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A portrait of process safety: From its start to present day

07.01.2012 | Mannan, M. S., Mary Kay OConnor Process Safety Center, Artie McFerrin Department of
Chemical Engineering, Texas A&M University System, College Station, Texas; Chowdhury, A. Y., Mary Kay
OConnor Process Safety Center, Artie McFerrin Department of Chemical Engineering, Texas A&M University
System, College Station, Texas; Reyes-Valdes, O. J. , Mary Kay OConnor Process Safety Center, Artie
McFerrin Department of Chemical Engineering, Texas A&M University System, College Station, Texas
The driving force for process safety has been primarily based on catastrophic events.
Keywords:
By looking at the history of process safety and the improvements that each decade has brought in terms of
regulations and techniques, industry can invariably make itself safer. Determining how major incidents such as
Bhopal, Flixborough, Chernobyl, Piper Alpha and others have influenced the industry, academia, government
and subsequent regulations can offer a firm foundation for future endeavors. There is still research needed in
the near future to further cement the foundation, and researchers and process safety experts need to pay
attention to what incidents of this millennium are telling us about what is still needed in order to make process
safety second nature.
Background
The 19th century is known as the era of industrial revolution. Each technical progression has brought with it a
certain amount of threat and hazardous activity. Chemical process safety was not a major public concern prior
to almost the end of the 18th century. However, safety concerns were always there from the beginning of
industrialization but not necessarily as we know or call it today. The primitive instinct of human beings to stay
alive and protect themselves is probably the most visceral driver for the growth of process safety initiatives.1
Process safety: An ongoing phenomenon
The driving force for process safety has been primarily based on catastrophic events. With an increasing number
of tragic incidents, the process industry and governments started taking initiatives to minimize loss of life and
property, as well as to protect the environment. In the US, safety regulations started back in 1899 when the US
government issued the River Harbor Act to avoid excess dumping in waterways. At the beginning of the 19th
century, especially in the mines, thousands of innocent lives were lost because of the hostile environment. The
year 1910 was reported as the worst, with 1,775 deaths in mines.2 These tragedies forced governments and local
establishments to initiate regulatory regimes. In order to understand the growth of process safety, we have
divided the significant initiatives and incidents into three broad sections. This categorization is based on the
changes that took place between years 19301970, 19702000 and 20002012. This is shown in Fig. 1.

Fig. 1. Broad classification of process safety

development based on time period.

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From 19301970. This period was mostly about establishing regulations. The Walsh-Healy Public Contracts
Act in 1936 in US restricted working hours and employing child labor.1 This act also was concerned with
occupational diseases, a basis of many present safety regulations. The 1947 presidential conference on industrial
safety was another noteworthy step forward. Some other regulations were established in the years 19361969
(see Table 1). Individually, these acts did not have major impact in ensuring industrial safety but they played
an imperative role for process safety to reach the position that it has achieved.

Congress passed the Occupational Safety and Health Act in 1970, which is a landmark legislation that put into
motion programs that continue to evolve. Under this act, the Department of Health established the
Occupational Safety and Health Administration (OSHA) with wide-ranging authority to enforce safety and
health standards to ensure a safer workplace.1 Also, the US Department of Health and Human Services
instituted the National Institute for Occupational Safety and Health (NIOSH) which had the responsibility to
conduct research, provide recommendations to OSHA and train professionals for increasing awareness.1 In
addition, the US Environmental Protection Agency (EPA) was established in 1970 to address environmental
issues.
From 19702000. In the 1970s and 1980s, some of the worlds most shocking and tragic industrial accidents
took place. Consequently, industries and government bodies everywhere were forced to rethink about the
technology and management systems in industries from the safety point of view. Fig. 2 offers a timeline of the
catastrophes during this time period.

