SKPP 3123 : SAFETY IN PETROLEUM ENGINEERING

ASSIGNMENT 1

WEST FERTILIZER COMPANY FIRE AND EXPLOSION

NAME : NICHOLAS GAWAN ANAK TADONG

MATRIX NUMBER : SX152971KPPF30

LECTURER : PROF MADYA IR DR. ZAINAL BIN ZAKARIA

Petroleum Engineering Department

Faculty of Chemical & Energy Engineering
Universiti Teknologi Malaysia
81310 UTM Johor Bahru, Johor
 Table of content

1.0 Overview
2.0 Background
2.1 West Fertilizer Company (WFC)
3.0 Incident description
3.1 Consequences
3.1.1 Fatalities and Injuries
3.1.2 Property Damage
4.0 Incident Analysis
4.1 Fertilizer Grade Ammonium Nitrate (FGAN)
4.2 Factors Contributing to the Massive Fire and Explosion at the WFC
4.2.1 Heating and Ventilation
4.3 Emergency Response
4.3.1 Key Contributing Factors to Emergency Responders Fatality
4.3.2 Lack of Incident Command System
4.3.3 Lack of Established Incident Management System
4.3.4 Lack of Pre-Incident Planning at Facility
4.4 Lessons Not Learned and Lessons Learned
4.4.1 Pre-West-Incident FGAN: Lessons Not Learned
4.4.2 Post-West Incident FGAN-Related Fire: Lessons Learned
5.0 Recommendations

5.1 Inherently Safer Technology

5.2 Inherently Safe Building Design and Storage

References
1.0 Overview

On April 17, 2013, a fire and explosion occurred at the West Fertilizer Company
(WFC), a fertilizer blending, retail, and distribution facility in West, Texas. The violent
detonation fatally injured 12 emergency responders and three members of the public.
Local hospitals treated more than 260 injured victims, many of whom required hospital
admission. The blast completely destroyed the WFC facility and caused widespread
damage to more than 150 offsite buildings. The WFC explosion is one of the most
destructive incidents ever investigated by the U.S. Chemical Safety and Hazard
Investigation Board (CSB) as measured by the loss of life among emergency responders
and civilians; the many injuries sustained by people both inside and outside the facility
fenceline; and the extensive damage to residences, schools, and other structures.
Following the explosion, WFC filed for bankruptcy.

The explosion happened at about 7:51 pm central daylight time (CDT),

approximately 20 minutes after the first signs of a fire were reported to the local 911
emergency response dispatch center. Several local volunteer fire departments responded
to the facility, which had a stockpile of between 40 and 60 tons (80,000 to 120,000
pounds) fertilizer grade ammonium nitrate (FGAN), not counting additional FGAN not yet
offloaded from a railcar.

More than half of the structures damaged during the explosion were demolished
to make way for reconstruction. The demolished buildings include an intermediate school
(552 feet southwest of the facility), a high school (1,263 feet southeast), a two-story
apartment complex with 22 units (450 feet west) where two members of the public were
fatally injured, and a 145-bed nursing home (500 feet west) where many of the seriously
injured civilians resided. A middle school (2,000 feet southwest) also sustained serious
but reparable damage. Section 3 describes the incident and its consequences in detail.

The CSB investigated the factors that contributed to the detonation of FGAN.
Section 4 describes the properties of FGAN and posits three scenarios that could lead to
its detonation under the conditions present during the WFC fire. CSB concluded that the
construction of the bins and other building materials as well as the lack of an automatic
sprinkler system plausibly contributed to the detonation.
2.0 Background

2.1 West Fertilizer Company

The West Fertilizer Company (WFC) was located in the city of West, Texas. The city is
approximately 80 miles south of Dallas, Texas, and has a population of about 2,800.The
WFC stored and distributed fertilizers, chemicals, grains, and various other farming
supplies. At the time of the incident, stockpiles of about 40 to 60 tons of FGAN were
estimated to be onsite, and about 30 tons detonated. Table 1 shows the WFC inventory
at the time of the explosion and fire

The fertilizer building was constructed in 1961, and business operations started in 1962.
Photographs from 1972 show the closest residence about 265 feet from the WFC
property. In addition, a baseball field was 58 feet from the property. In 1972, the town
nursing home and the nearest group of homes were constructed about 500 feet away.
The WFC operated two buildings and a number of tanks One building served as a
chemical warehouse, shop area, and office space. Most chemicals purchased by farmers

were stored in that building. Such chemicals included Roundup , Sevin , and additives
to make pesticides adhere to plants and were stored in containers ranging in size from 2
to 300 gallons.

