plans are constructed around the structural
which to react to the event. Once the availability of information aspects of command and control. They are built to ensure
and the nature of the threat is factored in, the almost impossible information can pass to the people who need it, and the roles
situation that the responders faced is apparent. Widening the reflect the generic tasks that are required, but how can we make
discussion away from ammonium nitrate to any hazardous the information, and guidance, available to those first responders
substance that could contribute to a major accident, the core issues who most need it and in a timely manner?
of experience, information and timing will remain. But how realistic Regulations and standards play an important role in ensuring
is it to expect that responders from external agencies could be organisations deliver effective emergency response. But there
prepared for all situations? remains a danger that the regulations may create a tick box
Making information readily available, not just on the hazard approach, one that colours the pre-planning for emergency
but the potential impact, is vitally important, as are the actions response by focusing on what the regulations require and not
necessary to draw this information to the attention of responders on the reality of the situation. There is clear evidence in the
at the time they need it. Techniques for improving the means of CSB report on West Texas that the responders and the local
achieving this deserve a wider debate across industries. There community focused on the threat posed by the storage of
is also a need for organisations to recognise and understand the anhydrous ammonia, a substance that is listed in the OSHA
skills and knowledge of the responders. Do we expect too much process safety management standard, whilst ammonium nitrate is
of them? Most fire departments are not staffed with experts in not. The report highlighted:

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“The firefighters did not fully understand the hazards of since the early 1960s and one of the volunteer fire-fighters
ammonium nitrate detonation and consequently shifted their working at the site. It is also perhaps worth noting that the
firefighting tactics to strategies to ensure that the anhydrous location is less than 250 miles from Texas City, the site of a 1947
ammonia tanks onsite did not rupture.” ammonium nitrate explosion, when a fire onboard a ship resulted
Whilst the knowledge of the risks posed by a release of anhydrous in the detonation of 2300 tons killing some 581 people (more than
ammonia was recognised by the responders at West Texas and twice the number of those reported killed in Beirut) including all
they had trained on an ammonia release at the site, the threat but one member of the Texas City fire department.
from ammonium nitrate was not recognised. It is likely that the How regulation influenced the responders approach in both
regulatory listing for anhydrous ammonia raised awareness of the events is open to interpretation but it does seem likely that in the
hazards but overshadowed the threat of ammonium nitrate. West Texas explosion the inclusion of anhydrous ammonia in
What seems to compound this tragedy is that the PSM OSHA’s PSM standard and the absence of ammonium nitrate may
regulation did not apply to the site because as a retail facility it have framed the decision making; even though the regulations did
qualified for an exemption. not apply to the site.
Regulations and standards do have an important role to play Whilst major accidents are thankfully rare, we should not make
but they cannot be all encompassing and fit every situation. assumptions that responders are superhuman. They have a right
They should be used as a minimum standard for compliance not to expect that operating companies, who manage and handle
as a guide to best practice. Effective emergency response must hazardous substances, will protect them. This paper signals how
be built around a thorough analysis of the hazards, knowledge important the timeline is when developing emergency plans. The
of escalation and impacts and an assessment of the options for final words are quoted from the CSB report West, Texas:
response. Whilst this paper has focused on the responders, it
“without a robust incident pre-planning process in place,
raises questions for owners and operators of sites to answer.
without adequate hazardous materials awareness training, and
Conclusions with no previous ammonium nitrate-related fire emergency
A site’s emergency management arrangements must provide training or drills, the firefighters had no expectation of a
for protection for emergency responders. The following possible ammonium nitrate explosion.” (adapted from the CSB
recommendations should be considered when preparing or report on the West, Texas explosion).
reviewing emergency plans:
In Memoriam
• A thorough understanding of the hazards is required and
both foreseeable events and worst-case scenarios should be Beirut blast: West Fertilizer Company blast:
considered. Najeeb Hati, Charbel Hati, Ralph Morris Bridges, Perry Calvin, Jerry
• Prepare timelines for an incident, from its discovery and the Malahi, Charbel Karam, Joe Noun, Dane Chapman, Cody Frank Dragoo,
Rami Kaaki, Joe Bou Saab, Elie Kenneth Harris, Adolph Lander, James
raising of the alarm, through the potential for escalation to the
Khouzami, Mathal Hawa, Sahar Fares. Matus, Judith Ann Monroe, Joseph
timings for control or mitigation. Check any assumptions on Pustejovsky, Cyrus Adam Reed,
the timings and judge how sensitive the timings may be to a Mariano C. Saldivar, Kevin William
successful intervention. Sanders, Douglas Snokhous, Robert
Snokhous, William Uptmor, Jr.
• Match these timings against the likely actions of responders The explosion killed ten members of
and check how feasible it is to establish control against the the Beirut fire department, there is also Twelve emergency responders were
time for escalation. Against this time scale recognise what evidence of port workers assisting the killed alongside three members of
responders, but no record of names the public who are reported to have
information will be needed and when it will be needed. could be found. offered assistance to the fire team.
• Consider the emergency response organisation’s needs,
for example in the UK the fire and rescue service define six
basic response phases from mobilising and en-route through
References
arriving and gathering information etc. Check timings and 1. Samar Al-Hajj. etal. “Beirut Ammonium Nitrate Blast: Analysis,
information flow against their operational guidance5. Review, and Recommendations.” Frontiers in Public Health
• Check that the procedures and arrangements do not make journal, Policy and Practice Reviews published 04 June 2021
unrealistic assumptions with regards to the capability of 2. Seddon. B & Shiotani. H. 2020 “The Beirut Port Explosion:
responders (internal and external). Consider how variations in Understanding Its Impact and How to Reduce Risks from
information and resources could impact the event. Explosive Precursors”, Geneva, Switzerland: UNIDIR.
• Understand the importance of safe zones and cordons to 3. Social and print media various. 2020 “ Beirut Ammonium
control the movement and location of personnel. Nitrate Explosion”, responder photographs. Twitter,
• Respect the regulations that are in force but treat them as a Telegraph, New York Times, Al Jareera etal.
minimum standard for compliance and not as a guide to good 4. U.S. Chemical Safety and Hazard Investigation Board, 2016.
practice. “Investigation Report West Fertilizer Company Fire and
• Continually challenge at all stages of an incident how Explosion Report. Final Report 2013-02-I-TX
information is managed and shared. 5. Chief Fire and Rescue Advisor. “Fire and Rescue Service;
From the CSB report it is clear that the responders to the West Operational Guidance Incidents Involving Hazardous
Fertilizer Company did not appreciate the hazard posed by Substances” 2012. Department for Communities &Local
ammonium nitrate. This is despite the facility being operational Government. Pub. TSO

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 Loss Prevention Bulletin 284 April 2022 | 11

Incident

Texas City 1947 — America’s worst industrial

accident
Phillip Carson and Tony Fishwick
19th Century. Work to develop the site commenced in 1893
Summary with extensive industrial expansion around the port to support
A ship containing fertilizer detonated in a port 75 years efforts during and immediately after World War II, including
ago this month. The explosion initiated a chain of events production facilities for petrochemicals, tin smelting, and oil
resulting in America’s worst industrial disaster in terms refining.
of loss of life due to a single event. The accident and In April 1947 the SS Grandcamp was moored at Pier O, Texas
its causes are reviewed. Parallels are drawn to the 2020 City port (see Figure 1). The vessel, originally the SS Benjamin
explosion in Beirut. R. Curtis, was used by America to ship ammonium nitrate
for munitions during World War II. At the end of the conflict
Keywords: Ammonium nitrate the ship was assigned to the French as a goodwill gesture,
renamed, and used for hauling the chemical to Europe for use
as fertilizer.
Introduction Ammonium nitrate (AN) fertilizer, mixed with rosin/paraffin
In August 2020 ca 2750 t of ammonium nitrate exploded in the wax/clay to prevent caking, and packed into 100lb paper
port of Beirut resulting in 207 fatalities, 7500 injured and $15 bags was sourced elsewhere and shipped by rail to Texas City.
billion collateral damage. Dangerous properties of this compound, Allegedly, the weather was warm enroute. The loading of
the cause of the accident together with hazard prevention and fertilizer sacks commenced on 11 April, but the operation was
risk control measures were discussed by Tariq1 with a responder’s hampered by heavy rain. By the morning of 16 April, the

knowledge and
competence
perspective provided in a companion paper by Evans.2 Numerous SS Grandcamp’s mixed cargo comprised a considerable
previous explosions involving this compound1,3,4d have occurred number of bales of sisal twine, cotton, machinery, tobacco,
globally as exemplified by the following brief description of a peanuts and other items. Some were carried on deck but most
similarly catastrophic disaster 75 years ago. This in itself provided below deck including 2,300 t of fertilizer stowed in holds 2 and
ample warnings for Beirut and served as a stark illustration of how 4, with 16 wooden boxes of small-arms ammunition in hold 5,

engineering
and design
quickly incidents, and the lessons that can be learned from them and fuel-oil housed in tanks between holds 3 and 4.
to prevent repetitions, are forgotten. The SS High Flyer, also moored at Pier O, carried a cargo ca
900 t of ammonium nitrate in her hold 3 together with 2000 t of
Background4 sulphur in holds 2 and 4. She was moved to Pier A to take on
The strategic potential of a deep-water port at Texas City additional cargo and was also destined for France. Across the

systems and
main slip from SS High Flyer the SS Wilson B. Keene was being

procedures
leading to the Gulf of Mexico was recognised at the end of the
loaded with flour.

