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Domino effect in process-industry accidents e An inventoryof past events and identification of some patterns

Bahman Abdolhamidzadeh a, Tasneem Abbasi b, D. Rashtchian a, S.A. Abbasi b,*aCenter for Process Design, Safety and Loss Prevention, Department of Chemical and Petroleum Engineering, Sharif University of Technology, Tehran, IranbCenter for Pollution Control and Environmental Engineering, Pondicherry University, Kalapet, Pondicherry 605014, India

a r t i c l e i n f o

Article history:Received 12 May 2010Accepted 22 June 2010

Keywords:Domino effectChemical process-industryAccidentsPast accident analysis

a b s t r a c t

The paper presents an inventory, perhaps the most comprehensive till date, of the major process-industry accidents involving domino effect. The inventory includes, among other relevant information,the sequence of accidents that had occurred in each domino episode. The information has been analyzedto identify several patterns which may be useful in further work on understanding domino effect andreducing the probability of its occurrence in future. A concept of local domino effect has beenintroduced.

2010 Elsevier Ltd. All rights reserved.

1. Introduction

In contrast to most other branches of science and technology,wherein reproducible experiments provide the foundation forbuilding, testing, and refining theoretical frameworks, there is verylimited scope of conducting such experiments in the domain ofaccident forecasting and prevention. Experiments have beendesigned and conducted from time to time which make scaled-down attempts to simulate vessel failures, explosions, toxicreleases, etc (Eckhoff, 2005; Khan & Abbasi, 1999a, 1999b; Lees,2005) but it is well neigh impossible to experiment at scalesapproaching full-scale installations.

This situation bestows great importance to past accident anal-ysis in chemical process industries. By careful reconstruction ofevents, and identifying their triggers, sequence, and their conse-quences, valuable wisdom of hindsight can be acquired with whichpointers for developing accident prevention strategies can bedrawn (Attwood, Khan, & Veitch, 2006; Kirchsteiger, 1999; Meelet al., 2007; Oggero, Darbra, Munoz, Planas, & Casal, 2006;Pasman, 2008; Qiao, Keren, & Mannan, 2009; Sales, Mushtaq,Christou, & Nomen, 2007).

Among the challenges posed by the risk of accidents, the mostvexing one involves prevention of secondary or knock-on acci-dents e i.e. one accident creating the ground for another. To fore-cast and prevent a stand-alone accident is in itself fraught with

great complexity and uncertainty; any attempt to deal with theprobability of knock-on accidents and their consequences has tocontend with even greater complexity. This is perhaps the reasonwhy much less work has been done towards the study of thedomino effect caused by the knock-on accidents in comparison tostand-alone accidents (Abdolhamidzadeh et al., 2010). But dominoeffect is a frequent occurrence; indeed more often than not majoraccidents in the past which have resulted in substantial harm tohuman lives and other resources, have involved domino effect. Theexamples of over 224 accidents summarized in Table 1, bear thisout.

Attempts have been made in the past to develop methodologiesto forecast domino effect (Antonioni, Spadoni, & Cozzani, 2009;Bagster & Pitblado, 1991; Cozzani, Gubinelli, Antonioni, Spadoni,& Zanelli, 2005; Cozzani, Gubinelli, & Salzano, 2006; Khan &Abbasi, 1998a, 1998b, 2001a, 2001b) but such efforts are few andfar between. Even fewer reports are available on the past accidentanalysis of domino effect e the last and perhaps the only onecoming from Kourniotis, Kiranoudis, and Markatos (2000). It isbased on the databases current up to 1998. But a number of majordomino events have occurred since then including the tragedy atNeyshabur, Iran (UNEP, 2009) which, in terms of number of fatali-ties, is the fifth largest process-industry related accident ever. Theperiod has also witnessed several other major knock-on accidentslike the one that occurred at the BPL Refinery at Texas, USA in 2005causing 15 deaths besides injuries to 170, and other losses worthover $1 billion. Moreover this period has seen catastrophic eventsof this type occurring in all parts of the world e be it theeconomically and technologically advance nations or the ones

* Corresponding author. Tel.: 91 94432 65262.E-mail address: [email protected] (S.A. Abbasi).

Contents lists available at ScienceDirect

Journal of Loss Prevention in the Process Industries

journal homepage: www.elsevier .com/locate/ j lp

0950-4230/$ e see front matter 2010 Elsevier Ltd. All rights reserved.doi:10.1016/j.jlp.2010.06.013

Journal of Loss Prevention in the Process Industries 24 (2011) 575e593

Author's personal copyTa

ble

1Acciden

tsinvo

lvingdom

inoeffect,191

7e20

09(F:fire;MaE

:major

explosion

;MiE:minor

explosion

).

No.

Yea

rLo

cation

Plan

t/unit/chem

ical

Sequ

ence

ofacciden

tsDea

ths

Injuries

Other

reportedim

pacts

Referen

ce

1.19

17Ash

ton,U

KEx

plosive

sfactory/

nitrator

Spillag

eof

hot

HNO3

/F/

MaE

/F

46>12

0So

me10

0hou

ses

dem

olished

Billings

&Cop

land,1

992

2.19

17Nov

oScotia,

Can

ada

Ammunitionsh

ipCollis

ionwithan

other

ship

/F/

MaE

1800

8000

500To

tally

blinded

;massive

property

dam

age

Assheton

,193

0

3.19

33Neu

nkirchen

,German

yGasholder/tow

nsga

sMiE

/rupture

ofpipeline/

F/

MaE

65Sev

eral

hundred

Kier&Mulle

r,19

83

4.19

36Sa

intCham

as,

Fran

ceTN

Tproductionunit/TNT

F/

MaE

5315

0MHID

AS,

2009

5.19

43Lu

dwigsh

afen

,German

yBASF

works/railtankcar

Leak

/VC/

MaE

5743

9Marsh

all,19

87;

Nash,1

976

6.19

44Cleve

land,U

SALiqu

efaction

plant/LN

GTa

nkrupture

&leak

/F/

series

ofMaE

128

200e

400

Seve

redam

age

totheplant

andproperty

Marsh

all,19

87;

Nash,1

976

7.19

47Te

xas,USA

Ship/ammon

ium

nitrate

F/

MaE

/MaE

552

>30

00Morethan

3300

dwellin

gsan

d13

0bu

siness

build

ing

dam

aged

,600

automob

ilean

d36

0bo

xcardam

aged

,seve

ralstorag

etanks

destroy

ed

Marsh

all,19

87;

Nash,1

976;

National

Boa

rdof

Fire

Underwriters,1

948;

Whea

ton,1

948

8.19

48Lu

dwigsh

afen

,German

yTa

nkcar/dim

ethyl

ether

Tankrupture

&dispersion

ofco

ntents/

VC

207

3818

Lewis,1

993;

Marsh

all,19

87

9.19

49Pe

rthAmbo

y,USA

Asp

halttank

MaE

/F

4e

MHID

AS,

2009

10.

1951

Port

New

ark,

USA

LPGstorag

e/propan

eF/

MiE

/

seve

ralB

LEVEs

014

73Bulle

ttanks

were

destroy

ed,m

issiles

dem

olished

afilling

stationan

druptured

undergrou

nd

water

main

Lewis,1

993.

11.

1951

Baton

Rou

ge,

USA

Refi

nery/nap

htha

VCE/

multiple

explosion

s2

6.5Million

property

dam

age

Lenoir&Dav

enport,

1993

12.

1952

Bou

ndBrook

,USA

Phen

olic

resinplant/

phen

olic

resinpow

der

Powder

smou

ldering

dueto

overhea

ting

/MaE

/MaE

/MaE

521

Lewis,1

993

13.

1953

Cam

pan

a,Argen

tina

Refi

nery/reco

very

unit/gasoline

VCE/

threeex

plosion

s2

Lenoir&Dav

enport,

1993

14.

1953

Miami,USA

Storag

eunit/LPG

F/

Fe

eMHID

AS,

2009

15.

1954

Lake

Port,

USA

Storag

earea

/LPG

MiE

/MaE

4e

MHID

AS,

2009

16.

1955

Whiting,

USA

Refi

nery/

hyd

roform

erunit/nap

htha

MaE

/F

240

Lenoir&Dav

enport,

1993

;Le

wis,

1993

;Mah

oney

,199

0;W

oodworth,1

955

17.

1957

Mon

trea

l,Can

ada

Storag

etanks/butane

VC/

F/

3BLE

VEs

13Storag

etanks

dam

aged

Kier&Mulle

r,19

83

18.

1957

Merau

x,USA

Storag

etank/dieseloil

Tankco

llapse

/seve

refire

1e

MHID

AS,

2009

19.

1958

Boron

,USA

Tanktruck

/LPG

F/

MaE

s1

eMHID

AS,

2009

B. Abdolhamidzadeh et al. / Journal of Loss Prevention in the Process Industries 24 (2011) 575e593576


Table

1(con

tinu

ed)

No.

Yea

rLo

cation

Plan

t/unit/chem

ical

Sequ

ence

ofacciden

tsDea

ths

Injuries

Other

reportedim

pacts

Referen

ce

20.