Fig. 2. Timeline of major industrial disasters

between 1974 and 1989.
The Flixborough explosion in 1974 was by far the most severe disaster in the UK chemical industries and proved
to be a major driver for process safety issues in the UK. As a result of these initiatives, at the end of 1974, the
Advisory Committee on Major Hazards (ACMH) was implemented. The impact of Flixborough was reinforced
by that of the Seveso tragedy in 1976.3
However, the unforgettable Bhopal gas disaster in India on December 3, 1984, which resulted in varying
estimates of 3,000 to upward of 20,000 fatalities and injuries to another 500,000, was a wake-up call for the
chemical process industry. Both the industry and the public became aware of the potential hazard of chemical
facilities.2 This piloted the intensification of efforts within industry to ensure the safety of major hazard plants.
Process safety finally gained absolute recognition as a standard practice. After the Bhopal tragedy, many

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regulatory initiatives were taken worldwide. In India, the Environment Protection Act (1986), the Air Act
(1987), the Hazardous Waste (Management and Handling) Rules (1989), the Public Liability Insurance Act
(1991) and the Environmental Protection (Second Amendment) Rules (1992) were promulgated.3
In 1984, the Mexico City disaster represented the largest series of boiling liquid expanding vapor explosions
(BLEVEs) in history that killed almost 500 people.3 The nuclear disaster which took place on April 28, 1986, in
Chernobyl, Ukraine, killed 56 people and caused the development of cancer and radiation sickness in many.3
The Piper Alpha accident on July 6, 1988, resulted in 167 deaths. The Piper Alpha Inquiry has been of crucial
importance in the development of the offshore safety regime in the UK sector of the North Sea. On October 23,
1989, in the Phillips 66 plant in Pasadena, Texas, a massive gas explosion caused the death of 23 people and
more than 300 injuries. 3
These incidents made it even more evident that implementation of safety legislation was indispensably
necessary. Table 2 and Table 3 show the significant legislative and regulatory steps taken in the US and
Europe.

Process safety in the new millennium

Process safety has certainly made remarkable progress. However, it is still impossible to adequately answer a
simple question, Are we safe enough? The incidents that occurred in this millennium are a reminder that
process safety has a long way to go.
The Columbia disaster on February 1, 2003, caused the death of all seven astronauts onboard and scattered
shuttle debris over 2,000 square miles of Texas.11 This tragic incident can be traced back to flaws in decision
making at NASA. The Columbia explosion was an important lesson for crisis communication professionals, as
well. In fact, the NASA lessons can be mapped to many other catastrophes, such as the Piper Alpha or the

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Flixborough incidents, that reveal a sense of vulnerability, establish an imperative for safety, and reinforce the
need for valid on-time risk assessments.11
The Macondo blowout in the Gulf of Mexico (GoM) on April 20, 2010, killed 11 employees and led to an
uncontrolled oil spill lasting 87 days.12 This blowout was the most significant offshore incident in the US, and it
had a profound impact on safety regulations in the GoM. The Drilling Safety Rule regarding well-bore reliability
and well-control equipment was implemented on October 14, 2010. The Modified Workplace Safety Rule was
put into place on October 15, 2010, based on the lessons learned from the Macondo blowout.
Finally, there was the Fukushima Daiichi nuclear plant incident in March 2011 that drew the attention of the
global process and power industries, encouraging them to incorporate natural disaster risks in a hazard analysis
study.12
Technical achievements pre-1970. Techniques to identify and evaluate hazards, calculate consequences
and quantified event probabilities and risk (such as What-If, Checklist, HAZOP, Fault- and Event-Tree analyses)
were developed in the middle of the 20th century. These developments occurred in some cases years or even
decades before the well-known major incidents in the 1970s and 1980s. However, these catastrophic incidents
reflected the need for more understanding and research regarding the underlying issues about process safety
incidents. For example, the HAZard and OPerability (HAZOP) study, was developed by ICI in 1963, when a
team was looking for ways to design a plant for phenol production with the minimum capital cost, but was
considering possible deficiencies in the design.13 The Flixborough and Seveso incidents clearly showed the
importance of identified hazards before fatal incidents occur, and HAZOP gained extensive popularity within
operating and design companies. In the case of the Flixborough disaster, more than 40 tons of cyclohexane were
released due to the rupture of a temporary bypass line. The temporary pipe was designed by a person who did
not know how to design large pipes operating at high temperatures. After this incident, companies started to
include procedures for management of change (MOC). Fault tree analysis (FTA) was developed in the early
1960s, and its use as a safety system and reliability technique quickly gained widespread interest, especially in
nuclear and power installations. Since the development of FTAs, great efforts and advances (analytic
methodologies, computer programs, computer codes) have occurred in the quantitative evaluation of fault
trees.14
Technical achievements: 1970s and 1980s. In the US and Europe, models for pool formation, releases,
evaporation and fire and explosions were refined in the late 1970s and the early 1980s.15 In these two decades, a
series of fatal incidents (Fig. 3), reinforced the importance of these models and were one of the principal
motivations for further research and improvements.

