Industrial Fires and Explosions
Industrial
fires and explosions are usually determined to be accidents. When an incident occurs in industry the
investigation and analysis are done by some of the best and brightest engineers
in the world. One of the many cases I have worked on involved an industrial
explosion with 5 fatalities in Illiopolis, Ill.
This case ties into poor management decisions as a root cause and
therefore has the most relevance to this management information systems class. Attached below are summary points from the Investigation of the U.S. Chemical Safety and Hazard Board (CSB).
• The U.S. Chemical Safety and Hazard Investigation Board (CSB) INVESTIGATION REPORT
• REPORT
NO. 2004-10-I-IL
• MARCH
2007
• VINYL
CHLORIDE MONOMER EXPLOSION
(5 Dead, 3 Injured, and Community Evacuated)
•
On
April 23, 2004, an explosion and fire at the Formosa Plastics Corporation,
Illiopolis, Illinois, (Formosa-IL) polyvinyl chloride (PVC) manufacturing
facility killed five and severely injured three workers.
•
The explosion
and fire destroyed most of the reactor facility and adjacent warehouse and
ignited PVC resins stored in the warehouse.
•
Vinyl
chloride monomer (VCM), a highly flammable chemical and known carcinogen and
the primary raw material in the PVC manufacturing process, was the fuel for the
explosion and initial fire.
•
Formosa-IL,
a wholly owned subsidiary of Formosa Plastics
•
Corporation,
USA (FPC USA), bought the Illiopolis facility from Borden Chemical and operated
it for approximately two years before the incident.
•
The
U.S. Chemical Safety and Hazard Investigation Board (CSB) determined that this
incident occurred when an operator drained a full, heated, and pressurized PVC
reactor. The CSB believes
that the operator cleaning a nearby reactor likely opened the bottom valve on
an operating reactor, releasing its highly flammable contents.
•
Opening
the bottom valve on the operating reactor required bypassing a pressure
interlock. The safeguards to prevent bypassing the interlock were insufficient
for the high risk associated with this activity.
•
Two
similar incidents at FPC USA PVC manufacturing facilities highlight problems
with safeguards designed to prevent inadvertent discharge of an operating
reactor.
•
Two
operators working with the shift supervisor attempted to manage the release,
did not evacuate, and subsequently died.
•
The CSB determined that facility emergency
procedures for evacuation were ambiguous and that facility staff had not
conducted a large release emergency drill in more than 10 years.
•
When
FPC USA bought the Borden facility in 2002, management reorganized and reduced staff.
•
Interviews
and documents obtained by the CSB investigators indicate that when considering
what changes to make, FPC USA compared similar Formosa plant sites and Formosa
operating philosophy, but conducted
no formal managerial or human resource analysis of the staffing changes.
These changes occurred on the day Formosa-IL took ownership of the plant.
•
Borden
Chemical had assigned operators and a group leader (a working supervisor) for
each area (such as PVC1).
•
The group leader was an hourly employee
responsible for supporting the operators in his/her area.
•
Employees interviewed indicated that the group
leader, a respected position at the Illiopolis facility, had an elevated level
of responsibility.
•
FPC USA management eliminated the group leaders
when it bought the facility.
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