The accident4
While preparing to finish loading, dock workers noted smoke
assurance

billowing from the cargo hold of SS Grandcamp around 8am.

Attempts to put out the fire with a gallon jug of water and
two fire extinguishers proved ineffective. In order to keep the
cargo intact, the captain decided not to use water to extinguish
the fire but instead to batten down the hatches and snuff
out the flames with steam. This was a common fire-fighting
practice aboard ships at the time to minimise damage to cargo
and prevent the hold from flooding with water. Workers began
moving crates of ammunition from hold 5 which was separated
from the fire by a 0.3 inch (8mm) steel barrier. After only three
crates had been removed, the men were instructed to leave
Figure 1 – Depicting the Port and juxtaposition of ships and the ship.
Monsanto Chemical Co (Reproduced from Fire Engineering, Crowds gathered to watch the operation and at 8.30 am the
May 1947) temperature and pressure within the hold had risen enough

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 12 | Loss Prevention Bulletin 284 April 2022

Figure 2 – Monsanto Chemical Company ablaze at Texas City

to blow off the hatches and release orange smoke plumes allegedly more-catastrophic explosion occurred destroying SS
(probably nitrogen dioxide). Just after 9 am the ship detonated High Flyer and obliterating the SS Wilson B. Keene nearby. The
with a massive explosion that was heard 150 miles (240 km) pier and grain elevators were demolished with more molten
away with tremors felt 250 miles (400 km) away. The blast debris sent flying to start further fires and thereby adding to
initiated a catalogue of domino effects. the death toll and destruction from the previous day’s tragedy.
The ship’s 40-member crew, hundreds of onlookers, and One of SS High Flyer’s propellers was subsequently discovered
28 firefighters (almost the town’s entire fire-brigade) were approximately one mile inland. Although some of the fires
killed instantly. The blast ejected much of the ship’s 6000 t were extinguished when a 15-foot (4.5 m) mini tidal wave,
steel into the air, and released SS High Flyer from its moorings created by the first blast, flooded parts of the harbour area,
which then drifted alongside the SS Wilson B. Keene. Nearly many fires in the area continued to burn for over a week which
1,000 buildings were levelled, including most of the dock area, was exacerbated by the destruction of the town’s fire-fighting
adjacent warehouses (some containing fertilizer), the nearby capabilities.
Monsanto chemical plant killing 145 of its 450 workers (see
Figures 2 and 3), local businesses and residential properties Post the accident4
rendering up to 2,000 people homeless A mushroom cloud No central disaster plan and organisation had been prepared
rose 2,000 feet (600 metres) into the air reportedly destroying by the city, but most of the local chemical and oil plants had
two small planes passing above. Molten shrapnel landed in emergency plans that were quickly put in to action, albeit
industrial areas, setting off fires in oil refineries, chemical tanks somewhat hampered by the lack of water and power. Hundreds
and ships along the waterfront, including the SS High Flyer. of local volunteers supported by Red Cross personnel and
The blast shattered windows within a 10-mile (16 km) radius. responders from neighbouring cities assisted with rescue and
SS Grandcamp’s 2-ton anchor was hurled 1.62 miles (2.5 km) emergency aid. Temporary hospitals, morgues, embalming
and was found in a 10-foot (3 m) deep crater near the Texas rooms and shelters were established
City railway terminal. The ship’s other 5-ton anchor was found Estimates were that nearly 600 people lost their lives (63
1/2 mile (800 m) away. Over 1000 vehicles were damaged never identified) and almost 4000 were injured during the two
(including the four fire-fighting trucks and their associated days of America’s worst industrial accident; the exact number
equipment), and 362 freight cars destroyed. The 150ft (45 m) of fatalities is unknown because of the condition of many of
Longhorn oil barge anchored at the port was lifted into the air the bodies and an unknown number of visiting seamen and
by the blast and landed 100 ft (30 m) away on the shore. itinerant dock workers. In addition, all records of personnel
Attempts failed both to extinguish the fire aboard the and payrolls of the Monsanto Company were destroyed. The
SS High Flyer with water and to tow her away from the vicinity devastation caused property damage estimated at US $1.2
to minimise the consequences of the now-inevitable second billion (at 2021 rates) with $4.5 billion worth of oil products lost.
explosion. Thick oily smoke and sulphurous fumes forced the Public commemoration of the event began in June of 1947
crew to abandon ship and at 1.10 am on 17 April a second, when a park containing artefacts and plaques was established

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 Loss Prevention Bulletin 284 April 2022 | 13

was application of copious volumes of water to reduce the

temperature. Furthermore, since AN is an oxidizer with its own
oxygen supply, it is able to support combustion in an otherwise
‘oxygen-deficient’ atmosphere. Steam may have converted a
significant amount of the ammonium nitrate to nitrous oxide,
increasing the heat and pressure in the confines of the hold.
The paper sack containers and the rosin/wax in the fertilizer
also provided a potential fuel in intimate contact with oxidizer.
Impurities (e.g.in the clay additive or S dust) are known to
reduce combustion temperature. It was claimed that the likely
trigger for the explosion was fuel oil leaking as a consequence
of fire on to burning AN. In 1944 a similar explosion had
occurred at an ordnance plant in Tennessee when lubricating
grease and oil dripped on to molten AN.4a
The use of S in high explosives was well established but it
Figure 3 – Rescue workers search through debris near the is unlikely the reaction between AN and S would have been
Monsanto Building after the Texas City Disaster of 1947 fully appreciated in 1947and was only published some 20 years
(Courtesy of Moore Memorial Public Library, the John P. later5. Nevertheless, the presence of elemental sulphur on SS
Blizetec Collection) High Flyer may have exacerbated her demise whilst the flour
on SS Wilson B. Keene theoretically could have formed an
explosive dust cloud to add to her woes. Whatever the initial
in Texas City in memory of those lost during the tragedy. At the source of ignition the outcome was two spectacular deadly
centre of the park is the 2-ton anchor from the Grandcamp. A explosions and many fires that should not have occurred.
sculptured marbled angel is dedicated to the firefighters who
were killed, and a small cemetery contains the remains of the Human factors
63 unidentified victims. A new section was added to the park As is often the case, public blame for the disaster was targeted
in 1991.
at individuals including Grandcamp’s crew for possibly
Some temporary housing was built and donated to the city, discarding a lit cigarette, and the ship’s mate for the manner
and other housing, docks, warehouses, and chemical plants in which he attempted to deal with the fire. Clearly, had they
were rebuilt by 1950. 1,394 survival victims filed the very first
been aware of the dangers it is highly unlikely these actions
class-action lawsuit seeking compensation, but it wasn’t until
would have been undertaken. There was failure to provide
1957 that Congress completed its compensation of $17 million
hazard information/training to those handling and managing
to the 1,394 claimants
the fertilizer. Labelling of the paper bags (see Figure 4)
The disaster catalysed changes in chemical manufacturing
provided a false security since there were no instructions
and new regulations for the bagging, handling, and shipping of
concerning the handling of the material nor was it labelled
chemicals.
as being hazardous with no coloured lettering (often Yellow)
to attract attention to a hazardous nature. Indeed, the vice
Discussion4
president of the Texas City Railway Company stated that he
Technical causes considered AN to be safe and similar to handling cement,
The technical cause of the fire and explosion aboard SS despite the US Dept of Agriculture in 1943 recognising AN to
Grandcamp is unknown with speculation that the fire could be a high explosive. Apparently, the Port of Houston prohibited
have been started by a discarded cigarette; two days before loading of AN fertilizer because of risks.4a
the explosion a fire amongst sacks of AN in another of Questions then focus on government for lax legislation.
Grandcamp’s holds was claimed to have been started by a Accountability for safety at Texas City was fragmented. In
burning cigarette. The influence of heat on AN is itself able the absence of a port authority, responsibility for health
to create danger under certain conditions (see Appendix 1).
By 1947 it was known that AN could ignite or explode under
certain conditions but no one handling it knew the dangerous
circumstances. It had also been established that AN coated
FERTILIZER
with organic matter was more prone to detonation than pure (Ammonium Nitrate)
AN, especially when hot. The fact that the AN, packaged
in heavy paper sacks, may have been stored at higher than
32.5% Nitrogen
normal temperatures before being loaded onto the ship could 100 lbs. Net
have been a contributing factor. Dock workers reported the 101.5 lbs. Gross
bags were warm to the touch before they were loaded. The
higher temperature may have increased the rate of thermal 1.6 cu. ft
decomposition of the bulk fertilizer in the confined space as Made in U. S. A.
may the steam used in the futile attempt to douse the fire in the
sealed hold. Even prior to this disaster it had been established Figure 4 – Labels on bags of fertilizer with the letters shown in
that the most effective way to extinguish fires involving AN relative sizes as they appeared on the bag6

