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Author's personal copy
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
Author's personal copy
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
Author's personal copyTa
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
B. Abdolhamidzadeh et al. / Journal of Loss Prevention in the Process Industries 24 (2011) 575e593578
Author's personal copy
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)
B. Abdolhamidzadeh et al. / Journal of Loss Prevention in the Process Industries 24 (2011) 575e593 579
Author's personal copyTa
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
B. Abdolhamidzadeh et al. / Journal of Loss Prevention in the Process Industries 24 (2011) 575e593580
Author's personal copy
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
$21
0million
Lenoir&
Dav
enport,
1993
121.
1988
PerthAmbo
y,USA
Roa
dtanke
r/hex
ane
F/
F1
eMHID
AS,
2009
122.
1988
Bom
bay,
India
Storag
etank/
benze
ne
MiE
/F
3516
MHID
AS,
2009
123.
1988
Kings
Ripton,U
KStorag
e/LP
GF/
BLE
VE
ee
MHID
AS,
2009
124.
1988
Brisb
ane,
Australia
Chem
ical
factory/
deterge
nt
MiE
/toxicrelease
e30
MHID
AS,
2009
125.
1989
Antw
erp,B
elgium
Ethylen
eox
ideplant/
distilla
tion
column/
ethylen
eox
ide
Intern
alex
plosion
/pipew
ork
fracturedan
dflam
eflashed
back
toan
other
column/
intern
alex
plosion
5Kletz,1
990;
Mah
oney
,199
0
126.
1989
Pasaden
a,USA
Polyethylen
eplant/HCs
Hyd
rocarbon
vapou
rrelease/
VC/
MaE
s(a
storag
etankan
da
reactor)
24>13
0Le
wis,1
993;
Mah
oney
,199
0
127.
1989
Jonov
a,Lithuan
iaAmmon
iastorag
e/am
mon
iaAmmon
iatank
rupture
/Fs
and
toxicdispersion
757
32,000
Person
evacuated
Andersson
,19
91;Kletz,1
990
128.
1989
AlHillah
,Iraq
Tran
sportation
/ex
plosive
sMaE
/F
19e
MHID
AS,
2009
129.
1989
Baton
Rou
ge,U
SARefi
nery/ethan
ean
dpropan
eMiE
/F
ee
Mah
oney
,199
0
130.
1990
Stan
low,U
KBatch
reactor/
chem
ical
mixture
(Jet)F/
MaE
andfireba
ll1
5Le
wis,1
993
131.
1990
Sydney
,Australia
LPG
term
inal/LPG
Gas
Leak
/F/
BLE
VEs
MHID
AS,
2009
132.
1990
St.P
eters,Australia
Gas
dep
ot/LPG
MaE
/fireba
ll/
MiEs
ee
MHID
AS,
2009
133.
1991
Coa
tzacoa
lcos,M
exico
Petroc
hem
ical
complex/vinyl
chlorideplant
MiE
/MaE
ee
Mah
oney
,199
0
(con
tinu
edon
next
page)
B. Abdolhamidzadeh et al. / Journal of Loss Prevention in the Process Industries 24 (2011) 575e593 581
Author's personal copyTa
ble
1(con
tinu
ed)
No.
Yea
rLo
cation
Plan
t/unit/chem
ical
Sequ
ence
ofacciden
tsDea
ths
Injuries
Other
reportedim
pacts
Referen
ce
134.
1992
LaMed
e,Fran
ceRefi
nery/hyd
rocracke
runit/hyd
rocarbon
and
hyd
roge
n
MaE
/Fan
dMiEs
US$
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
B. Abdolhamidzadeh et al. / Journal of Loss Prevention in the Process Industries 24 (2011) 575e593582
Author's personal copy
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)
B. Abdolhamidzadeh et al. / Journal of Loss Prevention in the Process Industries 24 (2011) 575e593 583
Author's personal copyTa
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
B. Abdolhamidzadeh et al. / Journal of Loss Prevention in the Process Industries 24 (2011) 575e593584
Author's personal copy
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)
B. Abdolhamidzadeh et al. / Journal of Loss Prevention in the Process Industries 24 (2011) 575e593 585
Author's personal copyTa
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
B. Abdolhamidzadeh et al. / Journal of Loss Prevention in the Process Industries 24 (2011) 575e593586
Author's personal copy
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)
B. Abdolhamidzadeh et al. / Journal of Loss Prevention in the Process Industries 24 (2011) 575e593 587
Author's personal copy
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
B. Abdolhamidzadeh et al. / Journal of Loss Prevention in the Process Industries 24 (2011) 575e593588
Author's personal copy
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.
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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.
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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.
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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