The WFC also owned the fertilizer building, constructed in the 1960s, where dry fertilizer
was stored .Fertilizers stored in that building included diammonium phosphate,
ammonium sulfate, potash (potassium chloride), potassium magnesium sulfate (K-Mag),
and FGAN. A seed room was located at the north end of this building.

The WFC facility had two 12,000-gallon anhydrous ammonia (NH3) storage vessels,
located to the south of the fertilizer building, for distribution and sale of the product to
farmers.
3.0 Incident Description

On April 17, 2013, at approximately 7:29 pm, citizens reported signs of smoke and
fire at the West Fertilizer Company (WFC) facility to the local 911 dispatch center. Within
20 minutes, a massive explosion occurred, killing 15 people and sending a blast wave
through the town that damaged or destroyed many buildings and homes. The fire was
witnessed from several vantage points by different individuals associated with the West
Police Department, Dallas Fire-Rescue Department, and volunteer fire departments
(VFDs) from West, Abbott, Bruceville-Eddy, Mertens, and Navarro Mills.

Video Stills of WFC Fire and Explosion

3.1 Consequences

3.1.1 Fatalities and Injuries

The violent explosion at the WFC facility fatally injured 12 emergency responders
and 3 members of the public. All of the fatalities except one resulted from fractures, blunt
force trauma, or blast force injuries sustained at the time of the explosion. Two fatally
injured members of the public lived at a nearby apartment complex while the third resided
at the nursing home and died from injuries brought on by the trauma of the explosion
shortly after the incident. According to the Waco-McLennan County Public Health
Districts report, the incident resulted in more than 260 injured victims, including
emergency responders and members of the public.
3.1.2 Property Damage

The West incident caused considerable property damage, including the complete
destruction of the WFC facility . An initial estimate by the Texas Department of Insurance
set total property damage resulting from the explosion and fire at $100 million. CSB hired
a consulting firm to perform an assessment of the structural and property damage caused
by the fire and explosion. The assessment involved a thorough examination of damage
to the WFC facility and to the community structures and facilities. As of the publication of
this report, neither the owners of the WFC nor the city of West has decided whether the
WFC facility would be rebuilt. Currently, the local farmers are using fertilizer from another
fertilizer facility in Leroy, Texas, seven miles east of the city of West.

The explosion completely demolished the scale house; the roof and all four walls
failed. The explosion flattened the chemical storage and office building east of the fertilizer
storage building all that remained was a stack of metal debris where the building once
stood. The explosion also destroyed the corn silo north of the fertilizer storage building.
In addition, the blast heavily damaged the above-ground vertical liquid fertilizer storage
tanks
4.0 Incident Analysis

4.1 Fertilizer Grade Ammonium Nitrate (FGAN)

Historical Knowledge of AN Fire and Explosion Hazards

Over the years, the explosibility and fire hazards of AN have been the subject of a number
of research papers. The paper notes the following:

Under favorable conditions of pressure, rapid heating, and retention of heat, AN

may be exploded partially from heat alone near 300F. AN can detonate if subjected to
a very strong initial impulse. Six factors influence the sensitivity of AN toward an
explosion: temperature, strength of initial impulse, density, packing, particle size, and
moisture content of the material.

4.2 Factors Contributing to the Massive Fire and Explosion at the WFC

Because of the unpredictable behavior of FGAN in fire situations, the scenario that
contributed to the detonation at the WFC might never be precisely determined; however,
several detonation scenarios are plausible. CSB identified two factors or conditions that
likely contributed to the intensity of the fire and detonation:
(1) the contamination of FGAN with materials that served as fuel and
(2) the nature of the heat buildup and ventilation of the FGAN storage space. These
factors and scenarios for how the FGAN behaved on the night of the incident are based
on the physical evidence that remained and blast analysis.

