1 | Loss Prevention Bulletin 117

1994

Incident

Flixborough: 20 years on
Robin D Turney, Eutech Engineering Solutions Limited ICI Brunner House, Winnington, England
Introduction
Looking back at Flixborough after 20 years provides the process industries with important lessons which are still valid today. We have only to look at the photographs or videos to remind ourselves that this was the worst onshore disaster the process industries have known in the UK. Photographs 2.1, 2.2 & 2.3 show the devastation both on and off site. Many aspects of the incident were clear even before the court of inquiry started its work. It was quite clear from early on that the explosion, which killed 28 people, 18 of whom were in the control room, was caused by the escape and ignition of a massive cloud of cyclohexane. What events lead up to this? 4 outlet and reactor 6 inlet the temporary pipe had a dog-leg construction, see Figure 2.1. Once installed the temporary pipe was supported by scaffolding and was tested at operating pressure with nitrogen. All seemed to have gone well and the plant was returned to service on the 1 April (a quick turnaround considering the amount of work which had been carried out). On the 29 May it was noticed that the isolating valve on one of the vessels was leaking and the plant was once again shutdown for repair. The leak was repaired and the plant start-up commenced at 04.00 on the 1 June. The start-up seems to have been troublesome and it is likely that the pressure in the reactors rose to values between the normal value of 8.6 bar and the relief valve pressure of 11.3 bar. Exact details of this could not be determined since the control room with all the records was destroyed and all the relevant shift staff killed by the explosion.

The events leading to the accident

On the 27 March 1974, some two months before the explosion, a leak was noticed on one of the six reactors in series where cyclohexane was oxidised to caprolactam. These reactors operated at a pressure of 8.6 bar and a temperature of 155C (above the atmospheric boiling point of cyclohexane). Each reactor was slightly lower than the one before so that the liquid in them flowed by gravity from Number 1 down to Number 6. Investigation of the leak, which was on Number 5 reactor, showed that it came from a crack almost 15cm long which went through both the 1.25 cm mild steel reactor shell and the 0.3 cm stainless steel lining. Once this was noticed, the plant was immediately shutdown and depressurised. The next day a meeting of the operational and engineering staff agreed that the reactor needed to be taken out for repair. At the same time it was agreed that the plant could be operated without No5 reactor and the engineer responsible was asked to arrange for a temporary pipe to be installed in place of this reactor. At this stage the first deviation from good engineering practice was made. Although it was not certain that the reasons for the failure were limited to No.5 reactor little consideration was given to the need to inspect the other reactors internally. Further deviation from good engineering practice followed. One of the features of the design was the installation of large (72 cm diameter) bellows to allow for expansion during heat-up of the reactors. It was decided to retain both of these in place, with the temporary pipe. No design work was undertaken, other than a chalk drawing on the workshop floor, and no hydraulic tests carried out on the fabricated piece. To take account of the difference in levels between reactor

Causes accepted by the court of inquiry

Following its detailed study of the evidence and experimental work the court of enquiry concluded that the dog-leg in the temporary pipe caused out of balance forces. These could, under certain pressure conditions above 8.6 bar lead to squirm of the bellows together with jack-knife and failure of the temporary pipe. A study of the full report (1) is interesting since a number of factors are involved including the stiffness of the bellows. In some instances the bellows could squirm to a new stable state which could not lead to the jack-knife failure. This failure caused the release of 30-50 tonnes of hot cyclohexane. The cyclohexane mixed with air and a vapour cloud explosion occurred, devastating the plant. What is quite clear is that the use of two bellows with an offset required very careful consideration. The Designers Guide issued by the bellows manufacturer made it clear that two bellows must

Figure 2.1 Arrangement of reactor-train and temporary pipe

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1994 | 2

not be used out of line in the same pipe without adequate support. To quote the official report the instructions on this point are clear and explicit and there are helpful diagrams. It is plain that if the engineers at Nypro had read the Designers Guide they would have realised that their pipe and bellows assembly was unsafe. Similar advice was available in the relevant British Standard. The Specific Lessons of the official report state: The disaster was caused by the introduction into a well designed and constructed plant a modification which destroyed its integrity. The immediate lesson to be learned is that measures must be taken to ensure that the technical integrity of the plant is not violated. We recommend:

1)

that any modifications should be designed, constructed, tested and maintained to the same standards as the original plant...