Fig. 3. Research motivated by major disasters

in the 1980s.
Bhopal increased substantially the interest and activity of the research and academic communities in a wide
range of areas related with process safety,2 principally in reactivity hazards (employees did not have knowledge
of the reactivity of MIC mixed with water16), inherent safety and chemical releases. The 500 deaths involved in

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Mexico City clearly demonstrated the importance and hazards involved in BLEVEs.3 Piper Alpha focused
attention on jet fires, pool fires, carbon monoxide fires (initial CO poisoning caused most of the deaths) and
explosions in modules with turbulence generation.17 This incident, and the sinking of the Alexander L. Kielland
in 1980, were the most important events in the history of offshore operations in Europe, and together made a
great impact in the use of quantitative risk assessment (QRA) techniques to assess offshore facilities.18
The aftermath of the Chernobyl disaster gave birth to the safety culture concept.19 According to the Phillips
report,20 the cause of the incident was a modification in a routine maintenance procedure. This reinforced to the
process industry the importance of incorporating management systems, such as MOC procedures. The 1970s
and 1980s were decades of major incidents and great losses, but there is no doubt that these two decades made
a great impact on what today we call process safety.
Technical achievements: 1990s to present day. During the 1990s, in response to new regulations and
regulatory initiatives, collection of incident history data started at a rudimentary level. Advances in technology
and the research conducted by different centers, such as the Mary Kay OConnor Process Safety Center (which
was established in 1995), allowed for the development and availability of increasingly reliable incident
databases.21 In the late 1990s, the Chemical Safety Board (CSB), in its MOC safety bulletin, highlighted the
importance of having a systematic method for MOC, and how this is an essential ingredient for safe chemical
process operations.
In the 1990s and early 2000s, the development of engineered nano-materials increased considerably. This
development introduced a new area of research to process safety, an area where researchers are trying to
understand the workplace exposure and environmental aspect of nanotechnologies.
Research needed in the near future
There is no doubt that the field of process safety has made great advances in terms of regulation and techniques
in the last 40 years, but industry changes every day, and more sophisticated and complex processes are
developed. This, combined with factors such as human errors (which will be always present), and challenges in
creating and maintaining organizational memory, among others, is the reason why incidents continue to occur.
Fatal incidents in this new millennium highlighted some of the areas of process safety where research is still
needed (Table 4).

Dust explosion. Dust explosion research has been conducted on and off for more than 100 years.22 However,
events such as the Imperial Sugar Co. incident in Georgia (14 deaths, 14 life-threatening burns, 38 total
injures23) demonstrate the need for further research, awareness and management systems. In order to prevent
these kinds of incidents, it is imperative to perform experimental and theoretical work to understand the
chemistry and physics of dust cloud generation and combustion, flame propagation and potential ignition
sources. It is also important to understand and develop models for fire and explosion of nano-materials.