1958

Sign

alHill,U

SARefi

nery/visb

reak

erplant/oil

Tankeruption

/F

218

Lewis,1

993;

Woo

dworth,1

955

21.

1959

Dee

rLake

,USA

Roa

dtanke

r/LP

GLP

Gleak

andignition

/F/

BLE

VE

1110

Kier&Mulle

r,19

83

22.

1959

Mac

Kittrict,USA

Storag

earea

/LPG

MiE

/BLE

VE

e2

MHID

AS,

2009

23.

1960

Bak

ersfi

eld,

USA

Storag

etank/caustic

MiE

/F

eMHID

AS,

2009

24.

1961

Perry,

USA

Tanktruck

/LPG

F/

MaE

se

eMHID

AS,

2009

25.

1962

Pampa,

USA

Refi

nery/isop

entane

MiE

/F

e1

MHID

AS,

2009

26.

1962

Doe

Run,

USA

Ethan

olam

ineplant/

ethylen

eox

ide

Intern

alex

plosion

dueto

runaw

ay/

VC

121

Lewis,1

993;

Mah

oney

,199

027

.19

62Marietta,

USA

Phen

olproduction

plant/be

nze

ne

Disch

arge

ofbe

nze

ne

through

relie

fva

lve

/VCdam

age

pipew

ork/

F

13

Mah

oney

,199

0

28.

1962

Ibbe

nbu

ren,

German

yPipeline/hyd

roge

nMiE

/Fan

dtoxic

release

e1

MHID

AS,

2009

29.

1963

Evan

ston

,USA

Wareh

ouse/

methan

olF/

Toxicrelease

e1

MHID

AS,

2009

30.

1964

Attlebo

ro,

USA

Vinyl

chloride

polym

erization

plant/vinyl

chloride

Leak

/E/

MaE

740

Lewis,1

993;

Mah

oney

,199

0

31.

1964

Niig

ata,

Japan

Refi

nery/oil

Oilsp

illag

eF/

E/

F2

97Storag

etanks

destroy

edMah

oney

,199

0

32.

1964

Libe

ral,USA

Com

pressor

station/propan

eVCE/

multiple

explosion

se

0.5Million

property

dam

age

Lenoir,19

93

33.

1965

Louisville

,USA

Neo

preneplant/mon

ovinyl

acetylen

eDecom

positionof

mon

ovinyl

acetylen

edueto

overhea

ting/

MaE

s

128

Lewis,1

993;

Mah

oney

,199

0

34.

1965

Carthag

e,USA

Proc

essplant/oil

F/

MaE

andF

ee

MHID

AS,

2009

35.

1966

Feyz

in,

Fran

ceRefi

nerystorag

etanks/propa

ne

Prop

aneleak

/

F/

MaE

1881

Five

spheres

destructed

Lewis,1

993;

Mah

oney

,199

036

.19

67Lake

Charles,USA

Refi

nery/isobu

tane

MaE

/major

F7

13Hea

lthan

dSa

fety

Executive

,197

8;Marsh

all,19

7737

.19

68Rom

ford,U

KNap

htha

(jet)F

/F

ee

MHID

AS,

2009

38.

1968

Milford

Hav

en,U

KRefi

nery/hyd

rocarbon

sMiE

/F

ee

MHID

AS,

2009

39.

1968

Port

Arthur,

USA

Storag

etank/petrol

MiE

/F

35

MHID

AS,

2009

40.

1968

Pern

is,

Netherlands

Refi

nery/hyd

rocarbon

vapou

rOve

rflow

lead

toVC/

MaE

/F

285

Fontein,1

968;

Lewis,1

993;

MSA

PHreport,

1968

41.

1968

Leve

rkusen,

German

yFo

rmam

idinesulphinic

acid

plant/urea

F/

MaE

114

MHID

AS,

2009

42.

1969

Dormag

en,

German

yEthylen

eox

ideplant/

ethylen

eox

ide

MaE

/MaE

140

MHID

AS,

2009

43.

1969

Glendora,

USA

Railtan

kcar/vinyl

chloride

Tankderailm

ent

andleak

/series

ofFs

andEs

1Kier&Mulle

r,19

83;Slater,1

978

(con

tinu

edon

next

page)

B. Abdolhamidzadeh et al. / Journal of Loss Prevention in the Process Industries 24 (2011) 575e593 577


ble

1(con

tinu

ed)

No.

Yea

rLo

cation

Plan

t/unit/chem

ical

Sequ

ence

ofacciden

tsDea

ths

Injuries

Other

reportedim

pacts

Referen

ce

44.

1969

Laurel,USA

LPG

tankcars/LPG

Tankderailm

ent

lead

toserial

tank

explosion

san

dfireba

lls

2>33

Structurald

amag

ewithin

400ft.A

lmost

allg

lasses

were

shatteredwithin

halfamile

Eisenbe

rg,L

ynch

,&Breed

ing,

1975

;Le

noir&Dav

enport,

1993

45.

1969

Rp

celak,

Hunga

ryCarbo

nic

acid/storage

/purified

CO2

MaE

/MaE

s9

15Chile

s,20

01

46.

1969

Rou

nd

Brook

,USA

Rea

ctor/nitrophen

olMiE

/MaE

11

MHID

AS,

2009

47.

1969

Gea

ry,U

SARailtankcar/bu

tane

F/

BLE

VE

ee

MHID

AS,

2009

48.

1969

LongBea

ch,

USA

Tank/petrol

F/

MaE

183

MHID

AS,

2009

49.

1969

Texa

sCity,

USA

Petroc

hem

ical/

butadiene

Deton

ation/

VCE

330

Millionproperty

dam

age

Lenoir&Dav

enport,

1993

50.

1970

Bea

umon

t,USA

Oilslop

etank/oil

Tankfailu

rean

doilsp

illag

e/

F/

Fin

other

16tanks

nea

rby

Mah

oney

,199

0

51.

1970

Crescen

t,USA

Railtankcar/

propan

eProp

aneleak

/

F/

serial

MaE

s66

Lewis,1

993;

Strehlow,

1973

;W

atrous,19

70.

52.

1970

Ludwigsh

afen

,German

yTran

sportation

/propylen

eVCE/

Fan

dMaE

53

2Barge

caugh

tfire

andsu

nk

MHID

AS,

2009

53.

1970

Big

springs,

USA

Refi

nery/alky

lation

/hyd

rocarbon

vapors

VCE/

MaE

eProp

erty

dam

age

worth

$9.7

million

Lenoir&Dav

enport,

1993

54.

1970

Linden

,USA

Refi

nery/

hyd

rocracking/oil

Physical

explosion

/VCEan

dfire

eProp

erty

dam

age

worth

$87

.6million

Lenoir&Dav

enport,

1993

55.

1971

Baton

Rou

ge,

USA

Roa

dtanke

r/ethylen

ePh

ysical

E/

Fe

21MHID

AS,

2009

56.

1971

Hou

ston

,USA

Railtankcar/vinyl

chloridemon

omer

Tankderailm

ent

andpunctured

/serial

tank

explosion

san

dfires

15

Eisenbe

rget

al.,

1975

;Le

wis,1

980

57.

1971

Longv

iew,U

SAPo

lyethylen

eplant/ethylen

eGas

pipebrok

e/

VC/

rupture

ofother

ethylen

epipelines

/VCs

460

Eisenbe

rget

al.,

1975

;Le

wis,1

980

58.

1972

Yok

kaichi,Japan

Rubb

erplant/waste

water

trea

tmen

tunit/

waste

water

MiE

/Fan

dreactorrupture

ee

MHID

AS,

2009

59.

1972

Rio

de

Janeiro,B

razil

Refi

nery/storag

earea

/LPG

MiE

/BLE

VE

3753

Mah

oney

,199

0

60.

1972

Duqu

ede

Cax

ias,Brazil

Storag

etank/LP

GVCE/

BLE

VE

/series

ofex

plosion

s39

51MHID

AS,

2009

61.

1973

Kingm

an,U

SARailtankcar/propan

e(Jet)F/

BLE

VEan

dfireba

ll13

Morethan

90Marsh

all,19

8762

.19

74Clim

ax,U

SARailtankcar/vinyl

chloridemon

omer

Tankderailm

entan

dVCM

leak

/VC/

F/

BLE

VE

Eisenbe

rget

al.,

1975

63.

1974

Bea

umon

t,USA

Hyd

rocarbon

sVCE/

Fan

dMaE

210

MHID

AS,

2009

64.

1974

Petal,USA

Term

inal/saltdom

estorag

e/bu

tane

MiE

/MaE

eGlass

brea

kage

upto

11km

Lenoir&Dav

enport,

1993

65.

1975

EaglePa

ss,U

SATran

sportation

/LPG

VCE/

fire

andan

other

VCE

17Le

noir&Dav

enport,

1993

66.

1975

Phila

delphia,

USA

Storag

earea

/fuel

oil

Ove

rfilling/

VCE/

major

Fe

eMHID

AS,

2009



Table

1(con

tinu

ed)

No.