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 14 | Loss Prevention Bulletin 284 April 2022

and safety was fragmented and left by default to Terminal from operator to regulator. In West, Texas on April 2013 a
Railway but with no jurisdiction aboard ships which was the fire started at a fertilizer company storing AN. The nitrate
responsibility of the shipping agents and Coast Guard. This exploded, levelling about 80 houses and trapping 133
led to inadequate management and supervision. Hot bags residents of a nursing home. Fifteen people were killed
of AN were often loaded on board in a brittle and torn state and about 260 injured. It was reported that the facility
leaking contents in ships’ holds and onto other incompatible exceeded the storage limit without approval from the
cargo and not cleaned up as required. “No smoking” signs Department of Homeland Security. The Chemical Safety
were displayed at the docks and on ships but despite being a Board report also noted that OSHA and the Environment
known common practice the rules were never enforced. Protection Agency had both failed to use their regulatory
When High Flyer caught fire valuable time was lost in powers to address the hazardous nature of AN and to make
dealing with the incident because relevant people were not recommendations for safety improvement.
informed and did not know that she carried AN. • Lack of a central disaster plan with associated organisation
There was little regard for planning to prevent hazardous and training.
industries co-existing in close proximity to each other and to • A failure to consider elements listed in Appendix 2 for the
residential dwellings. Also, there were no plans for dealing safe storage of AN fertilizer.
with the aftermath of major disasters. A formal investigation
Other measures, incorporating 21st century risk assessment,
report6 drew attention to the need to prohibit smoking and
safety management systems and modern-day tools such as
use of open lights on piers or on docks at any time regardless
HAZOP, could not have been employed.
of cargo being handled since they pose a common source
of ignition. It also emphasised that any port facility and city Parallels with Beirut explosion
where large industrial operations are present should possess
a complete disaster plan which anticipates the worst possible • The accidents at both Texas City and Beirut involved AN
scenario. It should involve all relief agencies e,g. police, fire, fertilizer stored at ports under cramped conditions and
medical departments, civil officials and where applicable exposed to hot humid environments with incompatible
military authorities. materials nearby and with no controls over ignition sources.
Furthermore, the Texas City’s poor standard of record • Whilst the risks with AN may not have been fully
retention has prevented others from maximising their learning appreciated in 1947 the dangers of this compound and
the lessons. the safety requirements were clearly well known by
2020 and highlighted by the fact that no fewer than 24
Conclusions accidents involving AN occurred across eleven different
countries and resulted in some 540 fatalities before the
Texas City Beirut explosion including Texas City itself, which was
At the time of the accident the science, safety standards, well publicised in the literature and even featured in a TV
and legislation relating to ammonium nitrate were less well- film9. Again, this illustrates a failure to learn from previous
developed than nowadays. Nevertheless, some of these catastrophes. Barriers to learning from history have been
postulated causes could reasonably have been foreseen and discussed elsewhere10.
measures put in place to avoid or mitigate them. The most • Allegedly Beirut port officials had warned the government
significant root causes include: of the dangers but requests for removal of the fertilizer
were ignored for unknown reasons1.
• An inadequate regulatory regime for shipping, handling
and transportation of AN fertilizer. As with Texas City this illustrates a government’s dereliction of
• Inadequate understanding of AN hazards and provision of duty regarding public safety.
information, guidance and training. • Both accidents suffered from inadequate regulatory and
• Uncoordinated responsibility for, and complacency inspection system with no government oversight.
towards, health and safety landside and waterside and • Responders arrive on scene with no appreciation of the
absence of supervisory enforcement of day-to-day risks involved.
hazardous activities.
• Both incidents overwhelmed emergency services.
• Inability to learn lessons from previous accidents.
Arguably, government authorities should have been Appendix 1 — Thermal degradation of
more aware of the risks with ammonium nitrate after the
Oppau explosion7 – indeed there had been eleven major ammonium nitrate
fires/explosions involving AN fertilizer prior to Texas ‘Pure’ ammonium nitrate is considered a stable salt that
City. In July 1947 the Ocean Liberty carried 3,300 tons of can be stored safely under normal conditions. However, its
AN fertilizer from Baltimore to France. Whilst unloading thermal breakdown is complex and influenced by a variety of
she caught fire. Attempts to smother the fire by closing factors such as particle size, temperature, pressure, humidity,
portholes were unsuccessful. Within a short while she confinement, the presence of reducing agents including
was destroyed in an explosion involving petroleum inorganics such as sulphur and certain metals, or organics such
barrels and AN in adjoining holds and killing 20, injuring as charcoal (from paper), diesel oil, grease, etc. Low levels
approximately 500 and causing $5 million waterfront (e.g. 0.1%) of some chlorides cause the nitrate to decompose
damage. This failure to learn from past mistakes extends explosively below 175oC.

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In theory decomposition of pure material at elevated • training and provision of hazard information
temperatures, and breakdown on extreme shock, occurs • regulation and monitoring
according to at least one of the following two routes. • thorough emergency procedures to mitigate the
consequences of a loss of control
200–260 oC • the dangers of the public treating disasters as a “free
(1) NH4NO3 → N2O + 2H20 firework show” with the 21st Century phenomenon of
(2) NH4NO3 → 2N2 + O2 + 4H2O spectators filming emergencies on mobile phones. These
impede escape routes for those affected, hampering the
The first reaction may be performed safely under controlled efforts of emergency response teams, and potentially
conditions when the salt is heated to about 210oC and it forms increasing the number of casualties.
the basis for the manufacture of nitrous oxide. The second
reaction takes place with great rapidity and forms large References
volumes of gases when the compound is subjected to extreme 1. Tariq, Z., Loss Prevention Bulletin, 2022(284), 2
heating under confinement, or when initiated by a priming
2. Evans, D., Loss Prevention Bulletin, 2022(284), 7
explosive charge.
3. a. Gyenes, Z., Loss Prevention Bulletin, 2016(251), 32 b.
Although the above two reactions characterise the extremes
b. Gyenes, Z, and Wood, M., Loss Prevention Bulletin,
of controlled decomposition and complete detonation, in
2015(242), 15
reality decomposition may take place according to both
c. Dechy, N., Gyenes, Z., and Merad, M. Loss Prevention
equations in varying ratios. Higher oxides of nitrogen may also
Bulletin, 2019(269), 25
be formed.11
The resulting heat and pressure from the decomposition may 4. a. Stephens, H.W. The Texas City Disaster, 1947.
build up if the reaction takes place in a confined space (e.g. University of Texas Press, 1997
tanks, shipping containers).12 As the temperature rises, the rate b. 1947 Texas City Disaster: The Deadliest Industrial
of decomposition increases. In a confined space, the pressure Accident in US History (freerangeamerican.us)
can reach dangerous levels and cause an explosion that will c. Texas City explosion of 1947 | industrial disaster, Texas
include the detonation of the ammonium nitrate. When dealing City, Texas, United States [1947] | Britannica
with a large quantity of ammonium nitrate, localized areas of d. Texas City disaster - Wikipedia
high temperature may be sufficiently confined by the mass e. 1947 Texas City Disaster | Texas City, TX (texascitytx.gov)
f. TSHA | Texas City Disaster (tshaonline.org)
of material to initiate an explosion. The explosion of a small
g.Texas City Explosion (1947) | Uvadisasters Wiki |
quantity of ammonium nitrate in a confined space may act as a
Fandom
booster charge and initiate the explosion of larger quantities.
h. Beirut Explosion Stirs Memories of 1947 Texas City
The evolution of either nitrous oxide or oxygen enables
Disaster (spectrumlocalnews.com)
materials to burn in an atmosphere otherwise starved of air (i.e.
i. Texas City disaster - Alchetron, The Free Social
external source of oxygen).
Encyclopedia
Appendix 2 after8: Factors to consider for safe 5. a. Mason,C.M. et al, J.Agri. Food Chem., 1967, 15, 954
b. Prugh, R.W., Chem.Eng.Progr., 1967, 63(11), 53
storage of AN fertilizer
6. Texas City Disaster Report (local1259iaff.org)
Factors include the following: 7. Oppau explosion - Wikipedia
• design (e.g. climatic conditions, avoidance of combination 8. a. Shah, K.D., Loss Prevention Bulletin, 2018(268), 2
of heat and confinement, etc.) b. HSE INDG230 Storing and handling ammonium nitrate -
• materials of construction http://www.hse.gov.uk/explosives/ammonium
• absence of ignition sources 9. Explosions! Texas City (TV Movie 1999) - IMDb
• fire prevention and control 10. Bunn, J. and Carson, P.A., Loss Prevention Bulletin,
2021(282), 7 and 2022(283), 21
• specification and volume of the fertilizer stored
11. Carson, P A., Loss Prevention Bulletin, 2019(265), 17; ibid
• prevention of contamination by extraneous matter
2020(273)
• nearby presence of incompatible materials
12. a. Du Teaux, S,B., in Encyclopaedia of Toxicology (Third
• housekeeping Edition), Elsevier 2014
• security b. van den Hengel, E.I.V., et al, Loss Prevention Bulletin,
• planning 2008(202), 19

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Safety practice

Hydrogen projects – business as usual?

