Know-how
In the rst of a new series on how
disasters have shaped industrial
safety worldwide, Becky Allen
revisits the Nypro explosion and
reects on its legacy
BEFORE 1974, few outside North
Lincolnshire would have heard of
Flixborough. Situated on the River
Trents ood plain, a few miles south of
where it joins the Humber, the village had
a population of just 544 and was too small
to merit a mention in the Encyclopaedia
Britannica.
Villagers shared the low-
lying land east of the Trent
with a sizeable chemical
works. Relatively isolated
behind the Normanby Park
Steelworks, the plant dis-
tinguished itself only by the
odours that occasionally
drifted into surrounding ham-
lets and its almost pictur-
esque nightly illumination.
Chemic als had been
produced at Flixborough
since 1937, when a succes-
sion of rms began manu-
facturing fertilisers using
c oke - oven gas from the
steelworks. Though some
residents assumed the plant
still made fertilisers in 1974,
it had since the late 1960s
become a linchpin of UK
Nylon manufacture.
In 19 6 4, Fi s o n s a n d
Dutch State Mines (DSM)
set up a joint venture, Ny-
pro, to produce Nylon-6.
DSMs proc-
ess produced
caprolactam
14
Flixborough:
(the chemical precursor to Nylon-6 from
cyclohexane, allowing Nypro to compete
head-on with ICI and Duponts patented
method for making Nylon-66. By 1967, the
Flixborough plant the only one of its kind
in the UK was supplying caprolactam to
textiles and chemicals manufacturer Cour-
taulds and in 1969 Nypro announced it was
trebling capacity to 75,000 tonnes a year.
28 dead
Then on Saturday 1 June 1974, events
at the plant turned a little-known village
into a synonym for disaster. At 4.53pm, as
residents enjoyed the Appleby Frodingham
steelworks childrens gala or watched the
schoolboy football international on televe-
sion, the works were virtually demolished
by a massive explosion.
The blast, which was detected by
scientists at Leicester university almost
250 kilometres away and later estimated
as equivalent to up to 45 tonnes of TNT,
blew over concrete buildings, distillation
columns and pipelines. Of the 70 staff on
site that weekend, 28 were killed and 36
injured. None of the 18 men working in the
control room survived. Had it been a week
day, the number of fatalities at Nypro, which
employed 553 people, would have been
far greater.
It was a scene of utter devastation: cars
in the works car park were compressed to
the size of dustbins, a neighbouring
eld of wheat was sucked into the
partial vacuum created by the blast
and large pieces of the plant came
to rest in ironstone workings nearly
eight kilometres away.
Fifty three people off site
reported injuries and hundreds
more patched up their own
cuts and bruises. Almost all
homes in Flixborough, and
nearby Amcotts and Burton
were affected, along with
789 in Scunthorpe, more
than six kilometres away.
In all, 1821 houses and
167 shops and factories
February 2011 health and safety at work
were damaged. The blaze that enveloped
the plant took 250 re ghters with 50 re
engines three days to contain, and res
burned for a week and a half. While the
plant burned, reaction began.
Price of progress?
Two days after the disaster, local MP John
Ellis told the House of Commons: The
cost in terms of grief and misery that my
constituents have had to suffer and are still
suffering on the altars of wealth and so-
called technical achievement is too high for
a so-called civilised society to bear.
Industrys in-house disasters are bad
enough but when they reduce a village to
rubble, put dozens of stitches in toddlers
faces and frighten the wits out of people
living as far away as 20 miles the risk as-
sumes new dimensions, the Economist
commented. And, said a BBC TV reporter
filming in front of the smoking Nypro:
Flixborough has joined the unhappy band
of communities who pay for other peoples
progress with human lives. This is the
price of Nylon. (You can see the BBCs
ve minute news report at www.lexisurl
.com/hsw5908).
But what caused the disaster, and how
did events over 35 years ago shape industrial
safety today? The answers lie in the Flixbor-
ough inquiry and the Advisory Committee on
Major Hazards (ACMH), both swiftly set up
by then secretary of state for employment
Michael Foot.
As the inquiry would nd out, on 27
March 1974, a crack had ap-
peared in reactor number 5.
The reactors were lled with
liquid cyclohexane under pres-
sure at 155 C, through which
compressed air was bubbled
to cause the reaction. The
plant was shut down and the

reactor, one of a series of six, was removed
and a bypass installed to link reactor num-
bers 4 and 6.
Infamous dog-leg
The 50cm diameter bypass pipe was de-
signed by Nypro engineers who were not
experienced in high-pressure pipework. No
plans or calculations were produced, the
pipework was not pressure tested and was
mounted on temporary scaffolding, unsup-
ported from above. Bellows were used to
join the pipe to the 60cm reactor anges
and crucially, because the gravity-assisted
reactor series was built on a slope, the pipe
included a dog-leg bend to accommodate
the change in height.