Yea

rLo

cation

Plan

t/unit/chem

ical

Sequ

ence

ofacciden

tsDea

ths

Injuries

Other

reportedim

pacts

Referen

ce

67.

1975

Bee

k,Netherlands

Ethylen

eplant/

propylen

eVC/

F(numerou

sfires)

1410

4(Insidethe

factory);3(outside)

Dam

agein

aradiusof

4.5km

,6tanks

burn

ed,

control

room

dem

olished

Lewis,1

980,

MSA

RE,

1976

;Van

Eijnatten,

1977

68.

1975

Avo

n,U

SACok

ingunit/drum/

crudeoil

F/

Fe

eMHID

AS,

2009

69.

1976

Geism

ar,U

SAPe

troc

hem

ical

plant/polyg

lyco

lether

reactor/ethylen

eox

idean

dpropylen

eox

ide

MaE

/major

Fe

eMah

oney

,199

0

70.

1976

Baton

Rou

ge,U

SAChem

ical

plant/naturalga

sMaE

/toxicrelease

ee

MHID

AS,

2009

71.

1976

Addyston,U

SAStorag

earea

/methan

olMaE

/F

ee

MHID

AS,

2009

72.

1976

Guay

aquil,

Ecuad

orTa

nke

r/LN

GVCE/

series

ofex

plosion

se

>50

MHID

AS,

2009

73.

1977

Pueb

la,M

exico

Storag

ebu

llets/vinyl

chloridemon

omer

VCM

leak

age

/VCF/

4BLE

VEs

13

Lewis,1

993.

74.

1977

Westw

ego,

USA

Grain

silo/grain

dust

MaE

/MaE

/MaE

3610

Lewis,1

993.

75.

1977

Galve

ston

,USA

Grain

silo/grain

dust

MaE

/MaE

/MaE

15Kier&Mulle

r,19

83;Marsh

all,19

8776

.19

77Rom

eoville

,USA

Refi

nery/storag

earea

/dieselfuel

F/

Fe

eMHID

AS,

2009

77.

1978

Abq

aiq,

SaudiA

rabia

Gas

processing

unit/m

ethan

eGas

leak

dueto

intern

alco

rrosion

/VC/

(apipe

sectionstruck

aLP

Gsp

herical

tank/

release

&VCE)

Mah

oney

,199

0

78.

1978

Texa

s,USA

LPG

storag

etanks/LPG

Crack

dueto

intern

alov

erpressure

ledto

LPG

leak

/F/

BLE

VE

710

Mah

oney

,199

0

79.

1979

Pittsfi

eld

Townsh

ip,U

SARoa

dtanke

r/propan

eLe

akag

e/

series

ofex

plosion

ee

MHID

AS,

2009

80.

1979

Mississau

ga,

Can

ada

Railtank

car/propan

e,etc

Tanks

derailm

ent

andF/

BLE

VEs

andtoxicrelease

Amyo

t,19

80;

Lewis,1

993;

Mississau

ga,

1979

81.

1979

Taco

ma,

USA

Hyd

roge

nco

mpression

system

/hyd

roge

nMaE

/toxicrelease

e3

MHID

AS,

2009

82.

1979

Ras

Tanura,

SaudiA

rabia

Refi

nery/storag

etank/petrol

MaE

/F

26

MHID

AS,

2009

83.

1979

Priolo,Italy

Plasticplant/cu

men

eF/

F1

eMHID

AS,

2009

84.

1979

Milligan

,USA

Trainof

tankcars

containingam

mon

ia,

aceton

e,ch

lorine,

etc

Derailm

ent

/MaE

s/

F/To

x0

1445

00Pe

ople

evacuated

;dam

ageworth

$1.26

million

MHID

AS,

2009

85.

1980

Dee

rPa

rk,U

SASh

ip/vacuum

distilla

teMaE

/F

312

MHID

AS,

2009

86.

1980

Bienville

,France

Chem

ical

storag

edep

ot/

resins,acetates,solve

nts

MiE

/F

ee

MHID

AS,

2009

(con

tinu

edon

next

page)



ble

1(con

tinu

ed)

No.

Yea

rLo

cation

Plan

t/unit/chem

ical

Sequ

ence

ofacciden

tsDea

ths

Injuries

Other

reportedim

pacts

Referen

ce

87.

1980

Borge

r,Te

xas,USA

Refi

nery/alky

lation

unit/lightHCs

Vesselrupture

andHCrelease/

VC

41Blast

destroy

edthealky

lation

unit,w

hole

refinerysh

utdow

n

Lewis,1

993;

Mah

oney

,199

0

88.

1980

Salin

aCruz,

Mex

ico

Storag

etank/oil

Ligh

tening/

F/

Fe

eMHID

AS,

2009

89.

1980

Dee

rPa

rk,U

SAPh

enol

plant/cu

men

eF/

Fe

eMHID

AS,

2009

90.

1981

South

Hutchinson,U

SARailcar/ammon

iaF/

MaE

ee

500Pe

ople

evacuated

MHID

AS,

2009

91.

1981

Mon

tana,

Mex

ico,

USA

Railtankcar/ch

lorine

Tanks

derailm

ent

/MaE

s17

1000

Marsh

all,19

87

92.

1981

WestGlamorga

n,

UK

Refi

nery/propan

eMiE

/MaE

ee

MHID

AS,

2009

93.

1982

Livingston,U

SAFreigh

ttrain/

petroch

emical

products

Tankderailm

ent

/seve

rale

xplosion

se

eNTS

Ban

nual

report,19

8394

.19

82Ph

iladelphia,

USA

Storag

etank/cu

men

eMaE

/F

ee

MHID

AS,

2009

95.

1982

Hou

ston

,USA

Tanktruck

/propan

eF/

Fe

3MHID

AS,

2009

96.

1982

Caracas,

Ven

ezuela

Electricityco

mpan

y/storag

e/oil

E/

F/

boilo

ver

150

>50

0Le

wis,1

993;

Mah

oney

,199

097

.19

83Milford

Hav

en,U

KRefi

nery/storag

etank/

crudeoil

F/

2bo

ilove

rse

20Le

wis,1

993;

Mah

oney

,199

098

.19

83Hou

ston

,USA

Chem

ical

plant/

methyl

brom

ide

Physical

E/

toxicrelease

2Se

veral

2Block

swere

evacuated

MHID

AS,

2009

99.

1983

Port

Neches,U

SASh

ip/dieselfuel

F/

MaE

se

eMHID

AS,

2009

100.

1983

Dursley,

UK

Dieselen

gine

productionplant

F/

toxicrelease

e5

Hundredsof

peo

ple

evacuated

MHID

AS,

2009

101.

1983

Baton

Rou

ge,

USA

Plasticplant/vinyl

chloridemon

omer

MaE

/F

e2

1500

Peop

leev

acuated

MHID

AS,

2009

102.

1983

Swindon

,UK

Proc

essplant/resin

F/

MaE

MHID

AS,

2009

103.

1983

Dalhou

sie,

Can

ada

Electrolysis

plant

MiE

/toxicrelease

ee

MHID

AS,

2009

104.

1983

New

ark,

USA

Storag

earea

/unlead

edga

solin

eTa

nkov

erfilling/

MiEs/

MaE

PressTV,2

009

105.

1984

LasPied

ras,

Ven

ezuela

Refi

nery/hyd

roge

nplant/oil

Oillin

efractured

/F/

F(jet

fire

ofaga

spipe)

Mah

oney

,199

0

106.

1984

Mex

icocity,M

exico

Storag

etanks/LPG

Linerupture

andLP

Gleak

/VC/

F/

BLE

VEs

650

6400

Seve

redam

age

tonea

rbyhou

ses,

$31

milliondam

age

Lewis,1

993;

Mah

oney

,199

0

107.

1984

Rom

eoville

,USA

Refi

nery/ab

sorption

column/propan

e,bu

tane

Columncrack

/VC/

MaE

1731

Dam

ageto

electrical

pow

ersu

pply

system

andfire

extingu

ishing

system

s

Lewis,1

993;

Mah

oney

,199

0

108.

1985

Bom

bay,

India

Port

wareh

ouse/

chem

icals

Chainof

explosion

s/

major

Fe

eEn

tire

storag

eco

mplex

dev

astated,a

barge

caugh

tfire

dueto

flyingmissiles

MHID

AS,

2009

109.

1985

SanAntonio,U

SAStorag

etank/am

mon

iaMaE

/toxicrelease

423

20Pe

ople

evacuated

MHID

AS,

2009

110.

1985

Priolo,Italy

Ethylen

eplant/

dee

than

izer

column/

ethylen

e

Reliefsystem

operated

/

ethylen

edisch

arge

/F/

MaE

/tankco

llapse

andmoreMaE

s

Mah

oney

,199

0



Table

1(con

tinu

ed)

No.

Yea

rLo

cation

Plan

t/unit/chem

ical

Sequ

ence

ofacciden

tsDea

ths

Injuries

Other

reportedim

pacts

Referen

ce

111.

1985

Nap

les,Italy

Tran

sportation

/oil

MaE

/F

417

0MHID

AS,

2009

112.