Clare Dunkerley, Otto Simon Ltd, UK
Summary Historical gas provision in the United Kingdom
This paper looks at advances in process safety knowledge The 1960s and 70s saw nationwide change to the UK energy
gained from recent hydrogen trials. supply network. Prior to this large-scale conversion project,
Process safety practices have evolved over the decades, “town gas” was used for industrial use, as well as domestic
adapting to new findings from industrial incidents, regulatory cooking and heating services. “Town gas” constituents include
change and the emergence of new technologies. Industry is on methane, hydrogen and carbon monoxide, with the hydrogen
the horizon of major change once more as global efforts focus content typically being above 50% and up to 65% v/v1.
on reducing emissions of greenhouse gases and plotting a In 1964, Great Britain passed the Continental Shelf Act,
course to Net Zero by 2050. The UK’s independent advisor on sparking the exploration of the North Sea for exploitable
tackling climate change, the Climate Change Committee, has hydrocarbon deposits. Gas was discovered off the East Anglian
advised that the 2020s will be crucial in mainstreaming Net Zero coast in 1965. This changed the landscape for energy provision
solutions. There is no doubt that changes to industry, as well as in the UK, with the new source of gas being perceived to be
a move away from gas-fired power generation, will be necessary cheaper and cleaner than that produced in gas works as a
for further reduction in emissions. Part of the identified solution product from heating coal or coke.
is the use of low-carbon hydrogen as a fuel source. The practice Current Gas Safety (Management) Regulations, introduced
of using hydrogen as a fuel source is in its infancy, and recent in 1996, ensure the safe management of the gas network in
hydrogen trials such as HyDeploy and HyNet are providing Great Britain, placing strict limits on the quality of gas entering
advances in knowledge; informing operators, regulators, the network. Natural gas is predominantly methane, and the
and industry bodies alike. This paper shares a typical process current limit of hydrogen in the natural gas supply is 0.1%
safety lifecycle that was followed for recent hydrogen trials, (molar)2 according to the regulations.
where installing temporary modifications to existing facilities The changeover from “town gas” to natural gas took nearly
was necessary, and new infrastructure had to be provided to ten years to complete and converted 13.5 million domestic
enable a safe and controlled trial period whilst maintaining the and 650 thousand commercial and industrial consumers3. In
flexibility to give meaningful trial data and results.The paper the pursuit of low-carbon, or carbon neutral energy sources in
looks at the inherent properties of hydrogen to pinpoint how the 21st Century, parallels can be drawn with the monumental
those properties could introduce major hazards to an installation, scale of this past conversion and lessons can be taken, both
whilst looking at potential solutions for addressing them in from the UK’s historical abilities to safely transport and use
the design. The paper discusses the differences between an high percentage hydrogen gases, as well as the challenges and
innovative hydrogen trial project vs. a more well-established investments required to move to a more sustainable UK.
natural gas project. It highlights the need to follow a rigorous
hazard identification and risk assessment process and looks The drive for change
at the tools available to a process safety engineer to provide It is clear from the global trend in weather patterns and
reassurance that the correct steps have been taken, that best extreme climatic events, that the current international energy
practice has been followed, and the necessary documentary status quo is not sustainable.
evidence generated. The intent of this paper is to share Key messages issued jointly from the United Nations and the
insights gained from being responsible for the process safety World Metrological Organisation4 include that;
deliverables on recent hydrogen projects. It discusses the
challenges faced with trying to comply with natural gas industry “There is a growing chance of annual global mean near
standards when delivering a hydrogen project and demonstrates surface temperature temporarily exceeding 1.5°C above
that allowing for process safety from the earliest concept stage the 1850–1900 pre-industrial level, being ~20% in the 5-year
of a project onwards can save time and money. period ending in 2024”; and
The objective is to demonstrate that by applying known and
“The Emissions Gap in 2030 is estimated at 12–15
established techniques of hazard identification, risk assessment,
Gigatonnes (Gt) CO2e to limit global warming to below 2°C
risk analysis and best industry practice, you can: apply the
above pre-industrial levels by the end of this century. For the
familiar to the unfamiliar; give confidence to owners, operators,
1.5 °C goal, the gap is estimated at 29–32 GtCO2e, roughly
regulators and investors; and deliver a project where the
equivalent to the combined emissions of the six largest
hazards are identified, the risks are understood, and all the right
emitters.”
safeguards have been delivered.
Keywords: Hydrogen The UK has committed to becoming “Net Zero” by 2050 – this
means that the amount of greenhouse gases that the UK will

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add to the atmosphere will be balanced by that taken away The requirement to demonstrate hydrogen
from the atmosphere. The scale of the task is not insignificant
safety
in terms of the commitment in investment, the scale of the
required infrastructure change, ensuring favourable public The previous nationwide use of majority hydrogen gas in
perception, and the demonstration of safety. British homes during the times of town gas distribution and
The Climate Change Committee published the Sixth Carbon the long-term experience of industrial use in refineries and in
Budget in 20205, advising government ministers on the volume steam methane reforming (SMR) provide a sound and valuable
of greenhouse gases the UK can emit during the period basis for our understanding of hydrogen and hydrogen safety.
2033-2037. The advice published describes a blueprint for Having said this, it remains vital that a thorough safety case for
a fully decarbonised UK. The goals include a 78% reduction hydrogen, based on demonstrations and compilation of data,
in emissions by 2035 and estimates low carbon investment in conjunction with the regulators, is demonstrated to gain
must scale up to £50 billion each year, which will, in time, be acceptance within the wider public.
balanced out by the savings from cleaner and more efficient Recent ground-breaking hydrogen trials such as HyDeploy
fuel. The report includes the necessity of developing the role and HyNet are providing advances in knowledge; informing
of hydrogen, with a metric of low-carbon hydrogen production operators, regulators, and industry bodies alike. These
increasing from <1 TW h in 2019 to 105 TW h in 2035 and 225 trials are giving us the evidence we need and therefore the
TW h in 2050. confidence to move forward with the UK hydrogen strategy.
In 2021 the government published the UK Hydrogen Without the data and results from these vital projects, securing
Strategy6. The UK’s ambition is for 5GW of low carbon the necessary investment and commitment to go forward
hydrogen production by 2030. It summarises the role of would prove to be far trickier. These trials are likely to be the
hydrogen in the government’s plans: foundation from which a low carbon energy solution can be
“Hydrogen is one of a handful of new, low carbon solutions built and net-zero achieved.
that will be critical for the UK’s transition to net zero. As part
of a deeply decarbonised, deeply renewable energy system, Safe production and use of hydrogen
low carbon hydrogen could be a versatile replacement “Will it be safe?” is a reasonable question to be asked when
for high-carbon fuels used today – helping to bring down starting a conversation on the change from natural gas to
emissions in vital UK industrial sectors and providing flexible hydrogen or hydrogen blends. For some, memories of past
energy for power, heat and transport” 6 incidents such as the explosion in an electrolytor plant at
The strategy document acknowledges the successful hydrogen LaPorte Industries (1975)7, or the Hindenburg disaster (1937),
research and innovation to date, committing to provide or incidents from the nuclear industry; may disproportionately

knowledge and
competence
safety assurance and to address risks with new and emerging colour their perception of the true risk profile.
technologies. It aims to put the initial network regulatory and Hydrogen production by steam-methane reforming has
legal framework in place by the mid-2020s with the necessary been underway since the early part of the 20th century. This
regulations, codes and standards in place by the end of the industrial experience over many decades, in conjunction with
decade. the learning taken from incident investigation and published

engineering
and design
systems and
procedures

Figure 1 – HyDeploy Site at Keele University

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research, has led to a comprehensive understanding of how to