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Reactive chemicals. Reactive chemistry incidents continue to occur in the chemical processing industry, and
in other industries which handle chemicals in their manufacturing processes. A CSB study, released in 2002,
identified 167 reactive incidents that occurred between 1980 and 2001, which caused 108 deaths.24 More
experimental and theoretical research is necessary to fully understand the kinetics and thermal behavior of
industrial chemical reactions.4
Safety culture. The tragic Columbia shuttle incident showed the possible fatal consequences of bad industrial
communication. It is important that research and safety professionals understand and evaluate good safety
culture that enables the sharing of information and improvement of safety within the industries, taking into
account different specialties and environments.
Nuclear safety. The Fukushima incident definitely changed the risk perception of nuclear power plants.
Managers and researchers have a long journey in both risk communication and risk assessment models of
nuclear power plants.
Make safety second nature
Although process safety was not recognized as a practice or discipline before the mid-1980s, concern about
the health, safety and environment is intrinsic in human beings and as old as civilization. Great advances in
safety regulations and techniques have occurred during the last century. But as industry grows and changes
every day, processes present new challenges. Managers, operators and researchers must continue working
together to improve their overall safety knowledge in order to make safety second nature. HP
LITERATURE CITED
1

Mannan, M. S., J. Makris and H. J. Overman, Process Safety and Risk Management Regulations: Impact on
Process Industry, Encyclopedia of Chemical Processing and Design, ed. R. G. Anthony, Vol. 69, Supplement 1,
Marcel Dekker, Inc., New York, 2002.

Mannan, M.S., et al, The legacy of Bhopal: The impact over the last 20 years and future direction, Journal of
Loss Prevention in the Process Industries, 2005.
3

Mannan, M.S., editor, Lees Loss Prevention in the Process Industries, Volumes 13 (3rd Edition), Elsevier,
2005.
4

Qi, R., et al., Challenges and needs for process safety in the new millennium, Process Safety and
Environmental Protection, 2012.
5

Berger, S., History of AIChEs Center for Chemical Process Safety, Process Safety Progress, 2009.

US Environmental Protection Agency, The Emergency Planning and Community Right-to-Know Act (EPCRA)
Enforcement,EPA 550-F-00-004, March 2000, available at: www.epa.gov/osweroe1/docs/chem/epcra.pdf,
accessed on: March 15, 2012.

US Environmental Protection Agency, The Clean Air Act (1990), available online at: www.epa.gov/air/caa/,
accessed on: March 15, 2012.
8

US Occupational Safety and Health Administration, ProcessSafety Management (PSM) 2010, available online
at: www.osha.gov/Publications/osha3132.pdf, accessed on: March 15, 2012.

US Environmental Protection Agency, Risk Management Plan (RMP) Rule (updated 2009), available online
at: www.epa.gov/osweroe1/guidance.htm#rmp, accessed on March 16, 2012.

10

Willey, R.J., D.A. Crowl and W. Lepkowski, The Bhopal tragedy: Its influence on the process and community
safety as practiced in the United States, Journal of Loss Prevention in the Process Industries, 2005.

11

American Institute of Chemical Engineers (AIChE), Lessons from the Columbia DisasterSafety and
Organizational Culture, Center for Chemical Process Safety 2005.

12

McAndrews, K.L., Consequences of Macondo: A Summary of Recently Proposed and Enacted Changes to US
Offshore Drilling Safety and Environmental Regulation, Society of Petroleum Engineers, Americas E&P Health,
Safety, Security and Environmental Conference, Houston 2011. Available online at:
www.jsg.utexas.edu/news/files/mcandrews_spe_143718-pp.pdf, accessed on March 16, 2012.

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13

Kletz, T.A., Hazoppast and future. Reliability Engineering; System Safety, 1997.

14

Lee, W.S., et. al., Fault Tree Analysis, Methods, and ApplicationsA Review, IEEE Transactions on
Reliability, 1985.
15

Pasman, H. J., et. al., Is risk analysis a useful tool for improving process safety? Journal of Loss Prevention
in the Process Industries, 2009.
16

Center for Chemical Process Safety (CCPS), Guidelines for Investigating Chemical Process Incidents (2nd
Edition), Center for Chemical Process Safety/AIChE 2003. Available online at
www.knovel.com/web/portal/browse/display?_EXT_KNOVEL_DISPLAY_bookid=931&VerticalID=0,
accessed on March 16, 2012.
17

Crawley, F.K., The Change in Safety Management for Offshore Oil and Gas Production Systems, Process
Safety and Environmental Protection, 1999.
18

Turney, R. and R. Pitblado, Risk assessment in the process industries, Institution of Chemical Engineers.