4.2.2 Heating and Ventilation

As the fire progressed, the available oxygen in the building was depleted as it was
consumed in the fire. Although the fertilizer warehouse structure had some ventilation
louvers in the cupola at the top, ventilation at ground level was limited to only a few
louvered vents and the normal infiltration that exists around doors. The limited ventilation
increased the quantity of soot in the smoke and the potential contamination of the FGAN
pile.
4.3 Emergency Response

The FGAN explosion at the West Fertilizer Company (WFC) facility killed 15 people
and caused more than 260 injuries. Of the 15 fatalities, 12 were first responders
(firefighters and emergency services) personnel who responded to the fire eight volunteer
firefighters, with five from the West Volunteer Fire Department (WVFD), two from the City
of Abbott Fire Department.

4.3.1 Key Contributing Factors to Emergency Responders Fatality

CSB identified the following seven key factors that contributed to the fatalities of
firefighters and other emergency responders in West:

. Lack of incident command system.

. Lack of established incident management system.

. Lack of hazardous materials (HAZMAT) and dangerous goods training.

. Lack of knowledge and understanding of the detonation hazards of FGAN.

. Lack of situational awareness and risk assessment knowledge on the scene of an

FGAN-related fire.

. Lack of pre-incident planning at the WFC facility.

. Limited and conflicting technical guidance on AN.

4.3.2 Lack of Incident Command System

CSB found that none of the responding emergency response personnel trained
and certified in the National Incident Management System (NIMS) process formally
assumed the position of Incident Commander (IC) who would have been responsible for
conducting and coordinating an incident command system (ICS).
4.3.3 Lack of Established Incident Management System

CSB found that the emergency response personnel who responded to the WFC
incident did not take time to set up, implement, and coordinate an effective incident
management system plan that would have ensured evacuation of the nearby residents.
Because no formal IC was in charge of the incident, none of the firefighters took
responsibility for formally establishing and coordinating an effective incident management
system.

4.3.4 Lack of Pre-Incident Planning at Facility

The fire department did not have a formal pre-incident planning program for FGAN
at WFC. Firefighters responding to the incident were aware of the risks associated with
anhydrous ammonia leaking from the tanks and that it could form a toxic flammable cloud
that could leave the facility, drift into nearby homes, and potentially explode. Although
some responding firefighters knew that FGAN was onsite, they did not anticipate a
possible FGAN explosion. Some of the West fire department officials reported that they
were aware of the chemicals routinely stored at the WFC, but there was never any formal
training to prepare for a fire or chemical emergency.

4.4 Lessons Not Learned and Lessons Learned

4.4.1 Pre-West-Incident FGAN-Related Fires and Explosions: Lessons Not Learned

CSB found that lessons learned from previous firefighter fatalities and emergency
responses to FGAN- related incidents were not effectively disseminated to firefighters and
emergency responders in other communities where FGAN is stored or used. Had those
lessons been applied to the very similar situation

Although the firefighters in West knew of the hazards associated with the tanks of
anhydrous ammonia as a result of previous releases, they were not alert to the explosion
hazard from the FGAN inside the warehouse. Although FGAN itself does not burn, the
conditions under which AN might detonate when exposed to fire are unpredictable and
not clearly understood, and current guidance does not offer consistent advice on how to
attempt to guarantee firefighter safety. The deaths of the volunteer firefighters and
emergency responders in West was not the first time that firefighters have been killed
when responding to FGAN-related explosion incidents.
4.4.2 Post-West Incident FGAN-Related Fire: Lessons Learned

On May 29, 2014, at around 5:45 pm, a fire involving FGAN occurred at the East
Texas Ag Supply facility in downtown Athens, Texas. Emergency dispatchers and the
Athens Police Department promptly notified firefighters from the Athens Fire Department
(AFD). Emergency response units from the AFD arrived on the scene of the fire at 5:50
pm and found fire and smoke coming from the northwest end of the 3,500-square-foot
East Texas Ag Supply facility. This facility was built with masonry bricks and combustible
wooden structures, similar to construction at the WFC facility.

The AFD chief arrived about 2 minutes after the first responding units were
dispatched to the site of the incident, and he found that the fire had self-ventilated at the
northwest end. On the basis of his observation of the enormous scope of the fire and the
possibility of detonation of FGAN in the engulfed building, the fire chief promptly decided
to let the East Texas Ag Supply facility burn to the ground instead of attempting to
fight the fire. He ordered his firefighters to retreat from the scene and began an
extensive evacuation of the downtown Athens, Texas, area. The Athens Police
Department coordinated the evacuation of the nearby residential areas, setting up an
initial three-block evacuation perimeter, which was later expanded to five blocks.
Fortunately, No injuries were associated with this incident.