safely produce, handle, store and use hydrogen. Distribution
of hydrogen on a much larger scale and the use of hydrogen
for heating and transport in commercial and domestic settings
may be less well understood in more recent times, but the key
premise has been there since the days of “town gas”.
Where new hydrogen projects are started, the key to
preventing future accidents is identifying and understanding
the risk, i.e., it is no different to conventional good practice
for any other project. The established methods of hazard
identification, risk assessment, and applying the hierarchy of
controls to ensure the overall risks are at a broadly acceptable
level, or as low as reasonably practicable (ALARP), are still
applicable.
In the UK, the primary regulations that will govern the
handling of hydrogen and the associated infrastructure
are Dangerous Substances and Explosive Atmospheres
Regulations (DSEAR), Control of Major Accident Hazard
Regulations (COMAH), Pressure Equipment (safety)
Regulations (PER) and the Carriage of Dangerous Goods and Figure 2: Layout considerations on the HyNet fuel
Use of Transportable Equipment Regulations (CDG); all of switching project
which originated from implementation of EU Directives. As
the government have indicated in their Hydrogen Strategy6,
it is likely that these regulations are augmented by codes As you would expect, some of the more significant properties
and standards more specific to hydrogen, and in particular are shared with other cryogenically stored gases. Applications
low-carbon hydrogen. At the time of writing, there are three involving liquid hydrogen present additional fire and explosion
threshold values for hydrogen inventory that should be taken hazards to those arising from use in gaseous form. Again,
into account if considering the transition to hydrogen as a fuel there is significant experience with these types of behaviour in
source: the UK, for example, at large scale LNG terminals.
1. The controlled quantity of hydrogen for The Planning Hazardous Area Classification
(Hazardous Substances) Regulations 2015 is 2 tonnes.
Work carried out by Health and Safety Laboratory, Buxton
2. COMAH regulations specify hydrogen as a named
(HSL) for the HyDeploy Trial at Keele University looked at
dangerous substance.
concentrations of up to 20% hydrogen blended in Natural Gas
a. The threshold quantity is 5 tonnes (lower tier). (NG). The results showed that volumetric release rates could
b. The threshold quantity is 50 tonnes (upper tier). be up to 10% higher for the blend than NG, and dispersion
These threshold quantities will primarily affect sites or projects distances (to ½ LFL) could be up to 15-25% further for the
where gaseous or liquid storage is being considered. Reaching blend. HSL proposed pragmatic, conservative modified
these inventories at a facility is less likely if hydrogen is criteria to be applied at HyDeploy to the Natural Gas Standard
provided by distribution pipeline. IGEM/SR/258 for the blend. Further work will be required to
allow these criteria to be used outside the HyDeploy Project.
Designing for hydrogen In contrast, standards addressing Hazardous Area
Classification for pure hydrogen or hydrogen blends above
Understanding the inherent hazards associated with hydrogen 20% are in wide use already. The Energy Institute (EI)
is a good starting point to enable comprehensive risk Model Code of Safe Practice EI 159 guides that any mixture
assessment and ensure the design and operation of facilities containing above 30% volume hydrogen should be treated as
will prevent, control or mitigate against hydrogen hazards. hydrogen. The corresponding EI representative fluid category
Hydrogen’s inherent physical properties, much like other is G(ii). The HSL tool, Quadvent10, is also recommended for
flammable compounds such as natural gas, can be safely classifying zones and calculating extents.
managed through lifecycle management of a facility – from
design to operation and modification. A designer can use
the known properties of hydrogen to influence design BS EN 60079-20-1:2010
considerations. The earlier the identification of risks, the more
• NG with up to 25% hydrogen is Group IIA
time-efficient and cost-effective the solution.
As discussed, gaseous hydrogen is in common use in • Hydrogen is Group IIC
refineries and other industrial facilities, and there is a wealth
• Both NG and hydrogen have a T1 temperature
of experimental and anecdotal evidence of the properties that
class
might be useful to consider early in the design.
Having looked at gaseous hydrogen, it is also appropriate to
consider the properties of liquid (cryogenic) hydrogen (LH2). Figure 3 – Hydrogen Classification to BS EN 60079-20-1:201011

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Property Implication Design and operation solutions

Appearance Colourless, odourless, Difficult to detect. Provision of appropriate types of gas detection equipment – fixed, portable and
and odour and tasteless. personal.

Toxicity Non-toxic, however, Large clouds may cause Appropriate layout should be considered. Confined or congested spaces providing an
does not support life oxygen deficiency if not opportunity for gas build up should be avoided. Preferentially facilities and equipment
and may act as an ignited and affect the ability should be located outdoors. If indoors, good ventilation should be ensured.
asphyxiant. to escape. Potential leak points should be identified, and appropriate inspection and maintenance
regimes should be put in place.

Flammability Extremely flammable Potential for fires and Identify loss of containment scenarios for pressurised pipework and equipment and
in air. explosions. ensure adequate layers of protection are in place.
For “expected” small leaks, such as those covered by hazardous area classification,
appropriate extents of zones should be calculated, potential ignition sources
identified, and eliminated or controlled as appropriate.
Emergency response plans should be put in place.

Ignition Ignition energy is lower Pure hydrogen and high Tight control of ignition sources is necessary.
than methane and it percentage hydrogen flames Thermal imaging cameras (fixed) or portable may aid staff to detect an incident and
burns in air with a very are difficult to see. Fires or avoid/escape the area.
hot and almost invisible flames may be harder to
flame. detect.

Detonation Greater propensity to Deflagration to detonation The design should consider where oxygen-hydrogen boundaries exist, such as vents
detonate in mixtures of transition is more likely than to atmosphere. Appropriate detonation arresters should be fitted.
air than more common with a methane or natural gas Vent line design should be targeted where detonation may be a concern. This will
flammable fuels. explosion. include minimising fittings and bends and accommodating a higher diameter to length
Maximum burning Blast overpressure will be ratio where practicable.
velocity of a hydrogen- higher than for a deflagration Consequence assessment and perhaps QRA modelling may be required to fully
air mixture is about detonation and the effects understand the consequences from a detonation event, especially if consequences
eight times greater than may extend over larger areas. are likely to extend beyond the site boundary.
those for natural gas.

Density and Low density and low Leak prevention is difficult. If a hydrogen leak occurs in an open or well-ventilated area its diffusivity and
viscosity viscosity. Hydrogen is likely to pool buoyancy will help to reduce the likelihood of a flammable mixture forming in the
at high points, such as roof vicinity of the leak. Ensuring good ventilation and no “dead spots” is key.
apexes. Hydrogen leak detection should be placed accordingly.

Table 1 – Physical properties of hydrogen gas

Hazard Design and operation solutions

Boil off gas Cold boil-off gas, as well as the liquid hydrogen, can produce severe burns Segregation of people and equipment.
upon contact with the skin. Identification of likely leak points.
Well documented inspection and maintenance
procedures, including details of correct personal
protective equipment (PPE).

Rapid phase transition Liquid hydrogen carries a potential for rapid phase transition (RPT) explosion – Keeping potential loss of containment points away
(RPT) this is when cold liquid comes into contact with a liquid that is above the boiling from pools of water where possible. This may include
temperature (-253°C for LH2 at atmospheric pressure) of the cold liquid. the requirement for avoidance of entry into water
pools or directly into rainwater drainage.
Drainage.

Liquid spills The release of gaseous hydrogen from a spill would be initially very cold, Placement of gas detection at low level around areas
denser than air and start accumulating at low level. of potential liquid spills.
All gases will be condensed and solidified should they be exposed to liquid Ensuring low occupancy in areas identified with
hydrogen. Leaks of liquid hydrogen in air will cause oxygen to preferentially potential for LH2 loss of containment incidents.
condense out leading to oxygen enrichment of the solidified material. Oxygen-
enriched air reduces the ignition energies, increases the combustion rate
of flammable and combustible materials and increases the likelihood of a
detonation.
Spills of liquid hydrogen can result in air condensing out in and around the
pool of liquid. This can result in the formation of zones in the pool, containing
an explosive mixture of liquid hydrogen and solidified oxygen-enriched air.
These mixtures are shock-sensitive and can detonate with a yield similar to an
explosive.

Material degradation Liquid hydrogen presents severe challenges to the materials it comes into Selection of correct materials of construction.
contact with, due to low temperature exposure and hydrogen embrittlement. Pipe stress analysis.
The thermal expansion and contraction of equipment when exposed to Inspection and maintenance regimes.
temperature fluctuations of ambient to LH2 temperatures can cause wear and
premature failure.

Table 2 – Physical properties of liquid hydrogen

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Industry codes and standards Major Accidents to the Environment (MATTE) that have been
identified, along with brief details of potential initiating events
A number of organisations provide internationally recognised
and the main safeguards. If this is maintained throughout
codes with respect to Hydrogen, including the European
the lifecycle of a plant, it can be used as a useful tool in staff
Industrial Gases Association (EIGA), the National Fire
training as well as documentary evidence of management of
Protection Association (NFPA), and the American Compressed
risks at a facility. It is useful to start this document early in the
Gas Association (CGA). In the UK there is the British
project, with a preliminary issue around hazard study 1 or 2,
Compressed Gases Association, and several compressed
and further issues as the design becomes fixed.
gas suppliers have their own internal standards. These are
particularly useful for identifying requirements for provisional Hazard identification is also something that should begin
separation and segregation distances for hydrogen storage early in the life of a project, with hazard studies 1 and 2 being
during FEED. recommended. These studies provide early sight of hazards,
and provide a focus to the design, spotlighting areas of
concern in process. Late identification of hazards may lead
Hydrogen design project lifecycle
to design changes, the requirement for extra safeguards,
The plan new equipment or changes to layout. Avoiding this is key to
maintaining schedule and budget. Hazard study 3 can be tricky
One of the first tasks on a project is to produce a programme to schedule; too early and the design is incomplete, leading to
against deliverables, and that is as true for process safety inefficient workshops, high numbers of actions and potential
deliverables as it is for the more “traditional” disciplines. for rework under management of change and an administrative
Putting together a list of requirements allows the project to set burden on the project; too late may mean purchase orders
realistic expectations and allow key individuals to schedule have already been made for long lead items, making the design
blocks of time for key safety activities such as hazard studies impracticable to change. This can be alleviated by identifying
and layer of protection analysis (LOPA) workshops. In order to hazards early in HS1 and 2.
develop the list of process safety deliverables there are some Additional, more rigorous risk assessments may be required
key decisions to be made by the wider project team: should any high unmitigated consequence hazards be
• What regulatory requirements need to be met? This could identified. To aid the identification of such hazards, especially
include planning permissions, Construction (Design and if the hazard and operability study (HAZOP) is large, it is
Management) regulations 2015 (CDM), COMAH, DSEAR, recommended that risk ranking is done at HS2 and HS3.
CE or UKCA marking, or Environmental Permits. This may include LOPA, bow-ties, fault trees, event trees or
• Which organisation is responsible for obtaining any quantitative risk analysis (QRA).
permits? What data or other support do they need, how DSEAR assessment has already been discussed, but it should
long does the permitting process usually take? be mentioned here that hazardous area classification (HAC)
is an iterative process through the design phase. In early
• What codes, standards, and procedures need to be
revisions, final equipment may not have been fully identified,
followed?
or the layout may not have been fixed, however, order of
• When does management of change begin on the project, magnitude hazard zone extents are needed to progress with
how is it to be implemented, who needs to sign off? selection of components. It is probable that the early revisions
• Is the project going to use the full suite of hazard studies? are overly conservative and area extents may become less
Identify a facilitator early in the project and get them on onerous as design decisions are made.
board. The identification of pressure interfaces is, of course, as
• Are there likely to be safety instrumented systems (SIS)? important in hydrogen projects as it is in any other.
Start the SIS lifecycle plan as early as possible and put in
place key roles and responsibilities. The challenges
This can seem like a lot of hard work and an investment in So far, the discussion around finding design solutions, planning
time and resources, but agreeing all of the above information, a project and key process safety activities, clearly point to
deliverables, schedules and responsibilities at the outset can the fact that new energy projects utilising hydrogen are no
help the project to proceed far more smoothly. A well-run different to anything else that anyone working in the UK
project wants to avoid any surprises or misconceptions that can process safety field is familiar with. That is not to say that there
cause costly redesign late in the schedule, and maintain good have been no challenges, but these have been overcome and it
working relationships through the project team. is worth sharing those experiences.