Photograph 2.2: Immediately following explosion (note reactor train on left)

The need for training

Following Flixborough the importance of procedures to control modifications has been accepted by the process industries and implemented widely. As with any procedure these will only work if staff understand the need and a training module Hazards of Plant Modifications produced by the IChemE has been used extensively since its introduction. Recently the author was asked by the Loss Prevention Panel to lead a revision of the module with the assistance of other panel members (2). A review showed that although the training module adequately covered modifications to plant hardware, e.g. piping, vessels etc, it did not take account of the many non-hardware changes which can affect plant integrity. Inadequate consideration of these can have equally severe effects and an extensive revision of the module has been undertaken with new sections covering: Changes to process conditions Changes to process substances Changes to associated procedures Changes to specifications Changes to computer software Changes to manning and organization.

Figure 2.2 Organisation Chart: Those reporting to the General Works Manager

Each of these sections is illustrated in the training module by two or more case studies. There are also a number of supplementary case studies covering situations where either incomplete information or errors in the way a modification was made lead to serious accidents. In addition, the modification control procedures from two leading companies are included.

Organisational change
The consideration of changes to manning and organisation leads us back to Flixborough. Changes in the organisation at Flixborough produced a situation where the engineering errors which caused the accident could arise. These were due to failure by the management to adequately respond to changes which were forced upon them. To understand these we need to appreciate the organisation of the site shown on Figure 2.2. Of these positions the only manager/engineer with professional mechanical engineering training was the Works Engineer (Chartered Mechanical Engineer). The Works

Engineer had, however, left early in 1974 and although attempts had been made to replace him these had been unsuccessful. Below the Works Engineer were a number of other engineering positions shown in Figure 2.3. None of these engineers had any professional engineering qualifications although the Services Engineer had an ONC in Electrical Engineering (a Further Education College qualification) and was acting as co-ordinator for the engineering function. The management recognised the weakness of this situation and had established links with the Assistant Chief Engineer of a National Coal Board subsidiary. This man was, however, very busy and only able to make sporadic visits to site. As we can see, in making a change to a part of the plant which required careful professional consideration, those on site were being asked to do work outside of the areas in which they were trained and competent They did not know what they did not know. This lead the court of inquiry to some further recommendations. That the training of engineers should be broadly based. Although it may well be that the occasion to use such knowledge will not arise in an acute form until an engineer has to take executive responsibilities it is impossible at the training stage to know who will achieve such a position. All engineers should,

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1994

Photograph 2.3 The devastation on-site

therefore, learn at least the elements of other branches of engineering than their own in both academic and practical training. Also it is essential that: a) persons given certain responsibilities are competent to carry out those responsibilities, b) top management has a clear knowledge and understanding of individuals and the magnitude and type of demand made upon them, and c) top management has a clear knowledge and understanding of the total workload placed on each individual in relation to his capacity. Even good and competent individuals have increased potential for errors of judgement when overworked. Also in times of crisis and extreme demand it is easy to overwork the willing horses some of whom may not know their own limitations. At a time when re-organisations are taking place in so many businesses the lessons outlined above are just as relevant today as they were in 1974.

References
The Flixborough Disaster. Report of the Court of Inquiry, HMSO 1975, ISBN 011 361075 0 Modifications: The Management of Change, IChemE slide training package 025, June 1994, R D Turney, S J Burge and S R Jones
The views expressed by the author are his own and do not necessarily reflect those of ICI or of any of its subsidiaries.

Figure 2.3 Organisation chart: Those reporting to the works engineer

Photograph 2.4. The devastation on-site

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