MAJOR HAZARDS AND

CIMAH

FLIXBOROUGH ACCIDENT,
ENGLAND
Accident occurred on a Saturday in June 1974.
It had a major impact on chemical engineering in the UK.
As a result, safety achieved a much higher priority in the
country.
The plant was designed to produce 70,000 tons per year
of caprolactam, a basic raw material for the production of
nylon.
The process uses cyclohexane which has properties
similar to gasoline.
Under the process conditions in use at Flixborough
(155oC and 7.9 atm), the cyclohexane volatizes
immediately when depressurized to atmospheric
conditions.

 Several months before accident, reactor 5 in the series

was found to be leaking. Inspection showed a vertical
crack in its stainless steel structure.
Disaster due to bypass pipe section ruptured due to
inadequate support and overflexing of the pipe section
as a result of internal reactor pressures.
Upon ruptured, an estimated 30 tons of cyclohexane
volatized and formed a large vapor cloud. The cloud was
ignited by an unknown source 45 seconds after the
release.
The resulting explosion leveled the entire plant facility,
including the administrative offices. A total of 28 people
died and 36 others were injured. 18 of these fatalities
occurred in the control room when the ceiling collapsed.

Essential Factors
No works engineer
New plant manager
No formal procedures
No drawings of modifications
Scaffold tube supports
Assembly not tested
Unsuitable material
No local information
No site emergency plan
No planned emergency response

Some Lessons From Flixborough

Siting of major hazard installations
Licensing of storage of hazardous materials
Regulations for pressure vessels and systems; The structure, the
people, the systems and procedures, and the safety office
Relative priority of safety and production
Use of standards and codes of practice
Engineering of plants for high reliability
Design and location of control rooms and other buildings
Planning for emergencies
Unconfined VCE
Control of plant and process modifications
Restart of plant after discovery of a defect
Decision-making under operational stress.

Industrial Activities Covered by

CIMAH
(i) Process operations involve a
dangerous substance which is either
toxic, explosive or flammable.
(ii) Isolated storage covers sites such as
separate tank farms, warehouses and
fuel storage and must involve a
dangerous substance.

(a) On-Site Emergency Plans

Regulation requires manufacturers to prepare an
on-site emergency plan, and provides for
consultation with appropriate bodies.
(b) Off-Site Emergency Plans
Manufacturers are not responsible for the
preparation of the off-site emergency plan. This
is a duty placed on local authorities. However,
manufacturers are required to provide
information to local authorities adequate to
enable them to draw up off-site plans. This
information will cover major accident hazards,
possible consequences and any special
emergency measures.

(c) Informing Members of the Public

- Regulation requires that persons outside the site who
are likely to be affected by a major accident at an
industrial activity should be informed about the activity
and associated hazards so that they have advance
warning of the likely effects of such an accident and of
the precautionary action they should take.
- The responsibility for providing this information is
placed on the manufacturer, who has to try to reach an
agreement with the local authority for the local authority
to pass on the information to the public, else the
manufacturer must himself disseminate the information
to the public.
- It is for HSE to identify the public information zone
where people may be at risk and in which information
should be provided.

Information on Potential Major Accidents and

Their Prevention and Mitigation
Regulation requires a detailed consideration of
the dangerous substances, their properties and
the conditions under which they are processed
or stored.
The potential source of a major accident hazardnormally involves a failure of the containment
system (bulk vessels, pipework, pumps, process
upsets via relief system etc), leading to a release
of the dangerous substance.
Quantification of the consequences of such
hazards and preventative measures taken.

 An estimate of the number of people on

site who may be exposed to the hazards
considered in the report.
Information about the emergency
procedures laid down for dealing with a
major accident occurring at the site.
A diagram of any plant in which the
industrial activity is carried on, sufficient to
show the features which are significant as
regards the potential for a major accident
or its prevention or control.