1985

Algeciras,S

pain

Ship/nap

htha

MaE

/MaE

ee

MHID

AS,

2009

113.

1985

Nap

les,Italy

Petroleu

mterm

inal/oil

Tankov

erfilling

/VC/

major

F4

170

MHID

AS,

2009

114.

1986

Petal,USA

Pipeline/LP

GMiE

/MaE

and

fireba

lle

12Residen

tsin

2mile

radius

evacuated

MHID

AS,

2009

115.

1986

Thessaloniki,Greece

Oilterm

inal/oils

Oilsp

illag

ean

dF/

seve

ralFs

Browning&

Searson,1

989

116.

1987

Antw

erp,B

elgium

Ethylen

eox

ide

plant/distilla

tion

column/ethylen

eox

ide

EOdecom

position

andintern

alex

plosion

/F

14Le

noir&

Dav

enport,

1993

117.

1987

Port

Herriot,F

rance

Storag

etanks/oil

Oilsp

rayan

dflash

/F/

MaE

s2

8Man

sot,19

89

118.

1987

Gen

oa,Italy

Storag

efacility/

methan

olan

dhex

ane

F/

MaE

s4

160

Families

and

locals

choo

lev

acuated

MHID

AS,

2009

119.

1987

Ciudad

Mad

ero,

Mex

ico

Refi

nery/ga

solin

eMiE

/F

ee

3000

Residen

tsev

acuated

MHID

AS,

2009

120.

1987

Pampa,

USA

Petroc

hem

ical/

acetic

acid

plant/

butane

Deton

ation

/VCE

3Prop

erty

dam

age

worth

$21

0million

Lenoir&

Dav

enport,

1993

121.

1988

PerthAmbo

y,USA

Roa

dtanke

r/hex

ane

F/

F1

eMHID

AS,

2009

122.

1988

Bom

bay,

India

Storag

etank/

benze

ne

MiE

/F

3516

MHID

AS,

2009

123.

1988

Kings

Ripton,U

KStorag

e/LP

GF/

BLE

VE

ee

MHID

AS,

2009

124.

1988

Brisb

ane,

Australia

Chem

ical

factory/

deterge

nt

MiE

/toxicrelease

e30

MHID

AS,

2009

125.

1989

Antw

erp,B

elgium

Ethylen

eox

ideplant/

distilla

tion

column/

ethylen

eox

ide

Intern

alex

plosion

/pipew

ork

fracturedan

dflam

eflashed

back

toan

other

column/

intern

alex

plosion

5Kletz,1

990;

Mah

oney

,199

0

126.

1989

Pasaden

a,USA

Polyethylen

eplant/HCs

Hyd

rocarbon

vapou

rrelease/

VC/

MaE

s(a

storag

etankan

da

reactor)

24>13

0Le

wis,1

993;

Mah

oney

,199

0

127.

1989

Jonov

a,Lithuan

iaAmmon

iastorag

e/am

mon

iaAmmon

iatank

rupture

/Fs

and

toxicdispersion

757

32,000

Person

evacuated

Andersson

,19

91;Kletz,1

990

128.

1989

AlHillah

,Iraq

Tran

sportation

/ex

plosive

sMaE

/F

19e

MHID

AS,

2009

129.

1989

Baton

Rou

ge,U

SARefi

nery/ethan

ean

dpropan

eMiE

/F

ee

Mah

oney

,199

0

130.

1990

Stan

low,U

KBatch

reactor/

chem

ical

mixture

(Jet)F/

MaE

andfireba

ll1

5Le

wis,1

993

131.

1990

Sydney

,Australia

LPG

term

inal/LPG

Gas

Leak

/F/

BLE

VEs

MHID

AS,

2009

132.

1990

St.P

eters,Australia

Gas

dep

ot/LPG

MaE

/fireba

ll/

MiEs

ee

MHID

AS,

2009

133.

1991

Coa

tzacoa

lcos,M

exico

Petroc

hem

ical

complex/vinyl

chlorideplant

MiE

/MaE

ee

Mah

oney

,199

0

(con

tinu

edon

next

page)



ble

1(con

tinu

ed)

No.

Yea

rLo

cation

Plan

t/unit/chem

ical

Sequ

ence

ofacciden

tsDea

ths

Injuries

Other

reportedim

pacts

Referen

ce

134.

1992

LaMed

e,Fran

ceRefi

nery/hyd

rocracke

runit/hyd

rocarbon

and

hyd

roge

n

MaE

/Fan

dMiEs

US$

180,00

0,00

0Th

e10

0Largest

Losses,2

003

135.

1992

Bradford,U

KChem

ical

wareh

ouse/

azod

iisob

utyronitrile

AZD

Nco

ntainers

ruptured/

MiE

/Fs

33Sign

ificantair

andwater

pollution

Hea

lthan

dSa

fety

Executive

,199

313

6.19

92Castleford,U

KChem

icals

JetF/

Fse

eEx

tensive

property

dam

age

Hea

lthan

dSa

fety

Executive

,199

413

7.19

93Ringa

skiddy,

Irelan

dPh

armaceu

ticalfacility

MaE

/largeF

e32

Multinational

Mon

itor,2

009

138.

1993

Shen

zhen

,China

Wareh

ouse/

ammon

ium

nitrate

MaE

/MaE

1514

1Guoshun,2

000

139.

1993

Jack

sonville

,USA

Petroleu

mterm

inal/

unlead

edga

solin

eF/

tankov

erflow

/seve

ralpoo

lfires

1Em

ars,20

09

140.

1994

Bel

Pre,

USA

Petroleu

mplant/

thermop

lastic

rubb

erproduct

MiE

/F/

MaE

Twobu

ildings

andatankfarm

caugh

tfire

Hea

lthan

dSa

fety

Executive

,199

3

141.

1994

Milford

Hav

en,U

SATe

xaco

refinery/HCs

Pipefailu

re/

hyd

rocarbon

release/

MaE

/Fs

/flare

relie

fdam

age/

F

2648

Milliondam

age

HSE

,200

9

142.

1994

Siou

xCity,

USA

Ammon

ium

nitrate

plant/nitricacid

MaE

/toxicrelease

518

2500

Peop

leev

acuated

MHID

AS,

2009

143.

1994

New

Delhi,India

Tran

sportation

/nitrocellu

lose

MaE

/major

F8

2MHID

AS,

2009

144.

1994

Ued

a,Japan

Storag

etank/

gasolin

eMaE

/MaE

13

70Residen

tsev

acuated

MHID

AS,

2009

145.

1995

Kuco

ve,

Alban

iaStorag

etank/

crudeoil

F/

MaE

14

MHID

AS,

2009

146.

1995

Volgo

grad

,Russia

Railtanke

r/propan

eF/

MaE

ee

MHID

AS,

2009

147.

1995

Sava

nnah

,USA

Chem

ical

storag

e&

tran

sfer

facility

F/

toxicrelease

Nea

rbytown

evacuated

,en

vironmen

tal

impact(fish

kill)

EPA,1

998

148.

1996

Paese,

Italy

LPGload

ing

term

inal/LPG

Flashfire

/ex

plosion

andpoo

lfire

/BLE

VEs

/fireba

lls

ee

Zenier,Antonello,

Dattilo,&

Rosa,

2001

149.

1996

Martinez

,USA

Hyd

roge

nplant/hyd

roge

nMiE

/F

e2

MHID

AS,

2009

150.

1997

Burn

side,

USA

Grain

dryer/LPG

F/

BLE

VE

22

Abb

asia

ndAbb

asi,20

07a

151.

1997

Visak

hap

atnam

,India

HPC

Lrefinery/LP

GTa

nkF/

MaE

/MaE

andFs

60$2

0Million

dam

age

Khan

&Abb

asi,

1999

a,19

99b

152.

1997

Mag

dalla,India

Tran

sportation

/ethylen

ech

loridean

dsu

lphur

F/

major

Fe

eMHID

AS,

2009

153.

1997

Zambo

anga

,Ph

ilippines

Tran

sportation

/hyd

rocarbon

sF/

MiE

/Fs

16

MHID

AS,

2009

154.

1998

AlbertCity,

USA

Turkey

farm

/propan

eVeh

icle

struck

pipeline

/F/

BLE

VE

27

Wolf,20

06

155.

1998

Longford

Victoria,

Australia

Gas

processingplant/

hea

tex

chan

ger/

hyd

rocarbon

VCE/

major

F2

8Th

e10

0Largest

Losses,2

003

156.

1999

Laem

Chab

ang,

Thailand

Refi

nery/tank

farm

/gasoline

Tankov

erfilling

/VCE/

F7

1840

00Residen

tshad

tobe

evacuated

PressTV,2

009



Table

1(con

tinu

ed)

No.

Yea

rLo

cation

Plan

t/unit/chem

ical

Sequ

ence

ofacciden

tsDea

ths

Injuries

Other

reportedim

pacts

Referen

ce

157.

