❌Phillips Disaster of 1989 ❌ 
People
Workplaces
Event Sequence 
Management
System Parts
Design Lifecycle
Contractors
Staff
Job Design
Information Transfer
Commissioning
Maintenance
Operating
De-commissioning
Concept
Construction
Equipment Design
Work Environment
Workplace Factors
Management and Regulations
Operation
Staff
Roles and Responsibilities
Culture
Tasks
Training
Procedures
Cost
Controls
Training
Houston Chemical Complex (HCC)
Air hoses
Reactors #1-6
Storage tanks
Developmental reactor
Valves
Finishing plant
Culture
Cost
Training
Policies and Procedures
Testing
Equipment
Materilas
Skilled workers
Time needed
Function
Parts required
Availability
People
Operation of system
User access
Labelling
Most plants/complexs of this size and value are normally repaired and than sold to try and recop somem of the costs
Availability of skilled workers
Parts
Budget
Installation
Maintenance
Transporting parts from manufacturers
Testing
Operator skills
Training
Controls
Function
Needs to produce approximately 6.8 million tonnes of high density polyethylene (HDPE) per year
Safe operating procedures were not required when maintenance was carried out on clearing the lines
Unsuitable evacuations routes, no alternative routes were established
Allowance of ignition sources (forklift, welding, cutting torch tasks and vehicles) in high hazard areas without testing for flammable gases
No fire protection provided
Inadequate operating procedures
Insufficient separation between building
Blind flange was not installed as per plant policy
Process equipment crowded
Isolation ball valve left open during maintenance
No fail-safe valve
Fire protection system not maintained in readiness for use
❌Management/Organisational failure ❌
Insufficient amount of combustible gas detectors and alarm system
Too many workers in the control rooms
Inadequate separation between the reactors and control rooms for emergency shutdown procedures
Lack of ventilation systems
Organisational/System Factors
Using contractors to carry out maintenance as way to cut cost
Use of contractors caused conflict with staff
Failure to provide staff and contractors with respirators
Serious safety issues were ignored or overlooked
Inadequate lockout/tagout procedures
Lack of communication between staff and contractors
Inadequate training provided
Inadequate training provided on plant procedures
Lack of training on how to work safely with hazardous chemicals
At approximately 1 p.m. 85,000 pounds of highly flammable ethylene-isobutane gas was released into the air.
There was no gas detectors or warning systems in place to raise the alarm of impending disaster
Once clearing on the reactor leg was completed the air hoses were connected again but in the wrong way around so the single valve was actually open when its actuator was in the closed position
Within 60-90 seconds of the gas entering the atmosphere the gas came into contact with an ignation source and exploded with the force of 2.4 tonnes of TNT
During maintenance the air hoses were physically disconnected as a safety measure
10-25 later another explosion happened when two 20,000 gallon isobutane storage tanks exploded
22nd October a contractor company employed to carry out maintenance at Phillips 66 Chemical Complex started maintenance work clearing 3 of the 6 settling legs on a reactor
❌ Design Flaw - Latent ❌
Single DEMCO ball valve was only the cut-off point between the reactor and outside atmosphere
No physical barrier or identification markings to show that they were connected the wrong way
❌ Design Flaw ❌
❌ Management Policies and Procedures - Precusor ❌
❌ Management/Organisational Failure ❌
❌ Inadequate Management Policies/Procedures - Latent Failure ❌
❌ Management/Organisational Failure ❌
❌ Management/Organisational - Pre-condition ❌
No fail-safe valves built in, given the hazardous chemicals being produced it should of been something that was considered when designing
❌ Design Failure - Pre-Condition ❌
🚩 Intertek (2018) states that decommissioning covers repairs, replacement, abandonment or scrapping after an incident this size.
❌ Management/Organisational Failure ❌
❌ Management/Organisational Failure ❌
❌ Management/Organisational Failure ❌
❌ Inadequate Management Policies/Procedures - Latent Failure ❌
❌ Inadequate Management Policies/Procedures - Latent Failure ❌
❌ Management Decision Failure ❌
❌ Equipment Design Failure ❌
🚩 During Think Reliability (2011) root cause analysis they found a series of procedural errors were made before the first explosion.
🚩 Engineering (2013) highlights the importance of how companies need to put more focus on process safety management.
🚩 Chapanis and Holsteien (2018) discuss that the greatest challenge and complex problems happen in the design of human-machine systems and the incorporation of operators into the systems.
🚩 Bea (2006) found that most failures occur during daily operations and maintenance, more than half of these failures were linked back to flawed concept and design.
Controls
Rectors
Production capacity
Collection tanks
Control rooms were over crowded
Maintenance
🚩 Chao and Ishii (2004) identities that ins some cases a lack of a good management system leads to carelessness in processes and procedures, bad communications and other errors. While the lack of good processes and procedures allow and can cause mistakes and errors to be made by operators.
🚩 Chao and Ishii (2004) discuss that changes made by management to the design of a system can result in operator errors even when the work is carried out correctly.
🚩 Hesin (2015) states that human error is often mentioned as the root cause of most system failures but most of the time it is not only underlining element that causes the failure.
25 to 45 minutes after the initial explosion there was another explosion when the polyethlene reactor catastrophically failed.
It took 10 hours after the first explosion to get the fires under control
The explosions killed 23 people and injuried 314 people