Key activities Exemptions to GS(M)R

The Basis of Safety document is a “live” document which is As previously stated, the current limit of hydrogen in the
a focal point for what can be rather disparate process safety natural gas supply is 0.1% (molar)2 according to the regulations.
deliverables. This is particularly important where a COMAH For any project wishing to exceed these limits, official
Safety report is not required, as it is a summary of key studies exemption must be granted by HSE. This entails significant
that will or have been completed, a document map to all the effort on the part of the project to demonstrate the safety
other process safety deliverables, and a repository for ALARP case to the regulator, as can be expected. The expertise and
evidence and demonstration. More importantly, perhaps, it is knowledge to do this kind of demonstration is limited to a few
the location for the list of Major Accident Hazards (MAH) or organisations within the UK, and may include laboratory and

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 Process Safety Lifecycle Concept

284dunkerley.indd 21
Strategy, Feasibility & Construction, Installation, Operation &
Design & Development Decommissioning
Concept Selection Commissioning Life Extension

Audit, Monitoring & Review

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Risk Review Process

Management of Change
Selection of Design Standards

Define Safe Operating Envelope Review and Update

Original Assumption
Process Safety Design & Procurement
Activities
Identify Safeguards/Layers of Protection Maintenance

Identify HP/LP Interfaces Testing/Inspection

Over/Under Pressure Protection Collection of Data

Control System, Alarms and ESD Design

Figure 4 – Example of key process safety activities during the lifetime of a project
Assess Regulatory
Requirements and
Hazardous Areas/DSEAR
Permits:
• COMAH ALARP Demonstrations
PT

• COSHH
I&C
FAT

SAT
HS6
HS3
HS2
HS1
CSR
Key

• Environmental Permits Emergency Response Procedures

HS4/5

• Land Use Planning

• Etc Operations and Maintenance Procedures/Planning

Consideration of Human Factors

Proof Testing
Hazard Study 6
Hazard Study 3
Hazard Study 2
Hazard Study 1

Hazard Study 4/5

Concept Safety Review

Site Acceptance Testing

Factory Acceptance Testing
Installation & Commissioning
Loss Prevention Bulletin 284 April 2022 | 21

31/03/2022 11:03:34
 22 | Loss Prevention Bulletin 284 April 2022

pilot scale experiments, gas industry experience, experts in the other with regards to the process safety elements. Following
field of explosion sciences, as well as reliability modelling experts. best practice, scheduling the appropriate risk assessments,
With the excellent data from trailblazing projects such as allowing for inherent properties within the design and
HyDeploy proving the safety case for hydrogen blends and the planning for the right deliverables will get you most of the
government’s commitment to the hydrogen strategy, it could be way to delivering a safe, high-quality project. It is true that the
reasonably foreseen that the GS(M)R regulations will need to be early trials and demonstration projects may have a few extra
updated to widen the limits of hydrogen in the gas supply in the challenges, but nothing insurmountable if you are creative and
future. have a good working relationship with the wider project team.
Over the next decade, as the hydrogen roadmap is achieved, I
Gas industry best practice fully expect hydrogen projects to become, “business as usual”.
It seems obvious to say that gas industry standards and practices
are tailored to the definition of natural gas as mandated by References
the GS(M)R regulations. In working with gas companies, it is 1. Health and Safety Laboratory for the Health and Safety
natural that they wish to apply their own standards, which give Executive, 2015, RR1047 Research Report; Injecting
a high level of confidence both in the quality and safety of a hydrogen into the gas network – a literature search; ©
build. However, there is little leeway in some of these standards Crown copyright 2015
to account for a hydrogen or hydrogen blend. If taking these
2. Gas Safety (Management) Regulations, 1996, Schedule
standards literally, some of the more prescriptive elements
3 - Content and other characteristics of gas, Part I -
are difficult to meet. This requires good communication and
Requirements under normal conditions.
relationships between the operators and the designers to come
up with an agreeable and safe solution, based on a more flexible 3. Office for Budget Responsibility, 6th July 2021, https://
interpretation. obr.uk/box/decarbonising-domestic-heating-lessons-
from-the-switch-to-natural-gas/
Trials and demonstrations 4. World Meteorological Organization (WMO) under the
The very nature of a trial or demonstration project means it is direction of the United Nations Secretary-General; United
temporary and time limited. This comes with the need to find in Science 2020
creative and innovative solutions. The challenges are: 5. Committee on Climate Change, December 2020, The
Sixth Carbon Budget. The UK’s path to Net Zero
• Physically fitting new equipment into an existing facility,
6. Department for Business, Energy & Industrial Strategy,
finding the best layout solutions.
August 202, UK Hydrogen Strategy; © Crown copyright
• Planning for equipment and plant that can be removed at 2021.
the end of a trial.
7. Health & Safety Executive; A report by HM Factory
– Reinstating the plant to its “as-was” condition. Inspectorate, 1976, The explosion at Laporte Industries
– Potentially moving trial equipment to another location or Ltd Ilford, 5 April 1975; © Crown copyright 1976
“mothballing” for later use.
8. Institution of Gas Engineers & Managers, 2010, IGEM/
• Installing and commissioning without affecting current
SR/25 Edition 2 - Hazardous area classification of natural
production throughput or quality.
gas installations
– Potentially narrow and fixed windows during a planned
9. The Energy Institute, 2015, EI Model code of safe practice
shutdown.
Part 15: Area classification for installations handling
• Sourcing a temporary hydrogen supply.
flammable fluids
• Getting the trial results within the allocated window – there
10. Ivings, M. and Goff, R. (HSE’s Buxton Laboratory),
is little time to “tweak” or optimise during a commissioning
February 2018, Hazardous Area Classification using
phase.
Quadvent
11. British Standards Institute, 2010, BS EN 60079-20-1
Summary Explosive atmospheres Part 20-1: Material characteristics
In the author’s opinion, based on experiences to date, a for gas and vapour classification — Test methods
hydrogen energy project can and should be treated like any and data

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284dunkerley.indd 22 31/03/2022 11:03:34

 Loss Prevention Bulletin 284 April 2022 | 23

Incident

Reactive chemistry case study

Dr Andrea Longley, Scott Bader, UK

Summary
On 02 May 2019, the batch processing facility at the AB
Specialty Silicones, LLC (AB Specialty) in Waukegan, Illinois,
US, inadvertently added the wrong chemical to a tank, thus
mixing reactive chemicals in error. The tank contents reacted
which caused foaming and overflow and released hydrogen
gas inside the production building. The subsequent ignition
of the hydrogen gas cloud caused a massive explosion
and fire. The explosion fatally injured four employees
and destroyed the facility’s production building. The U.S. Figure 2 – Chemical structure of the siloxane co-polymer
Chemical Safety and Hazard Investigation Board (CSB) highlighting the Si-H bond. (Credit CSB)
subsequently responded to this incident and this report
summarises their findings1.
the operator was to add chemical ingredients to tanks in the
Keywords: Reactive chemicals, incorrect chemical added order and quantity specified on the batch ticket. Because
of a previous near miss incident, the likelihood of charging
an incorrect material during a batch had been recognised.
Background Operators were consequently required to have a co-worker or
AB Specialty Silicones, LLC (AB Specialty) is a US manufacturer supervisor cross check the product name, product code, and
and worldwide distributor of specialty silicone chemicals lot number on the raw material containers and then initial the

knowledge and
competence
(Figure 1). Products are used in a wide variety of applications, batch ticket before each material was added into the batch.
including personal care, roof coatings, chemical manufacturing, This was part of a “double initial procedure” program to reduce
adhesives, sealants and other coatings. the likelihood of making a mistake.
Production buildings were equipped with reactors, tanks, The tanks used in the batch process had an open hatch-type
storage vessels, and other equipment for the manufacture lid and no vent pipe to direct gases to a safe location.

engineering
and design
of various silicone products. The particular product being On completion of each manufactured batch, the final
manufactured at the time of the incident had been made at the product was tested for pH. If the final product was outside the
facility since 2013. allowable pH range, a written instruction was given to adjust its
In order to assure the right “recipe” for each individual pH by adding either an acid (i.e., glacial acetic acid) or a base
batch, a form known as a “batch ticket” was used. This detailed (i.e., potassium hydroxide (KOH)) to the product depending
the sequential operation steps and the chemical ingredients

systems and
on the pH requirements. AB Specialty used a solution of 10

procedures
and quantities required for the batch operation. The role of percent KOH in water (10% KOH) when the pH of the product

Figure 1 – AB Specialty production facility in Waukegan, Illinois, before the incident. (Credit: Google Earth and CSB)

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284longley.indd 23 31/03/2022 11:16:29

 24 | Loss Prevention Bulletin 284 April 2022

and fire. The building was destroyed by the explosion (Figure

3). Debris extended for several hundred feet from the building,
and nearby business properties were also damaged. Four
AB Specialty Silicones employees were fatally injured by the
explosion, and another was injured.