2000

Mex

ico

City,

Mex

ico

Gas

plant/

naturalga

sF/

series

ofex

plosion

s22

Indep

enden

t,20

0915

8.20

00Gloucester,U

KW

aste

tran

sfer

station

F/

MaE

s9

Environmen

t-Age

ncy

,200

915

9.20

00Dou

glas,U

SAOilfieldservice

compan

y/propan

eProp

aneleak

/

series

ofex

plosion

s(a

tankBLE

VEs)

Fireworld,2

009

160.

2000

Texa

s,USA

Tanke

rtruck

/propan

eMiE

/MaE

21

Evacuated

200

residen

tsAcu

safe,2

009

161.

2000

Ontario,

USA

Water

trea

tmen

tplant/co

rrosive

gases

F/

series

ofex

plosion

sSe

veralnea

rby

compan

ieswere

evacuated

Acu

safe,2

009

162.

2001

Ohio,U

SAChem

ical

plant

Chem

icals

overhea

ted

/series

ofex

plosion

s

e17

Acu

safe,2

009

163.

2001

Pennsylvan

ia,U

SADyn

amiteplant/

dyn

amitean

dfireworks

MaE

/MaE

s1

320

0Residen

tsev

acuated

Acu

safe,2

009

164.

2001

Louisiana,

USA

Refi

nery/turbinefuel

Leak

/ex

plosion

/F

e2

Acu

safe,2

009

165.

2001

Ron

cador,B

razil

Offsh

oreplatform/

drain

tank/mixture

ofwater

andhyd

rocarbon

s

E/

Ean

dplatform

floo

ding

10e

USD

515,00

0,00

0dam

age

The10

0Largest

Losses,2

003

166.

2001

Nev

ada,

USA

Chem

ical

plant

F/

aseries

ofex

plosion

se

5Acu

safe,2

009

167.

2001

Michigan

,USA

Pressedbo

ard

man

ufacturing

plant/woo

dch

ips

F/

MaE

e9

Acu

safe,2

009

168.

2001

Gastonia,

USA

Electrop

latingco

mplex

F/

series

ofex

plosion

se

e$1Milliondam

ages

Acu

safe,2

009

169.

2001

Delaw

are,

USA

Refi

nery/su

lfuricacid

F/

acid

spill

/releasinga

clou

dof

toxicga

s

18

Acu

safe,2

009

170.

2001

Pennsylvan

ia,

USA

Dyn

amitean

dfireworks

plant

MaE

/series

ofex

plosion

s1

320

0Pe

ople

evacuated

NYtimes,2

009

171.

2001

Day

ton,U

SAChem

ical

&polym

erco

mpan

yRefrige

ration

system

faile

d/

overhea

ting

ofch

emicals

/series

ofex

plosion

s

Acu

safe,2

009

172.

2001

Toulouse,

Fran

cePe

troc

hem

ical

plant/am

mon

ium

nitrate

wareh

ouse

MaE

/MaE

30Morethan

5000

V2.3Billion

UNEP

,200

9

173.

2001

Con

ocop

hillips,

Humbe

rRefi

nery,

UK

Refi

nery/dee

than

izer

overhea

dpipe/mixture

ofethan

e,propan

e,bu

tane

Piperupture

and

hyd

rocarbon

release/

VC/

other

pipe

ruptures/

fireba

ll

0HSE

,200

9

174.

2001

Rio

deJaneiro

offshore,

Brazil

Oilplatform/H

Cs

Tankrupture

due

toov

erpressu

re/

dam

ageto

variou

seq

uipmen

t/ga

sdispersion

/F/

MaE

12Th

eplatform

sankinto

thewater

Petrob

ras,

2001

;EP

A,

2001

175.

2001

Mex

icoCity,

Mex

ico

Dye

factory/alco

hol

andmethan

olF/

MAEs

e17

Morethan

5000

peo

ple

evacuated

Acu

safe,2

009

176.

2002

Mississippi,USA

Rubb

erplant/dryer/

pow

dered

rubb

erF/

MaE

48

Acu

safe,2

009

(con

tinu

edon

next

page)



ble

1(con

tinu

ed)

No.

Yea

rLo

cation

Plan

t/unit/chem

ical

Sequ

ence

ofacciden

tsDea

ths

Injuries

Other

reportedim

pacts

Referen

ce

177.

2002

Kuwait

Oilproducingplant/

crudeoil

Leak

/MaE

/F

4e

Acu

safe,2

009

178.

2002

Austin,U

SAFo

odprocessingplant

MiEs/

MaE

5Fireworld,

2009

179.

2003

Perm

Reg

ion,

Russia

Railtankcar/

propan

eebu

taneblen

dMaE

/series

ofex

plosion

s1

Prav

da,

2009

180.

2004

Skikda,

Algeria

LNGplant/bo

iler

VC/

MiE

/MaE

2774

7Pe

ople

missing,

nea

rbyelectricity

generationplant&

oilrefinery

shutdow

n

Bap

e,20

09

181.

2004

Chon

gqing,

China

Chem

ical

plant/

chlorine

Chlorinega

sleak

/

MaE

s/

chlorine

dispersion

93

1500

00peo

ple

evacuated

Chinad

aily,

2009

182.

2004

Vad

odra,

India

Oilrefinery/

slurryreactor

MaE

/F

216

Theh

indu

-bu

sinessline,

2009

183.

2004

Zahed

an,

Iran

Truck

/gasoline

Truck

lost

control

hitabu

s/

F/

other

lorryfire

9011

4UNEP

,200

9

184.

2004

Ney

shab

ur,Iran

Railtankcar/va

riety

ofch

emicals:

sulphur,

gasolin

e,fertilize

rs,

cotton

woo

l

Tankderailm

ent

/F/

MaE

328

460

BBC,2

009;

UNEP

,200

9

185.

2005

Texa

sCity,

USA

BPrefinery/

isom

erization

unit/hyd

rocarbon

s

VC/

MaE

/Fs

1518

0Morethan

1billion

dollardam

age

Chem

ical

Safety

andHazard

Inve

stigation

Boa

rd,2

007

186.

2005

Buncefield,U

KOilstorag

eterm

inal/

motor

fuel

Tankov

erfilling

/VC/

MaE

/F

060

HSE

,200

9

187.

2005

St.L

ouis,U

SAGas

repacking&

distribution

facility/

propylen

e

F/

MaE

san

dFs

1Chem

safety,

2009

188.

2005

Fort

Worth,U

SASo

lven

t&

other

chem

icals

F/

MiE

/other

fires

04

Infowars,20

09

189.

2007

Valero

McK

eeRefi

nery,

USA

Refi

nery/prop

ane

dea

sphalting

unit/propan

e

Prop

aneleak

/F/

piperack

colla

pse

/

other

piperupture

and

chlorinerelease

CSB

,200

9

190.

2008

Shazan

d,Iran

Chem

ical

plant/2-ethyle

hex

anol

MaE

/MaE

s/

F30

3890

%Plan

tdestroy

ed,

upto

300m

glasses

weresh

attered

BBC,2

009

191.

2008

Maricop

a,USA

Grain

silo/grain

MaE

/MaE

e3

Maricop

a360

,20

0919

2.20

08Nag

othan

e,India

Polymer

plant/LLDPE

unit/

cyclon

efilter

MiE

/MaE

446

Hindustan

times,

2009

193.

2008

Yizhou

City,

China

Polyvinyl

acetate&

other

chem

icals

F/

Es/

Fs16

5711

,500

peo

ple

evacuated

Topnew

s,20

09

194.

2008

Lalbag

h,

Ban

glad

esh

Polymer

F/

Fs6

6Fiftyhou

sesgu

tted

Ittefaq,

2009

195.

2008

SanAntonio,

USA

Atlas

pallet

F/

MaE

/F

ee

eKsat,20

09

196.

2008

Torkham

,Pa

kistan

Oiltanke

rsMaE

/MaE

/

Fs/

MaE

e60

Fortyoiltanke

rsdestroy

edKbri,20

09



Table

1(con

tinu

ed)

No.

Yea

rLo

cation

Plan

t/unit/chem

ical

Sequ

ence

ofacciden

tsDea

ths

Injuries

Other

reportedim

pacts

Referen

ce

197.

2008

Toronto,

Can

ada

Sunrise

propan

eindustrial

gases

MaE

/MaE

/F

254

Evacuationof

anarea

of1.6km

radius;

clea

nupco

sts

$1.5million

MHID

AS,

2009

198.

2009

SaoPa

ulo,

Brazil

Chem

ical

dep

otF/

MaE

s/

Fe

10Doz

ensev

acuated

;major

property

loss

Dailymail,20

09

199.

2009

Yerev

an,

Arm

enia

Synthetic

rubb

erfactory

F/

MaE

/MaE

/F

324

Oneperson

unacco

unted;massive

property

dam

age

Asb

arez

,200

9

200.

2009

Ambe

gaon

,India

Chem

ical

plant

F/

MaE

se

1Sa

unalah

ti,2

009

201.

2009

Bad

amiBag

h,

Pakistan

Chem

ical

dep

ot/sulphur,

sulfuricacid,p

otassium

perman

ganate,

and

industrial

andtextile

chem

icals

F/

seve

ralF

san

dMaE

s>12

Seve

redam

ageto

neigh

boringhou

ses

andfacilities

Saunalah

ti,2

009

202.