The plant was restarted but shut down
again two months later when, on 29 May, a
small leak was discovered on a sight glass
on a pressure vessel in the plant. Once the
leak was repaired, in the early hours of the
morning of 1 June, the plant started up for
what would be the last time.
According to chemical engineer Profes-
sor Tony Kletz: At 4.52pm the 50cm dog-leg
pipe and the bellows attached
to it ruptured, causing the
entire contents of all ve
reactors to escape at sonic
velocity to form a vast am-
mable vapour cloud the
size of a football pitch.
The vapours ignition
less than a minute later
resulted in an open am-
mable cloud explosion.
Rush job
The inquiry, whose remit
was to discover the im-
mediate causes of the
blast, sat for 70 days,
hearing evidence from
173 witnesses.
Chaired by Roger
Parker QC, the inquiry
The price of Nylon
health and safety at work February 2011
blamed the disaster on decisions made
in March when the crack was discovered.
Had it been decided to strip and examine
the other reactors and await a report on the
cause of the failure of reactor number 5, the
plant must have remained shut down for
several days. The design and construction
of the bypass assembly would not then have
been conducted as a rush job, as in fact it
was, its report said.
The hurried workaround, the inquiry
thought, would not have happened had a
works engineer been on site. As it was, the
previous post-holder had left early in 1974
and by June had still not been replaced.
The services engineer who provided cover
was not qualied to do the job, even for a
short time.
As a result, nobody realised that the
pressurised bypass assembly would twist
and buckle and ultimately fail.
The disaster was caused by the intro-
duction into a well designed and constructed
plant of a modication which destroyed its
integrity. The immediate lesson to be learned
is that measures must be taken to ensure
that the technical integrity of plant is not
violated, the inquiry concluded.
Though it was outside the inquirys remit,
the report commented on the plants siting,
saying the greater the risk of disaster and
the greater the disaster which may ensue,
the more important it is that the plant con-
cerned should be, as was Flixborough, away
from populated areas. It also noted that
had the control rooms layout
been differently sited or con-
structed or both, loss of life
might have been avoided.
The legacy
More than 35 years
on, it is hard for health
and safety profes-
sionals some of
whom were not yet
born when Nypro
Know-how
went up to appreciate how differently
things were done then, and the changes
wrought by Flixborough.
The explosion happened before the
Health and Safety at Work Act had its third
The disaster was caused by the
introduction into a well designed and
constructed plant of a modication
which destroyed its integrity
reading in parliament the tone of that
debate being greatly affected by the disaster
and also before the HSE was formed.
Debate intensied outside parliament
too, increasing public concern about a whole
industry. The disaster, says Kletz, cost in-
surers 70m but, as did [the 1984] Bhopal
[gas tragedy] and Seveso, Flixborough cost
the chemical industry much more.
Via the ACMH, which produced three
inuential reports between 1976 and 1984,
Flixborough and the 1976 Seveso disaster
which will be the subject of a later article
caused a sea-change in the way hazard-
ous industries operated and were regulated
in the UK and beyond.
Two European Directives, Seveso I and
Seveso II, were the outcome, implemented in
the UK as the Control of Industrial Major Ac-
cident Hazards (CIMAH) and then Con-
trol of Major Accident Hazards
(COMAH) Regulations.
15
 Know-how
Todays process safety, change man-
agement and risk management techniques
are also rooted in Flixborough. As Kletz
points out, a more efcient process would
have made Nypro safer: Flixborough de-
stroyed the condent feeling that we can
always keep large quantities of hazardous
chemicals under control, and therefore we
should keep the amounts of them in our
plants as low as reasonably practicable
16
or use safer materials instead. Inherently,
safer design arrived on the chemical indus-
trys agenda.
According to Phil Wright, chief engineer
at specialist insurers Allianz Engineer-
ing: Flixborough has left us with a useful
legacy of preventative work practices. We
no longer wait for things to go wrong, rather
we have developed techniques to minimise
the risks posed by our workplaces.
February 2011 health and safety at work
Combatting complacency
Remembering that modern health and
safety practices and legislation are the
direct result of lives lost at Flixborough and
other disasters is crucial, says HSE chair
Judith Hackitt.
O f an age when she remember s
Flixborough she was in her second
year at Imperial College London studying
chemical engineering she told HSW: I
refer to Flixborough a lot in my speeches
on disasters and learning lessons from
the past because it had a big impact on
me ... Flixborough really made me aware
of how important health and safety was
in industry.
But Flixboroughs most important les-
son lies in remembering it, because it is
only by doing so that we can avoid thinking
it couldnt happen here, she says.
For a generation who has grown up
without these events, because we have got
better at managing health and safety, there
is a danger of complacency.
I rmly believe that the unwise deci-
sions people make about cutting costs or
deferring maintenance are because people
have got detached from the consequences
of things going wrong, she adds. You can
never forget that people die.