Investigation
The investigation found many contributing causes to this
incident. The full causal analysis is shown in Figure 4. The
CSB recorded that neither of the US Process Safety standards
(OSHA PSM or EPA RMP) required AB Speciality Silicones
to have or use a process safety management (PSM) system.
Good practice would be for any company handling reactive
and hazardous chemicals to have an appropriate PSM system
in place. Central to the causal analysis are the facts that the two
reactive materials were both stored in the vicinity of the batch
Figure 3 showing the production building after the explosion
tank and in similar looking drums with only small identification
(Credit CSB)
labels. Figure 5 shows the drums and labels. It should be noted
at this point that the labels shown in Figure 5 did not include
needed to be increased. This final pH adjustment addition was the hazard information designated by the United Nations’
not listed on the batch ticket. (UN) Globally Harmonised System (GHS)2 standards for
The material being manufactured at the time of the incident classification and labelling of chemicals.
used a type of siloxane copolymer containing silicon hydride The CSB determined that due to the lack of an effective
(Si-H) bonds as a raw material. These Si-H containing materials hazard analysis program, AB Specialty Silicones did not identify
react readily with aqueous bases rapidly releasing hydrogen. the hazards associated with:
• storing reactive chemicals in similar containers
Incident report
• the practice of allowing reactive materials to be stored near
On the day of the incident, the production facility made one each other
batch of the material without incident and at the end of the • the ventilation system and the batch process design
batch, adjusted the pH of the final product using KOH solution • the lack of gas detection
with no adverse effects. The second batch was likely started
• insufficient emergency response preparedness.
when the KOH drums used to adjust the pH at the end of
the previous batch were still in the vicinity of the tank being The US Occupational Safety and Health Administration
used to manufacture the batches of product that day. Up to
eleven nearly identical drums were in the locality. The majority
of these would have contained the Si-H containing siloxane
raw material along with at least one drum of the KOH pH
adjustment solution which should not have been charged until
the end of the process and even then only if the pH needed
adjusting.
The operator likely misidentified the 10% KOH drum(s)
that remained in the area after the first batch because all the
drums in the area looked very similar and the labels and text
on them were relatively small. Eight drums of the Si-H material
should have been charged to the tank, but some 10% KOH was
also charged in error; the operator likely mistakenly thinking
that one drum of KOH was the Si-H containing siloxane raw
material. The blend was mixed and the batch tank contents
started to foam and overflow from the batch tank top opening.
A fog also formed and spread through production building.
The CSB determined that this process upset produced
hydrogen gas which collected in the production building due
to the lack of vent piping from the batch tank.
There were no flammable gas detectors or hydrogen gas
detectors to warn workers of the released hydrogen and the
workers did not evacuate the building.
Due to the haze, the operators decided to attempt to
increase the ventilation of the building but the hydrogen gas Figure 5 – Blue drums containing on the left, 10% KOH solution
ignited before they could do this, causing a massive explosion and on the right, the Si-H siloxane (Credit CSB)

© Institution of Chemical Engineers

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284longley.indd 24 31/03/2022 11:16:32

 Loss Prevention Bulletin 284 April 2022 | 25

Neither OSHA PSM Indicates CSB

nor EPA RMP cover all TSR system used to
analyse business risk and Recommendation
reactive hazards
REGULATIONS

some safety hazards

No regulation required TSR system did not identify Weakness of

AB specialty to manage or process operational hazards process safety
control reactive hazards culture

AB Specialty did not thoroughly assess the hazards of its Lack of a Safety
operations or identify and establish effective safeguards Management
System addressing
process safety
AB SPECIALTY SILICONES

AB Specialty did not have a KOH used for pH

written procedure requiring adjustments in first
chemicals to be removed from batch of EM652
production area after use

KOH stored in same KOH remained in emulsion

type of drum as XL10 area after first batch

Similar appearance of XL10 and KOH

drums likely contributed to personnel
adding incorrect chemical to tank

Incorrect chemical (aqueous KOH) charged Aqueous KOH The two

to tank containing methylhydrogensiloxane and molecules with SIH No hydrogen in-progress
polymer, XL 10 (has SiH bonds and bonds react to produce detection and trial LEL detector
TD 6/12 Blend hydrogen alarm system sensors found failed
in Emulsions in March 2019 and
PHYSICAL EVENTS AND CONDITIONS

Area not replaced as of

EM 652 Uncontrolled chemical May 2019
Ventilation Operation
system designed manufactured reaction occurred housed within
to introduce in open tanks producing hydrogen building
outside air into
building near Workers interviewed did
emulsion area, not recognise the hazardous
may have mixed condition created from the
hydrogen Hydrogen gas released from the process upset – there was no
with air tank into production building system to automatically warn
of a process emergency

Ignition Employees did not

Oxygen sources present
Hydrogen present evacuate building during
present
hydrogen release

Explosion and Fire People present

OUTCOME
OUTCOME

4 Fatalities and Building Destruction

Figure 4 – Causal analysis (Credit CSB)

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284longley.indd 25 31/03/2022 11:16:32

 26 | Loss Prevention Bulletin 284 April 2022

Improving Process Safety Culture – Management’s Obligations

Holding everyone (including Setting process safety

Looking for management
themselves) accountable for performance expectations and
system failures as
commitments and ensuring that issues providing the resources to
root causes for incidents
are resolved in a timely manner achieve them

Consistently identifying and Ensuring adequate funding

correcting substandard actions to maintain equipment and
or conditions during field safety systems in
walkthroughs good condition

Figure 6 – Examples of management strategies for improving process safety culture (Source credit: CSB and CCPS Conduct of
Operations and Operational Discipline – for improving process safety in industry)

(OSHA) conducted their own inspection of AB Specialty, issued the job wrong.
multiple wilful violations, proposed a penalty of approximately • Equipment that handles materials with the potential to
$1.6 million, and placed the company in the Severe Violator develop hazardous gases should be vented to a safe
Enforcement Program (SVEP). At the time of the CSB report location, away from personnel and away from structures
publication1, it was reported that AB Specialty Silicones had that could confine the hazardous gases.
contested the citations and remained in the SVEP. • Companies that handle hazardous materials need to ensure
that facilities are equipped to detect and alert employees
Lessons learned of a hazardous material release—through means such as
Amongst others, the CSB recommended that: gas detectors and alarms—and that personnel are trained
on how to recognise and respond to hazardous material
• Companies should use the chemical reactivity worksheet3 releases.
to help determine where the reactive chemistry hazards are
• Double initial procedures should not be used as a sole
on a production facility.
safeguard to prevent mixing of reactive materials.
• All final adjustment additions should be listed on the batch
• Chemical processing facilities should assess and strengthen
sheets so that the team assessing the hazards are aware of
process safety culture to help prevent catastrophic
the possibility of unintended reactions.
chemical incidents by following industry best practice
• Reactive chemistry hazards should be substituted for guidance, including guidance published by the Center for
alternative, less hazardous materials wherever possible Chemical Process Safety (Figure 6).
(inherent safety).
• Companies that handle reactive chemicals need to
• Containers holding different reactive materials should be establish a robust process safety management system
colour coded for clarity. to identify, evaluate, and control reactive and process
• Containers holding different reactive materials should be hazards. Many industry guidance documents have been
stored separately, in marked and designated locations. published on developing such systems, including ‘Essential
• Bar code control and verification systems should be used Practices for Managing Chemical Reactivity Hazards’,
for raw material feed control. ‘Guidelines for Risk Based Process Safety’, and ‘Guidelines
• The amount of any QC related adjustment material should for Implementing Process Safety Management’, all from the
be limited to that needed for a single batch. Center for Chemical Process Safety.
• Raw materials should be hard piped from designated
storage to reduce the risks of human error at the point of References
raw material feed. 1. Chemical Reaction, Hydrogen Release, Explosion, and Fire
• Hazardous gas detection with alarms should be provided. at AB Specialty Silicones. Report No. 2019-03-I-lL from
• Operators should be trained in the hazards of process the US Chemical Safety and Hazard Investigation Board
upset conditions so that they know when to evacuate. published September 24 2021.
https://www.csb.gov/assets/1/20/ab_specialty_
Conclusions investigation_report_final.pdf?16710
2. Background: Globally Harmonised System (GHS) (hse.gov.
Among the multiple recommendations of the CSB report, uk) https://www.hse.gov.uk/chemical-classification/legal/
several key lessons for industry were detailed, including: background-directives-ghs.htm
• Companies need to give thought to how they can arrange 3. Chemical Reactivity Worksheet | AIChE https://www.
work such that it is easy to do the job right and hard to do aiche.org/ccps/resources/chemical-reactivity-worksheet