19

Pidgeon, N.F., Safety Culture and Risk Management in Organizations, Journal of Cross-Cultural
Psychology, 1991.
20

Company, P.P., A Report on the Houston Chemical Complex Accident, Bartlesville, Oklahoma, 1990.

21

Mannan, M. S., T. M. OConnor and H. H. West, Accident history database: An opportunity, Environmental
Progress, 1999.
22

Eckhoff, R.K., Current status and expected future trends in dust explosion research, Journal of Loss
Prevention in the Process Industries, 2005.
23

US Chemical Safety and Hazard Investigation Board (US CSB), Investigation Report on Sugar Dust
Explosion and Fire, Report No.2008-050I-GA, 2009. Available online at
www.csb.gov/assets/document/Imperial_Sugar_Report_Final_updated.pdf, accessed on March 15, 2012.
24

US Chemical Safety and Hazard Investigation Board (US CSB), Improving Reactive Hazard Management,
Report No. 2001-01-H, 2002. Available online at:
www.csb.gov/assets/document/ReactiveHazardInvestigationReport.pdf, accessed on March 15, 2012.
The authors
M. Sam Mannan, PhD, PE, CSP, is a chemical engineering professor and director of the Mary
Kay OConnor Process Safety Center at Texas A&M University. He is an internationally recognized
expert on process safety and risk assessment. His research interests include hazard assessment
and risk analysis, flammable and toxic gas cloud dispersion modeling, inherently safer design,
reactive chemicals and run-away reactions, aerosols and abnormal situation management.
Amira Y. Chowdhury, BS, is a PhD student in materials science and engineering, and a
research assistant at the Mary Kay OConnor Process Safety Center at Texas A&M University. She
is a chemical engineer from the Bangladesh University of Engineering and Technology. Her
research interests include hazard assessment and dust explosions.
Olga J. Reyes-Valdes, BS, is a materials science and engineering PhD student at Texas A&M
University and research assistant of the Mary Kay OConnor Process Safety Center. She is a
chemical engineer from Universidad Industrial de Santander, Colombia. Her research interests
include reactive chemicals and run-away reactions, dust explosion, hazard assessment and risk
analysis.

Top 10 worst process safety incidents in history

This article discusses what the Mary Kay OConnor Process Safety Center at Texas
A&M University in College Station, Texas, consider the top 10 process safety
incidents in history. The incidents were ranked based on the cumulative impact
on loss of lives and economic losses, and the resulting impact on the development
of what today we know as process safety.