2009

Delhi,India

Paintfactory

E/

F1

12Fire

spread

tothe

nea

rbybu

ildings

causinghea

vydam

age

Thaindian,2

009

203.

2009

Delhi,India

Chem

ical

factory

E/

F2

Thaindian,2

009

204.

2009

Faridab

ad,

India

Footwea

rindustry/

materialinvo

lved

was

ahighly

flam

mab

lemixture

ofch

emicalsused

formak

ingsh

oes

andrubb

er

E/

F10

5Morepeo

ple

missing

Thaindian,2

009

205.

2009

Him

achal

Prad

esh,India

Air-con

ditioning

man

ufacturing

compan

y

F/

Ech

eck

819

Thaindian,2

009

206.

2009

Punjab,

India

Fertilize

rfactory

F/

MiE

2Lo

sses

incu

rred

due

totheacciden

tis

estimated

tobe

betw

eenRs80

and10

0million

Thaindian,2

009

207.

2009

Mad

hya

Prad

esh,

India

Idea

lExp

losive

sLimited

and

Rajasthan

Explosive

sPvt.L

td.

MaE

/causedMaE

innea

rbyplant

10>10

0Th

eex

plosion

scauseddam

age

toat

least15

nea

rbyplants

Thaindian,2

009

208.

2009

West

Carrollton

,USA

Veo

liaEn

vironmen

tal

Sciences

Leak

/E/

Fe

220

Residen

ces

dam

aged

Chem

safety,2

009

209.

2009

Viaregg

io,Italy

Freigh

ttrain/LPG

MaE

/2M

aEs/

F15

>50

1000

Residen

tsev

acuated

,ove

r10

0rendered

hom

eless

Reu

ters,2

009

210.

2009

Dunkirk,F

rance

Refi

nery

E/

F1

514

Peop

lesh

ocke

dby

theinciden

tnee

ded

psych

iatric

support.

Safetynew

s,20

09

211.

2009

Hyd

erab

ad,India

Chem

ical

solven

tex

traction

factory

E/

F/

leak

22

Hindu,2

009

212.

2009

Molo,

Ken

yaGasolinetanke

rTa

nke

rov

erturn

ed/

Leak

/fireba

ll11

1>20

0Firege

ezer,2

009

(con

tinu

edon

next

page)



ble

1(con

tinu

ed)

No.

Yea

rLo

cation

Plan

t/unit/chem

ical

Sequ

ence

ofacciden

tsDea

ths

Injuries

Other

reportedim

pacts

Referen

ce

213.

2009

Hyd

erab

adIndia

Druginterm

ediates

man

ufacturingco

mpan

y:MaE

/F

e2

Shoc

kwav

esdue

totheex

plosion

werefeltev

en10

kmaw

ay.

Deccanch

ronicle,2

009

214.

2009

Saravli,India

Chem

ical

dye

ingplant

E/

F2

4Sa

unalah

ti,2

009

215.

2009

Karachi,Pa

kistan

Chipbo

ardmak

ing

factory

E/

F3

5Dailytimes,2

009

216.

2009

Pawan

e,India

Darsh

anChem

icals

F/

Fs/

Es2

9Sa

unalah

ti,2

009

217.

2009

Columbu

s,US

Columbu

sch

emical

industries

F/

Ese

3W

kowtv,2

009

218.

2009

LaMesa,

US

Saltwater

disposal

factory

Ligh

tningbo

lt/

F/

Fs/

Ee

1W

hdh,2

009

219.

2009

Okh

la,India

Foam

man

ufacturing

factory

F/

Fs/

E1

8Th

een

tire

factory

was

destroy

edTribuneindia,2

009

220.

2009

Gazipur

Ban

glad

esh

Blademak

ing

factory/LP

GE/

Fs3

15Th

edailystar,2

009

221.

2009

Agra,

India

Firecracke

rGod

own

inaco

mmercial

complex

F/

MiEs/

Fe

eTh

efire

spread

tonea

rbysh

ops,

guttingsomeof

them

Taraga

na,

2009

222.

2009

Yan

shiCity,

China

Luoran

Co.

Ltd/

chem

ical

dye

production

F/

E/

Fs5

>10

8Residen

tswithin

a1km

radiuswere

evacuated

Xinhuan

et,2

009

223.

2009

Ulyan

ovsk,R

ussia

Arm

ydep

ot/

ammunition

E/

MaE

san

dFs

2Morethan

1030

00Pe

ople

wereev

acuated

BBC,2

009

224.

2009

Jaipur,India

Petroleu

mproducts

F/

VCE

/seve

ralpoo

lfireswithex

plosion

s

13>20

050

0,00

0Ev

acuated

;property

loss

worth

$40million

PressTV,2

009



trying to catch up. Lastly, even as the report of Kourniotis et al.(2000) is highly meritorious, it provides no clue to the accidentscovered by the authors except a set of references to 31 of the events.

Given this backdrop the present study has been conducted witha 2-fold objective:

a) To prepare an inventory of all major domino events current upto 2009, showing, inter alia, the sequence of accidents eachevent had, so that the information is available in public domainfor further study and possible analysis.

b) To identify patterns and useful pointers from a study of theinventory.

We have also proposed a concept of local domino effect (LDE)to highlight the problem of chains of accident that often occurwithin the same process unit with a time interval of a minute ormore between them.

2. The domino effect

Before proceeding with past accident analysis it may be neces-sary to specify the criteria we have applied in deciding which of thepast events qualify as domino events. It also becomes necessary torecapitulate the different interpretations of domino effect that arecurrently in vogue, and see the direction in which a broaderconsensus is tending to converge.

There is as yet no universally accepted definition of the termdomino effect in the context of accidents in chemical processindustry. Most scientists in Asia, North America and elsewhere usethe term to describe situations wherein a loss of containmentaccident in a process unit becomes the trigger of one ormore loss ofcontainment accidents in one or more other process units. At timesthe victim unit(s) become the cause of fresh accidents, and attimes the chain continues still further. The first of the knock-onevent is referred as the first level or the first order domino effect;events occurring at second or further stages in the chain arereferred as second level/order; or a higher level/order dominoeffect.

Within the European Union, domino effect is sometimes usedin a more restrictive sense and only for situations wherein a loss ofconfinement accident in one establishment becomes the cause ofa loss of confinement accident in another establishment. Thisinterpretation is based on Article 8 of the so-called Seveso IIDirective, which calls for the competent authority, using the infor-mation received from the operators in compliance with Articles 6 and9, identifies establishments or groups of establishments where thelikelihood and the possibility or consequences of a major accident canbe increased because of the location and the proximity of suchestablishments, and their inventories of dangerous substances. Theauthors who go by this definition use domino effect for only thatsituation in which an accident in an industry has occurred due tothe impact of an accident in another, adjacent or nearby, industry.They then use the terms internal domino effect to distinguishserial accidents that occur within a single establishment from theones that occur across more than one establishment.

One of the earliest, and a rather liberal, definition of dominoeffect is due to Lees (2005, 1980), as per which domino effectrepresents: A factor to take account of the hazard that can occur ifleakage of a hazardous material can lead to the escalation of theincident, e.g. a small leak which catches fire and damages by flameimpingement a larger pipe or vessel with subsequent spillage of a largeinventory of hazardous material.

The AIChE-CCPS (American Institute of Chemical Engineers eCentre for Chemical Process Safety) definition is also very liberal,calling domino effect as an incident which starts in one item and may

affect nearby items (e.g., vessels containing hazardous materials) bythermal, blast, or fragment impact (CCPS, 2000).

By these definitions all knock-on accidents including even theones which occur within a single process unit would fall under theumbrella term domino effect.

Between the extremes of the restrictive Seveso II definition andthe liberal definitions of Lees and AIChE-CCPS are the middle-of-the-road definitions such as the one of Bagster and Pitblado(1991) which define domino effect in terms of knock-on acci-dents involving two distinct process units (which may or may notbe the part of the same establishment).

Given the divergent ways in which the term domino effect isinterpreted in the context of process-industry accidents, it may beinteresting to recapitulate the origin of the term domino effect. Itcomes from the game of domino toppling; a domino being a small,flat block, often of wood, marked on one side with two groups ofdots representing numbers (Crowther, 1996). If several dominos arearranged in a manner that every falling domino would hit the oneplaced next to it, and if the domino at the head of the array is madeto fall, it may trigger a chain of collapsing dominos with each fallingdomino toppling the one standing next to it. Based on this analogy,the term domino effect is used to describe an event, usually anunpleasant one, which causes other similar events to happen. Theterm is commonly used by economists and political scientists todescribe the impact of actions which have the propensity to cause,or which do cause, one crisis after another.