Information Relating to Every Dangerous

Substance Involved in the Activity
The name of the dangerous substance and
chemical formula;
A general description of the analytical methods
available to the manufacturer for determining the
presence of the dangerous substance, or
references to such methods in the scientific
literature;
A brief description of the hazards which may be
created by the dangerous substance;
The degree of purity of the dangerous substance,
and the names of the main impurities and their
percentages.

Information Relating to the Installation

A map of the site and its surrounding area to a scale
large enough to show any features that may be
significant in the assessment of the hazard or risk
associated with the site;
A scale plan of the site showing the locations and
quantities of all significant inventories of the dangerous
substance;
A description of the processes or storage involving the
dangerous substance and an indication of the conditions
under which it is normally held; and
Information about the nature of the land use and the size
and distribution of the population in the vicinity of the
industrial activity to which the report relates.

On-Site Plan
1. Identification of Key Personnel
These include:
Incident Controller
- His primary task is to take charge at the
scene
- Likely to be the shift supervisor until he is
relieved by a more senior manager with
knowledge of the area in which the
incident occurring.

 Site Main Controller

- He will be primarily concerned with
coordinating the required actions across
the site, advising the Emergency Services
about the way the incident islikely to
develop and arranging backup support for
the Incident Controller.
- More information are required about the
current situation, likely weather changes,
resource availability, etc.
Personnel in Emergency Team

(2) Setting Out the Plan Arrangements

Plan initiation
Raising the alarm
Emergency control centre or centres must be
off-site
Safeguarding people on-site, for instance,
upgrading the evacuation procedures and safe
locations
Action by the emergency team this is to protect
those in danger and arrangements for caring for
those affected by an accident.

- During an emergency, it is important to provide sufficient

and adequate information. Hence, there must be good
communication between the control room and other
sources of data.
- All sorts of information related to the current situation are
needed by the controller. This will make task easier to
direct the emergency services and emergency team.
- Information also needs to be provided for the public
through media.
- The level of response depends on the level of the
incident. Initially, small fires or releases should be
brought under control and low priority alarms raised. If
the situation escalates and VCE or BLEVEs look
imminent, all personnel should be evacuated.

Off-Site Plan
Based on the events identified which would affect people
and the environmental off-site. Any relevant information
on the nature, extent and likely effects of the incidents
are required.
Need to cater in detail all identified events as being most
likely.
Should be flexible enough to permit the remedial
measures to be extended and increased to deal with
extremely adverse combinations of circumstances and
consequences.
Information provided must be detailed, unambiguous and
comprehensive for the dangers to be understood, so that
the necessary protective measures can be provided.

 Several different responses may be necessary at a

single site, depending on the size and characteristics of
the incidents.
The plan must ensure coordination of existing services
and their readiness for the specific hazards and
problems which may appear in an incident.
Identification of key personnel, their duties and proper
training achieved.
Set out a command structure and identify the respective
roles and responsibilities of the senior personnel
involved.
Set out the immediate action to protect those in danger.
Set out arrangements for caring people and environment
affected by an incident.

- In case of accident, off-site population is

subjected either to blast, missiles impact, flash
fire or exposure to thermal radiation.
- In the event of a major release of LPG, all roads
in the vicinity should be sealed off to avoid
ignition sources entering the gas cloud and
emergency services to get through.
- Thus, every effort should be made to stop traffic
by appropriate police action. All trains should be
informed to stop since the railway is on the limit
of lethality for a flash fire when the flow of LPG is
perpendicular to the track.

- People should go or stay indoors and shut all

windows and doors and turn off fans or air
conditioning.
- As there may be some overpressure affects from
explosions, it would be best for the people to
stay in a room preferably facing away from the
scene of the incident and to listen to local radio
for further information or action.
- People may also suffer more harm from a short
exposure during an evacuation then they would
experience while sheltering.
- Sheltering gives the best protection in most
cases involving the release of flammables
(LPG).