Dark Grey Smoke Originating from East Texas Ag Supply Facility in Downtown Texas.
5.0 Recommendation

5.1 Inherently Safer Technology

FGAN has certain risk characteristics that can make it inherently dangerous under
some conditions. Ammonium nitrate (AN) by itself is a powerful oxidizer; when mixed with
fuel oil, it can be used as an industrial explosive when exposed to fire or shock. Traditional
safety practices to control FGAN fire and explosion hazards through procedures, hazard
awareness, and emergency response are important. However, applying the concept of
inherently safer technology (IST) or inherently safer design (ISD) can substantially reduce
risk.

IST and ISD are recognized approaches for decreasing risk by permanently
reducing or eliminating the hazards associated with materials and operations used in an
industrial process. Trevor Kletz, an acknowledged expert on IST and chemical process
safety, defined IST as the avoidance of hazards rather than the control of hazards by
adding protective equipment. Inherently safer processes can be achieved by strategies
such as:

. Substituting dangerous chemicals or processes with safer alternatives.

. Simplifying processes.

. Minimizing the quantity of a chemical on hand or in a process.

. Moderating the operating conditions of a process.

IST is most effective when implemented during the earliest stages of the process design,
but it can be applied at all stages of a life cycle (design, operation, shutdown, and
demolition)
 Before the widespread adoption of IST, plant designs in the chemical industry
tended to address reduction of risk by relying on layers of protective equipment,
procedures, and alarms.

Table above lists some IST approaches that can be applied to FGAN.

Once all hazards associated with a chemical process are identified and
understood, IST can be applied in the design phase or to existing processes. According
to Kletz, the concepts of IST are not sharply defined and can merge into each other,
depending on how they are applied. Although not always feasible or cost-effective,
substitution is often the most desired approach for reducing hazards because it involves
replacing a hazardous material with a safer alternative. Minimization to reduce the
quantity of a hazardous chemical stored or used within a process can often have a
dramatic effect on risk, albeit usually only locally.
5.2 Inherently Safe Building Design and Storage

In the United States, FGAN storage practices at facilities similar to the WFC have
not significantly changed over time. Before the fires in Bryan, Athens, and West, these
Texas FGAN facilities had similar construction, with combustible materials and
construction and limited fire safety features. CSB visited another EDC facility in Itasca,
Texas, in 2013 and also noted combustible construction for the storage facility and bins.
Findings from the WFC incident demonstrate that inherently safer concepts can be
applied to storage practices to significantly reduce the risk of a fire or explosion. Modifying
existing facilities or constructing new storage facilities with inherently safe options such
as facility set-back distances and the use of noncombustible construction materials can
reduce such risks.

In July 2009, an FGAN-related fire at the EDC fertilizer storage facility in Bryan,
Texas, burned the facility to the ground, but the FGAN did not explode. The fire forced an
evacuation of more than 80,000 residents in the Bryan area and students at the Texas
A&M College Station campus. EDC rebuilt the facility, originally a wooden structure, with
concrete bins surrounded by a concrete dome (Figure above). EDCs insurance company
required the use of concrete construction materials instead of wood to minimize the fire
risk.
References

http://www.tdi.texas.gov/news/2013/news201320.html (accessed on October 7th, 2017).

The 2010 U.S. Census data indicate that the population of West, Texas, is 2,807. See:
http://www.census.gov/2010census/popmap/ (accessed on October 7th, 2017).

Waco-McLennan County Public Health District. A Public Health Report on Injuries

Related to the West (Texas) Fertilizer Plant Explosion, June 24, 2014.

http://www.dallasnews.com/news/west-explosion/human-toll/20130617-some-say-west-
blast-rushed-nursing- home-patients-deaths.ece (accessed on October 9th, 2017).

Clements, Bruce. Texas Department of State Health Services, The Texas Public Health
Response to the West Fertilizer Plant Explosion, October 8, 2013. See:
http://www.astho.org/Preparedness/DPHP-Materials-2013/WestTexasExplosion/
(accessed on October 11th, 2017).