Considering that the importance of studying chain of accidentsstems from the fact that such serial, knock-on or cascadingevents are not only fairly common but also cause much greaterdamage than stand-alone accidents, it appears of little relevancewhether the units associatedwith such chain of accidents happen tobelong to the same establishment or different establishments.Indeed, even within the EU, domino effect is often used in moregeneral sense than is reflected in the Seveso II Directive and hasbeen variously called a phenomena that occurs inside and outside theindustrial sites (Cozzani et al., 2005); an accident in which a primaryevent propagates to nearby equipment, triggering one or moresecondary events (Cozzani et al., 2006) a phenomena involvinga cascade of accidents inwhich the consequences of a previous accidentare increased by the following one(s), spatially as well as temporally(Reniers, Dullaert, & Karel, 2009) and physical effect due to a primaryevent.that may trigger secondary events. on other process units.(Antonioni et al., 2009). Some of the authors within EU, for exampleFievez, Delvosalle, and Brohez (2002), even feel that the Seveso IIDirective does not clearly specify the notion of domino effect andhave proposed their owndefinitions, for example Delvosalle, Fievez,and Benjelloun (1998) call domino effect as: a cascade of events inwhich the consequences of previous accidents(s) are increased by thefollowing one(s), leading to major accident.

In the present study domino effect has been used in the sensein which it is commonly used outside the EU, and oftentimes evenwithin EU, and refers to knock-on accidents in which one processunit jeopardizes another process unit. The effect is characterized bythe following sequence (Cozzani et al., 2006):

(i) a primary accidental scenario, which initiates the dominoaccidental sequence;

(ii) the propagation of the primary event, due to an escalationvector generated by the physical effects of the primaryscenario, that results in the damage of at least one secondaryequipment item;

(iii) one or more secondary events (i.e. fire, explosion and toxicdispersion), involving the damaged equipment items(the number of secondary events is usually the same of thedamaged plant items)



Moreover, situations are quite commonwherein, after a compo-nent of a process unit fails, causing a loss of containment, itprecipitates failure of another component of the same process unitbut after a significant time gap e say a minute or more. In suchsituations possibility exists ofmitigative action being taken after thefirst event to prevent it from causing another event. To be consciousof such possibilities, and to put in place appropriate emergencypreparedness measures, it is important to recognize thisphenomena of local domino effect. Hence in this paper we haveintroduced the concept of local domino effect (LDE) and have givenit a tentative definition.

Interestingly, whereas in the quintessential domino effectinvolving the game of domino toppling, themomentumwithwhicheach domino topples the next goes on decaying steadily from thefirst hit onwards (till a stage is reached when the momentum isinsufficient to topple the next domino and the chain terminates),domino effect in process industry is characterized by escalationrather than diminution as the chain proceeds further.

3. Collection of information on domino events

There are certain well-recognized problems associated with thetask of obtaining records of past accidents (Khan & Abbasi, 1999a,1999b; Van Der Schaff and Kanse, 2004; Korvers and Sonnemans,2008). The more serious among them include a) lack of a propermechanism of accident reporting and maintenance of recordsexisting in many countries, especially so in the previous century; b)intentional under-reporting of accidents by industries/governmentsto reduce or escape liability; c) contradictory versions of whatactually happened and the inability of post-mortems to resolve theuncertainty due to lack of unassailable evidence; d) inherentimprecision of a great deal of available recordse for example fire andexplosions are often recorded in generic sense and in many situa-tions it is not possible to figure out the specific event type, and e)unclear documentation of sequence of accidents in an episode.

Even in the case of accidents occurring in present times and indeveloped countries, on some occasions the nature of accidentobscures the fact whether it had involved domino effect or not. Forexample two major explosions occurred due to the derailment ofa train carrying tank cars filled with LPG (liquefied petroleum gas)at Viareggio, Italy, on June 29, 2009 (Wikipedia, 2009). But whetherboth explosions were independent of each other, or whether oneexplosion led to the other, is not known because both explosionsoccurred very close to each other in time and space. Hence even if ithad involved domino effect, there is no way to ascertain it.

If these hurdles in obtaining or interpreting records of pastaccidentsmake PAA (past accident analysis) difficult for stand-doneaccidents, they confer additional challenges to PAA of dominoevents. The reason is that to classify a series of accidents asa domino event, it is necessary to establish that the eventconfirmed to the definition of domino effect as stated in thepreceding section. Going by the generally incomplete and impre-cise records of the past accidents it is not easy to figure out whether,in the episodes which hadmultiple accidents, only one process unitwas involved or more than one. Operating within these limitationswe have surveyed the records of the following sources to cull outthe events for the inventory:

I. The APELL (Awareness and Preparedness for Emergencies atLocal Level) database

II. The COMAH (Control of Major Accident Hazards) databaseIII. MARS (Major Accident Reporting System)IV. The CSB (Chemical Safety Board) databaseV. The HSE (Health and Safety Executive, UK) databaseVI. MHIDAS (Major Hazardous Incident Data Service)

To pack together the essence of the available information per-taining to each domino event in a single row of a tabledespeciallythe defining traits of any domino event, viz the multiple accidentsand the sequence in which they had occurreddwe have usedsymbols and arrows. For example an event which began with a fire(F), followed by a minor explosion (MiE) which, in turn, set off a firein another unit, followed by a major explosion (MaE), has beendepicted as: F/MiE/ F/MaE. Whenever the documents haverecorded an accident type specifically as a VCE (vapour cloudexplosion), a BLEVE (boiling liquid expanding vapour explosion),a pool/jet fire, etc, we have recorded it in specific terms.

While presenting this information we are aware that almostalways a process-industry accident begins with an involuntary lossof confinement (LOC) which occurs due to failure of a valve ora container. That, in turn, is caused by amyriad of factors internal orexternal to the jeopardized unit. But, whereas a very large numberof accidents are quenched soon after a failure is detected, those thatescape mitigation evolve into significantly harmful events. Hencewhat really defines a major accident is the fire/explosion/toxicrelease that occurs after an LOC. Moreover by its definitiona domino event involves a major LOC in a unit caused by an earlierLOC in another unit. Hence the focus of the inventory is on majorLOC events involved in different chains of accidents. The events ofinitial crack or minor leak, which almost always occur in the initialstages of all process-industry accidents, have not been included. Ifthe initiating event has been a major leak, persisting for some timebefore causing a fire or an explosion, it has been specified.

The inventory, comprising of 224 events current up toNovember 2009, is presented in Table 1. We have scoured as manysources as we could and, hopefully, not many among the reportedincidents are missing in the inventory. Nevertheless the list doesnot include all the domino events that have occurred e for reasonsgiven in the first para of this section e which is why the list bearsthe title it does.

Considering that the events featuring in Table 1 have taken placerandomly, and from all the events that have taken place a few havebeen brought on one or other record (hence accessed by us), too,randomly, Table 1 represents, in the parlance of statistics,a random sample of the overall domino event population. For anyset of random samples to be representative of the population beingsampled, the sample size should be 40 or above. In the present casethe sample size (224) is much greater than that threshold; henceTable 1 can be deemed fairly representative.

4. Discussion

Flammable substances are associated with an overwhelminglylarge fraction, 89%, of all domino events (Fig. 1). Petroleum prod-ucts, downstream hydrocarbons, and condensed phase explosivesare the substances most commonly involved. But non-flammableshave also caused major domino events, as happened at Milligan,USA, in 1979 and at Chogging, China, in 2004; both involvingchlorine. Even a fire extinguisher like CO2 has been associated witha domino event, as happened at Repcelak, Hungary, in 1969. One ofthe major explosions during refinery disaster at Skikda, Algeria, in2004 was by all accounts, caused by water (overheated; leading toa boiler explosion).

Which type of accident is most likely to precipitate a secondaccident? The events recorded in this study reveal explosion to bethe most frequent cause of domino effect, followed by fire (Fig. 2).This is an interesting statistic because among stand-alone accidentsthe largest fraction is that of fire (Khan & Abbasi, 1999a, 199b; Lees,2005). An explanation for this curious deviation in domino eventscomes from the data on specific types of explosions and firesinvolved. In a large number of event histories, type of explosion or



fire has not been specified but from among the records where it hasbeen, the distribution is as in Figs. 3 and 4. Among the dominoevents initiated by a fire (Fig. 3) the most frequent cause has beenpool file (80%), followed by VCF (vapour cloud fire; 12%). Among thedomino events initiated by an explosion, VCE (vapour cloudexplosion) has been the most frequent cause (Fig. 4). Thus it can besaid that, all-in-all, leaks of flammable substances which generateVCF/VCE are themost frequently responsible cause of domino effectin process industry. A survey of accident histories summarized inTable 1 also reveals that even though BLEVE is rarely the initiatoraccident in a domino sequence, and is very often a result of a VCF/VCE, it becomes a powerful propagator of the accident chain e as,for example, happened at Port Newark, USA, in 1951; Feyzin,France, in 1966; and Mexico City, Mexico, in 1984 (Abbasi andAbbasi, 2007b; 2008).

Nearly three-fourths of all past domino events have been infixed installations (Fig. 5); of the 20% accidents that have occurredduring transportation, the largest fraction has occurred on roads,closely followed by railroad events; and pipelines and shippingaccount for the rest (Fig. 6).