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1. Bhopal
On the early morning of December 3, 1984, at the Union Carbide plant in India, a
storage tank containing methyl isocyanate (MIC) was contaminated with water
leading to a runaway reaction causing the release of more than 40 tons of toxic
MIC gas through a relief valve. The incident killed more than 3,000 people and
injured hundreds of thousands more. This was arguably the worst chemical
industry incident in terms of people affected, however; it was just after this fatal
tragedy that the chemical process industry became really conscientious of the
importance of process safety and it gained complete acceptance as a standard
practice.1 As a direct response to Bhopal, many regulatory initiatives were
implemented worldwide. In India, this event led to the Environment Protection
Act (1986), the Air Act (1987), the Hazardous Waste (Management and Handling)
Rules (1989), the Public Liability Insurance Act (1991) and the Environmental
Protection (Second Amendment) Rules (1992). In the US, the Emergency Planning
and Community Right-to-Know Act (EPCRA) was promulgated in 1986,2 and the
Clean Air Act Amendments (CAAA) were signed into law in 1990.1
2. Chernobyl
On April 28, 1986, in a power plant in Chernobyl, Ukraine, an experiment
performed in order to verify the emergency power supply of a reactor resulted in
unfortunate consequences. The core of the reactor was blown out by two violent
explosions causing a series of fires and the release of tons of radioactive
materials. It is considered to be the worst nuclear disaster in history. The incident
directly killed 56 people and influenced the development of cancer and radiation
sickness of hundreds in the subsequent years.3 Before the incident, there were no
written rules for the test that led to the catastrophic consequences. This fact has
made the adherence to safety-related instructions as the most highlighted lesson
learned regarding to process safety.4
3. Piper Alpha
Piper Alpha was a North Sea oil production platform. On July 6, 1988, the backup
condensate pump pressure safety valve was removed for routine maintenance.
However, since the maintenance could not be completed within the shift, it was
decided to complete the remaining work the next day. As a temporary measure,
the condensate pipe was sealed with a blind flange. Communication gaps between
different shifts resulted in a catastrophe when the night shift crew unknowingly
started the backup condensate pump after the failure of the primary pump. In just
22 minutes, fire broke out everywhere and the event escalated further because of
design and operational flaws resulting in 167 deaths. The Piper Alpha incident was
a wakeup call for the offshore industries. Significant changes in safety practice
include development and implementation of safety case regulations in UK,
adherence to a permit-to-work system and realistic training for emergency
response.4
4. The Macondo blowout
The Macondo exploration well located in the Gulf of Mexico (GoM) was drilled by
a deep water horizontal semi-submersible rig. On April 20, 2010, a blowout
caused a fire and explosion on the rig that killed 11 employees and caused a major

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oil spill that continued uncontrolled for 87 days. A series of mechanical failures,
lack of human judgment, faulty engineering design and improper team
interaction came together to result in the largest oil spill known to mankind. The
blowout was the biggest offshore incident in the US and it had a profound impact
on safety regulations in the GoM. As a direct outcome of the Macondo incident,
the Drilling Safety Rule regarding wellbore reliability and well control equipment
was implemented on October 14, 2010. The Modified Workplace Safety Rule was
also implemented on October 15, 2010, based on the lessons learned from the
Macondo blowout.56
5. BP Texas City
On March 23, 2005, during the startup of an isomerization unit, the safety relief
valves of a distillation tower opened due to overfilling, allowing hydrocarbon
liquids to flow into a disposal blowdown drum with a stack, which were also
overfilled, resulting in a liquid release. The evaporation of the hydrocarbons
produced a flammable vapor cloud that ignited and led to a series of fires and
explosions. Fifteen workers died and about 180 were injured.7 This incident led to
major investigations including the milestone Baker panel report headed by
former US Secretary of State James Baker III. This incident also resulted in
significantly more interest in and attention to issues such as facility siting,
atmospheric venting, leading and lagging indicators and safety culture.
6. The Flixborough disaster
On June 1, 1974, in a caprolactam production plant, a temporary bypass line
ruptured, resulting in the leak of almost 40 tons of cyclohexane that caused a
huge vapor-cloud explosion. The tragic disaster killed 28 people including all the
employees working in the control room. There was the alarming possibility of
killing more than 500 employees if it were a normal working day instead of
weekend. Also, widespread damage to property within a 6-mile radius around the
plant was another major consequence. The Flixborough explosion was a critical
driver in moving process safety issues forward in the UK. As a result of the
Flixborough incident, at the end of 1974, the Advisory Committee on Major
Hazards (ACMH) was formed. The lessons learned from this disaster highlight the
importance of HAZOP analysis, blast resistant control rooms and thorough
studies prior to any modification in process plants.4
7. Mexico City
On November 19, 1984, in an LPG installation in Mexico City, the failure of the
safety valve of an LPG storage tank caused an overpressure inside the tank and a
pipe rupture, leading to a leakage of LPG followed by an ignition and violent
explosions. Approximately 500 people were killed and more than 700 were
injured.9 This incident represents the largest series of boiling liquid expanding
vapor explosions (BLEVEs) in history.4 Mexico City clearly demonstrated the risk
of BLEVEs in process facilities and lessons learned from this event have
significantly impacted standards for design and operation.

