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:red_cross:Phillips Disaster of 1989 :red_cross: image (Event Sequence …
:red_cross:Phillips Disaster of 1989 :red_cross: 
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Workplaces
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Workplace Factors
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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
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Event Sequence
At approximately 1 p.m. 85,000 pounds of highly flammable ethylene-isobutane gas was released into the air.
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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
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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
25 to 45 minutes after the initial explosion there was another explosion when the polyethlene reactor catastrophically failed.
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Design Lifecycle
Commissioning
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Testing
No fail-safe valves built in, given the hazardous chemicals being produced it should of been something that was considered when designing
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De-commissioning
Most plants/complexs of this size and value are normally repaired and than sold to try and recop somem of the costs
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:red_flag: Intertek (2018) states that decommissioning covers repairs, replacement, abandonment or scrapping after an incident this size.
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:red_flag: During Think Reliability (2011) root cause analysis they found a series of procedural errors were made before the first explosion.
:red_flag: Engineering (2013) highlights the importance of how companies need to put more focus on process safety management.
:red_flag: 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.
:red_flag: 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.
:red_flag: 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.
:red_flag: 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.
:red_flag: 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.
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