Considering that developed countries use more energydhencelarger quantities of flammable liquids and gasesdbesides generallyharboring larger number of chemical industries than most devel-oping countries, it is expected that larger number of process-industry accidents will occur in the developed world. But accidentpreparedness is also much greater in the developed world which isexpected to bring down loss of confinement events from blowingup to major accidents. Considering these balancing factors, the

lesser proportion of domino events in developing countries ascompared to the developed ones shown in Fig. 7 can be attributedprimarily to the non-reporting, under-reporting, or unclearreporting of accidents in the former (Abbasi & Abbasi, 2005). Until1972 not a single report of the domino events occurring in thedeveloping world has been available in primary literature. This isclearly a result of non-reporting, not absence, of domino events. Forexample in 1944 there was a major explosion in the ship Fort Sti-kine docked at Mumbai (then Bombay) harbor. The ship wasunloading a cargo consisting of condensed phase explosives, lubeoil, and cotton when there was a fire which raged for several hoursbefore two massive explosions in the space of 34 min took the shipapart. The blasts were so powerful that they shattered the ship intoa large number of fragments which then ran down on the citizens ofBombay over a large area. The blasts also caused total destruction of10more ships. These events must have set off secondary and higherorder accidents but even as the main event has been documented(Lees, 2005), the records do not carry details beyond the primaryevent. In this manner other accidents associated with processindustry do often get media coverage in the developing world butare described in terms of the event which leads to most deaths andinjury; overall sequence of events and their precise nature arerarely covered. The situation has begun to improve since the mid1970s (Fig. 8). In less than 9 years of the present decade 35 domino

Fig. 2. Types of primary (initiating) accidents involved in the recorded instances ofdomino effect.

Fig. 3. Types of fires involved in initiating domino effect.

Fig. 4. Types of explosions responsible for setting in a chain of accidents.

Fig. 1. Types of hazardous substances involved in domino events related to thechemical process industry.



events have been reported compared to the 22 events reported inthe 25-years span of 1976e2000. A substantial fraction (12%) of theall the reports that have come from developing countries, is fromthe Middle East (Fig. 9). A large number of refineries and otherprocess industries in this region have a presence of consultantswho hail from countries (North America andWestern Europe) witha longer tradition in process safety R&D thanmost other parts of theworld. This may be a reason for better reporting from the MiddleEast. Indias position as one of the most technologically advancedamong developing countries is reflected in themuch larger numberof reports coming from India (34%) than any other single devel-oping country.

Fig. 5. Domino events occurring in fixed installations and during transportation.

Fig. 6. Domino events encountered during different modes of transportation.

0

10

20

30

40

50

60

70

80

90

1951-1975 1976 -2000 2001 -2025

Actual (up to September

2009)

Projected (up to 2025)

Fig. 8. Improvement in the reporting of domino events in developing countries.

Fig. 7. Domino event reports from the developing and the developed world.

Fig. 9. Pattern of domino effect reporting in the developing world.

Fig. 10. Length of accident chain in domino events.

0

5

10

15

20

25

1950s 1960s 1970s 1980s 1990s 2000s

Decade

Fig. 11. Global average of number of fatalities per accident. The statistical trend line isalso seen.



A major concern in domino effect management is the length ofthe accident chain. Analysis of the past data indicates that majorityof domino events have the second accident leading to a thirdaccident, or more (Fig. 10). This tendency to persist of dominoeffect warrants greater attention to its forecasting and control thanpaid hitherto.

Another finding of great concern is the trend of increasingnumber of fatalities per accident (Fig. 11). The present decade hasan year and a half still to go (at the time of drawing up this illus-tration) but it has already recorded a higher number of fatalities perdomino event than any previous decade except the 1980s. Thatdecade had witnessed two of the biggest process-industry disastersin terms of fatalities: the oil boilover disaster at Caracas, Venezuela(1982) and the San Juan Ixhuatepec refinery disaster at Mexico City(1984), with 150 and 650 deaths respectively (Abbasi & Abbasi,2007c). Indeed that decade had also witnessed the worst-everprocess-industry accident (Bhopal, 1984), but it hadnt involveddomino effect and hence doesnt feature in the calculation. Eventhough the number of fatalities per domino event has been lower in

subsequent decades, the overall trend is steeply upwards asreflected in the trend line of Fig. 11. The number of fatalities peraccident is much higher in developing countries compared to thedeveloped ones (Fig. 12).

4.1. Local domino effect (LDE)

During the course of studying the case histories of past accidentsone very often comes across situations in which a set of differentaccidents had taken place within the same process unit but witha time gap of a minute or more. A set of illustrative examples,picked from the e-MARS database, are presented in Table 2. Theseaccidents arent stand-alone in true sense of the term but theyarent treated as domino events either because, as per the mostcommonly followed interpretation (Section 2) for an episode toqualify as a domino event, it is necessary that an accident in oneprocess unit should have led to an accident in another process unit.

But distinct accidents, with significant time gap (say 1 min ormore) in the same process unit have essentially the same charac-teristics and type of consequences as the domino event viz onejeopardy leading to another, whereby the loss of confinement isexacerbated. We propose to give the name local domino effect(LDE) to situations of this type. It appears important to recognizeLDE and study it because the time gaps that occur in an LDEsequence provide an opportunity to quench the propagation of theLDE as well as to generate forewarnings and act upon them. Timeplays a decisive role in damage containment by first responders(Pasman, Jung, Prem, Rogers, & Yang, 2009). Study and analysis ofLDE events can help in the modeling of time influence on thegeneration of secondary or higher order accident triggers in an LDEsequence. Scenario analysis helps responders in their prepared-ness management (Pasman et al., 2009), and study of LDE wouldcontribute to it.

The duration of 1 min or more between two mishaps as an LDEqualifier has been proposed by these authors arbitrarily; it may berefined once the basic philosophy of the LDE is accepted.

0

20

40

60

80

100

120

1950s 1960s 1970s 1980s 1990s 2000s

Fa

ta

litie

s p

er d

ec

ad

e

Decade

Developed countries Developing countries

Fig. 12. Fatalities (average) per accident in developed countries and developingcountries.

Table 2Illustrative examples of multiple accidents occurring with significant time gap but within the same process unit e internal domino effect.

No. Year Location Plant/unit/chemical Sequence of accidents Deaths Injuries Other reported impacts Reference

1. 2000 a General chemicalsmanufacture

F/ confined explosion e 8 Fire-/explosion-damage:approximately 50,000,000 Euro

Emars, 2009

2. 2001 a LPG bottling & bulkdistribution)

MiE/ F 1 1 Cost of damages estimatedto be 3.5 mn Euro

Emars, 2009

3. 2001 Motiva Enterprisesrefinery, Delaware City

Petrochemical, refining,processing

Leak/ F 1 8 Spilled a million gallonsof sulfuric acid

Emars, 2009

4. 2002 a Other MiE/ F 1 e Material loss Emars, 20095. 2003 a Food and drink MiE/ F/ toxic release 1 e The facility suffered

extensive damageEmars, 2009

6. 2003 CTA Acoustics, Corbin,Kentucky, USA

Plastics and rubbermanufacture

A thick cloud of dustdispersed/ ignited bya fire/MaE

7 37 e Emars, 2009

7. 2003 Kinston, NorthCarolina, USA

Plastics and rubbermanufacture

F/ dust explosion 6 12 The shockwave from the initialexplosion broke windows up to1000 ft away, and debris fromthe explosion was propelled upto two miles. Property damageof $150 million

Emars, 2009

8. 2005 Hemel Hempstead,Hertfordshire, UK

Petrochemical, refining,processing

MaE/ several MiE/Large F

e 60 20 Businesses employing 500people were destroyed and thepremises of 60 businessesemploying 3500 people werebadly damaged.

Emars, 2009

9. 2006 Perstorp Groups productionplant, Bruchhausen, Germany

General chemicalsmanufacture

Release of pentaerythrite/dust explosion

1 2 1,000,000 Euro material damage Emars, 2009

10. 2007 Morganton, North Carolina, US General chemicalsmanufacture

F/VCE 1 14 The blast destroyed the facilityand damaged off-site structures

Emars, 2009

a Not specified in the record; efforts to locate them from other sources were unsuccessful.



5. Summary and conclusion

1. Past accident analysis (PAA) enables an understanding of theways in which accidents occur and provides useful inputs forthe development of loss prevention strategies. In spite ofinherent shortcomings of PAA which mainly arise from non-reporting, under-reporting, or improper reporting of accidentsin several parts of the world, PAA remains a very importantcomponent of loss prevention R&D.

2. Even as extensive PAA has been done of stand-alone accidentsby several authors from time to time, there is only one reportavailable on the PAA of domino events, by Kourniotis et al.(2000). Even as the report is meritorious and useful, it coversonly the events that occurred up to 1998 and provides refer-ences to only 31 events. The present study was taken up toprovide a complete inventory (from as many records as couldbe found on the basis of very elaborate search) of the majordomino events that have occurred right up to mid 2009.Recognition of patterns from the information thus gathered,was also envisaged.

3. The study has led to records of 224 major domino events whic

Documents

Author's personal copy - UM Repositoryrepository.um.edu.my/24398/1/Domino effect in process Published.pdf · Author's personal copy ... LPG MiE / MaE 4 e 2009 Whiting, USA Re nery