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 Loss Prevention Bulletin 284 April 2022 | 27

We invite read
ers
which accident to send their views on
s
next few years, they expect to see over the
Accidents of the future – part 6 and what have
Please visit ht
why these keep
n.
ha
we failed to lear ppening,
tps://www.ic
knowledge/lo hem
A selection of predictions from our readers ss-prevention- e.org/
submit-mater bu
ial/ if you wou lletin/
share your id ld like to
eas.

are working
w he n pe op le , pr obably contractors,
osion in a ta nk
There will be an expl op le will be seriously inju
red or killed.
e ta nk . Th e pe
on, or near th gineering
l Engineer – Risk En
Roger Stokes, Principa
before?
accident happened
When has a similar
x
at Avonmouth, UK -four--injures-one.asp
mb er 20 20 : Ef flu en t digester ex sion plo
los ion -at -U K- wa ter -treatment-works-kills
3 Dece e/182420/Exp
exonthenet.net/articl
https://www.hazard mbroke Refinery nery-explosion-in-201
1/
Ju ne 20 11 : Am ine Tank Explosio n at Pe
ro- fin ed -5m -fo llo wi ng-fatal-pembroke-refi
2 s/vale
icalengineer.com/new f
https://www.thechem em broke-report-2020.pd t plant.
e.g ov .uk /c om ah /c he vro n-p
Be ac h, waste water treatmen
https://www.hs n, Ci ty of Da yto na
ethanol tank explosio
11 January 2006: M dia /2 12 6/ lpb 24 6_pg24.pdf
rg/me
https://www.icheme.o Delaware.
lph ur ic Ac id Tank Explo n in sio
/
17 July 20 01 : Su ric-acid-tank-explosion
ww w. csb .go v/ mo tiva-enterprises-sulfu
https ://
ks.
ppening? le atmospheres in tan
Why does it keep ha za rd s ass oc iat ed wi th potentially flammab op era tio ns are undertaken.
d the ha ing or emptying
• Failure to understan ma y ch an ge as cle an
e that the conditions
• Failure to appreciat ac id tan ks ca n contain hydrogen. equate risk assessmen
t was conducted
to un de rst an d tha t ar the tan ks an d no ad
• Failure airing at or ne
tors are cleaning or rep
• Often the contrac m of work.
s no safe syste
and therefore there wa and
read failure to underst
What have we failed
to learn?
ati on rev ea led a lon gstanding and widesp ult ing fat ali tie s were
Pe mb rok e: The investig Th e ex plo sion and the res
Per HSE en qu iry int o
flammable atmosphere
inside the tan k. es, but be use of the
ca
ol ris ks po se d by the eq ue nc e of err ors by individual employe
and contr merely the cons
The incident was not safe systems of work.
therefore avoidable. sy ste ms to en sure a safe place and
ge me nt .pdf
failure of safety mana embroke-report-2020
:// ww w. hs e.g ov .uk/comah/chevron-p
htt ps s in storage
we tak e to pr event repetition? s an d ris ks of flammable atmosphere
What steps co uld el on the ha za rd risk assessments
mu st ha ve po lic ies of educating personn ZO P/ W ha tIf) on op erations and specific
• Companies ents (PHA/ HA
process safety assessm
tanks and conducting thorisation.
int en an ce ac tiv itie s. co uld be es ca lat ed to higher levels of au
for ma d around tanks st be tightly controlled
.
olving hot work on an uct work on tanks mu
• Permits to work inv rs, wh o oft en co nd
ntrol of contacto
• Management and co
n fuel
n u sual’ places, such as hydrogeg from
sions in ‘u ns resultin
Hydrogen explo ec trolysers, an d pipeline statio ts
el
stations, small ads after car and truck acciden
leaks, and on ro evelopment Dire
ctor
ess D
wner and Busin osion at a hydrog
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Hans Schwarz, O before? An expl
nt ha pp en ed , H an au , G ermany, 1991
ilar accide drogen tank
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vika, Norway, 20 w groups of user
s
fuel station, Sand n is handled by ne
in g? H yd ro ge
happen
Why does it keep
d human errors
w e fa ile d to learn? Avoi s,
Wha t ha ve Create awarenes
e ta ke to pr ev ent repetition?
dw
What steps coul
trainin g of us er s

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284futureaccidents.indd 27 31/03/2022 11:20:17

 28 | Loss Prevention Bulletin 284 April 2022

A fire and exp

losion due to
resulting in fa release of eth
talities. The c anol in the sm
‘visitor’ eleme o n sequences/ha all-scale distill
nt zard potentia ed spirits indu
Daniel D’Arcy- l are increase stry,
Kernan, Lead d due to the p
Whe n has a simila
Pr oc ess Safety Engineer ublic
r accident hap
There have be pened before?
en several rece
• Yorkshire, U nt incidents in
K: Loss of cont which a fatality
ainment from has been avoide
near-miss loca open gas-fired d by chance, in
l to petrol statio st ill which ignite cluding the follo
• Sheffield, U n. d. Significant bu wing:
K: Loss of cont ilding damage
Distiller rescue ainment from an d
d by emergenc same still type
• Tasmania: Lo y services and as Yorkshire w
placed in indu hi ch ignited (in th
ss of containm ced coma. e storeroom of
disfigurement ent of mixing di a pub).
and significant st ill at es which ignite
• Near-miss si building damag d. Significant bu
te: Loss of cont e. rn injuries incl
containing Gra ainment which uding perman
in Neutral Spiri fa ile d to ignite. Re ent
Why does it ke ts. lease of boiling
ep happening? liq ui d and vapour ne
A combination xt to tanks
of lack of safety
equipment, an kn owledge from
d poor regulatio plant owners (a
significant num n (e.g. no conn nd designers),
ber of sites op ection betwee the sale of unsa
er at in g with severe sa n pl an t safety and ob fe but low-cos
What have w fety gaps. taining a distill t distillation
e failed to lear ing license) ha
Small-scale dist n? s resulted in a
illation plants ar
experienced by e a credible ris
the industry (s k to life and sh
similar initiatin ome reportedly ould undergo
g causes and w labelled as “unf robust risk asse
er e re adily identifiabl oreseeable acci ssment and re
What steps co dents” by inve gulation. The in
uld we take to e by a su itable risk asse stigators) have cidents
Steps that coul prevent repet ssment (e.g. D broadly involv
ed
d be taken by ition? SEAR assessm
ent in the UK).
• In the short both plant oper
term, regulato ators and regu
prohibition in ry body notifie lators could in
the long term. s distilling indu clude:
• Implement st ry of unsafe eq
process safety uipment by writ
incorporated in as a prerequisi ten warning, w
to the proced te to starting a ne ith potential
• Regulatory ure to obtain a w distillery. Fo
body promotes distilling license r ne w plants in the U
enforcement af requirement fo in collaboratio K, this could be
ter transition pe r process safety n with HMRC.
• Site operator riod. in existing dist
s start working illeries in the sh
assessment) to towards improv ort term, with
identify safety ing process sa strict
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. initially via D
SEAR

Utility scale bat

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Linkedin.https:/
controls-result-b /www.linkedin.c
ig-battery-blaze om/pulse/poor-p
Wayne Vernon, -w ay ne-vernon lumbing-crumm
Safety Engineer y-
ing Consultant
When has a sim
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Why does it keep ened before? Th
e Victorian Big Ba
happening? Early ttery fire.
and po or control system indicatio ns point to poor
functional safety installation and co
What have we fa practice. mmissioning pr
iled to learn? To actice,
technology. apply known good
practice on desig
n and installation
What steps coul on new
d we take to prev
throughout the lif ent repetition?
ecycle of utility sc Follow good proc
ale batteries. ess safety practic
e

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by LPB articles is particularly
Charles Taylor Adjusting, UK
welcome, and should be addressed
Dr Hans Schwarz to the editor at:
ProsafeX, Germany
Loss Prevention Bulletin
Mr Roger Stokes Institution of Chemical Engineers
BakerRisk, UK 165 - 189 Railway Terrace
Mr Sam Summerfield Rugby, Warwickshire
Health & Safety Executive, UK CV21 3HQ, UK
Dr Ivan Vince Tel: +44 (0)1788 578214
ASK Consultants, UK Fax: +44 (0)1788 560833
Email: [email protected]

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 Human Factors in Health
and Safety
Modular training for the process industries
Online and face-to-face courses available in 2022

Would you like to develop your understanding of human

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Find out more: www.icheme.org/human-factors

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