ACCIDENT BACKGROUND

At approximately 05:35 hours on 19 November 1984 a major fire and a series

of catastrophic explosions occurred at the government owned and operated PEMEX
LPG Terminal at San Juan Ixhuatepec , Mexico City. As a consequence of these events
some 500 individuals were killed and the terminal destroyed.Pemex is a liquid
petroleum gas (LPG) distribution plant.

Three refineries supplied the facility with LPG on a daily basis. LPG gas is used
for heating and cooking in almost every household.The 54 LPG storage tanks has
overall capacity of 16,000 m3. There are 6 large spherical tank and 48 smaller tanks of
various size.The plant was being filled from a refinery 400 km away, as on the previous
day it had become almost empty. Two large spheres and 48 cylindrical vessels were
filled to 90% and 4 smaller spheres to 50% full.

A drop in pressure was noticed in the control room and also at a pipeline
pumping station. An 8-inch pipe between a sphere and a series of cylinders had
ruptured. Unfortunately the operators could not identify the cause of the pressure drop.
The release of LPG continued for about 5-10 minutes when the gas cloud, estimated at
200 m x 150 m x 2 m high, drifted to a flare stack. It ignited, causing violent ground
shock. A number of ground fires occurred. Workers on the plant now tried to deal with
the escape taking various action. At a late stage somebody pressed the emergency shut
down button.

About fifteen minutes after the initial release the first BLEVE occurred. BLEVE
(Boiling Liquid Expanding Vapor Explosion) is vapour explossion which may result
from catastrophic failure of a tank structure,which was containing cargo liquid above
the boiling point at nominal atmospheric pressure. For the next hour and a half there
followed a series of BLEVEs as the LPG vessels violently exploded. LPG was said to
rain down and surfaces covered in the liquid were set alight.

The explosions were recorded on a seismograph at the University of Mexico.

The first firefighters arrive 15 minutes after the BLEVE. There are 100 ambulance and
200 firefighters involved. And also 985 medics and 1780 paramedics involved. Result
from this accident are 574 people killed, 2000 people received severe burns , 7321
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people classed as injured, almost 60000 people made homeless, 31 milion dollars of
damages, and destruction of 1/3 of the LPG supply to Mexico city.

Figure 1 Before Accident

Figure 2: After Accident

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 ANALYZE OF ACCIDENT USING DOMINO’S THEORY

1. FAULT OF THE PERSON

a. Somebody was late pressed the emergency shut down button at the
refinery,stopping the pumps and the flow of LPG to the facility. In fact, the
pumping and flow of LPG through the pipeline and into the burning and
exploiding plant.
b. The site of the PEMEX plant was very restricted, and the entire firefighting
system was to close to central area which a major fire would start.

2. UNSAFE THE ACT OR CONDITION

a. The two large spheres and the 48 bullets were filled about 90% of capacity, and
the 4 smaller spheres to about 50%. So it causes overfilled of the 4 largest bullet
in front of the two larger storage spheres and failure of their pressure relief
valves to lift, and resulting overpressure in an 8-inch line between the spheres
and 4 bullets.
b. A drop in pressure was noticed in the refinery control room and also at a pipeline
pumping station. The 8-inch line between the spheres and 4 bullets had ruptured
which causes pressure drop. Unfortunately , the operators in the refinery could
not identify the cause of the pressure drop and continued to pumping.

3. ACCIDENT
a) The release of LPG from the ruptured 8-inch line, driven by the continued
pumping, produced an expanding cloud of LPG gas. When the drifting gas cloud
reached the flare, it ignited, resulting in a massive Unconfined Vapor Cloud
Explosion (BLEVE).
b) About fifteen minutes after the initial release the first BLEVE occurred. During
the next hour and a half, seven more large and violent explosions occurred.

4. INJURIES
The damage to the nearby houses was severe. There were additional explosions within
the houses, and many people suffered injuries and serious burns from flaming drops of
LPG. Virtually all the houses within 300 meters of the plant were completely destroyed.

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 CORRECTIVE ACTION
ENGINEERING

1. The plant had no gas detection system. Gas detection and emergency isolation is
needed to provide an early warning of a problem and help to ensure people’s safety.
2. Water system failures. The spheres were not equipped with adequate cooling water
systems to prevent BLEVEs.
3. Better maintenance.

EDUCATION

1. Effective operator training. Need some previous work-related skill, knowledge or

experience to be a chemical plant operator.
2. Timely inspections. Aware that evacuation is required when the alarm system is
activated and know where the nearest exits are located
3. Mis-design in the layout of the plant.They should proposed the proper layout of
large LPG storages.

ENFORCEMENT

1. Maintain industrial standard.

2. Planned evacuation routes.
3. Extra water hydrants in the streets. When a fire breaks out, firefighters rely on being
able to quickly locate and use fire hydrants.