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8. Phillips
On October 23, 1989, in the Phillips 66 plant in Pasadena, Texas, the rupture of a
seal on a polyethylene reactor caused the release of highly flammable ethylene
and isobutene gas, forming a gas cloud and leading to a massive explosion in less
than two minutes. Twenty-three people were killed and more than 300 injured.
The day before the incident, a maintenance procedure had been performed by
contractor personnel. This incident underscored the importance of rigid
adherence to operating procedures and the implementation of an appropriate
management system for contract workers. In response to this incident and other
incidents that occurred before in the 1980s (including Bhopal, Shell Norco, Arco
Channelview and Exxon Baton Rouge), the US Department of Labor, Occupational
Safety and Health Administration developed the Process Safety Management
(PSM) regulation.10
9. Columbia disaster
The physical cause of the Columbia shuttle disaster was separation of insulation
foam that then hit the carboncarbon reinforced panel of the left wing, thus
damaging the thermal protection system. Aerodynamic pressure caused by
superheated air destroyed the wing when the shuttle was reentering earths
atmosphere at about 10,000 mph on February 1, 2003. The tragic incident caused
the death of all seven astronauts and resulted in shuttle debris being scattered
over 2,000 square miles in Texas. However, the underlying causes for the disaster
can be traced back to flaws in decision making at NASA. The Columbia incident
also provided important lessons for crisis communication professionals, as well.
In fact, the lessons learned from the Columbia incident can be mapped to many
other catastrophes such as the Piper Alpha or the Flixborough incident, covering
issues such as sense of vulnerability, establishing an imperative for safety and
valid on-time risk assessment.11
10. Fukushima Daiichi nuclear incident
On March 11, 2011, this incident drew the attention of the process and power
industries around the world, encouraging them to incorporate natural disaster
risk in any hazard analysis study. When a powerful earthquake hit the plant, the
reactors shut down automatically. However, because of the earthquake and the
following tsunami, a power blackout ensued, leading to the loss of cooling, which,
in turn, led to overheating of the reactors (creating serious radiation hazards).
Fortunately, no one was killed because of the radiation, but there may be longterm consequences to the workers and to the neighboring communities who were
exposed to radiation.
Conclusions
These tragic events and the consequences of these events have provided us with
numerous lessons that help our understanding of the hazards and risks of the
modern process industry and, more importantly, how design, technology,
equipment, management systems, human factors and safety culture can be used
to improve the safety performance of the industry. Understanding the root causes
of incidents and learning from mistakes within the company, as well as other
organizations, is vital. These lessons need to be implemented both in the
engineering and the management sectors.

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LITERATURE CITED
1

Mannan, M. S., et al., The legacy of Bhopal: The impact over the last 20 years
and future direction, Journal of Loss Prevention in the Process Industries,
2005. 18(46): pp. 218224.

Mannan, M. S., J. Makris and H. J. Overman, Process Safety and Risk

Management Regulations: Impact on Process Industry, Encyclopedia of
Chemical Processing and Design, ed. R. G. Anthony, Vol. 69, Supplement 1, pp.
168193, Marcel Dekker, Inc., New York, 2002.
3

Dara, S. I. and J. C. Farmer, Preparedness Lessons from Modern Disasters and

Wars, Critical Care Clinics, 2009. 25(1): pp. 4765.
4

Mannan, M. S., Lees Loss Prevention in the Process Industries, 3rd Edition,
Elsevier, 2005.

McAndrews, K. L., Consequences of Macondo: A Summary of Recently

Proposed and Enacted Changes to US Offshore Drilling Safety and Environmental
Regulation, Society of Petroleum Engineers Americas E&P Health, Safety,
Security and Environmental Conference, Houston 2011. Available online:
http://www.jsg.utexas.edu/news/files/mcandrews_spe_143718-pp.pdf, accessed
on March 16, 2012.
7

Kaszniak, M. and D. Holmstrom, Trailer siting issues: BP Texas City, Journal

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