PREVENTION, CONTROL AND MITIGATION MEASURES OF MAJOR

INDUSTRIAL ACCIDENTS

Authors
Sa’ari Mustapha* and Izani Mohd. Zain**

*Department Chemical and Environmental Engineering, Faculty of Engineering, UPM

** En. Izani bin Mohd Zain, Major Hazard Division, Jabatan Keselamatan dan Kesihatan
Pekerjaaan(JKKP).

Control of Industrial Major Accidents Regulations (CIMAH) was gazetted on 1st

February 1996. The regulations aim to prevent and control of major accidents and to
minimize the effects of the accidents to people, property and the environment. This paper
discusses hazardous events, potential cause, prevention and mitigation measures of
accidents of major hazard installations such as storage and distribution of LPG, water
treatment plant, crude stabilization and gas processing plant, and oil refinery plant.
Recognizing of various potential hazards, accident scenarios, control and mitigation
systems and responders capability are crucial in preventing major accidents and
minimizing their impacts to people, property and the environment.

Keywords: CIMAH, prevention, control, mitigation, major industrial accidents

INTRODUCTION

Processing and storage of chemicals in large quantities have potential risk of

major accidents such as toxic release, fire and explosion if the installations are not
managed safely. Examples of major accident are an accident release of a toxic chemical
i.e. methyl-iso-cyanate (MIC) at Bhopal which consumed 2,500 lives, an explosion of a
chemical plant at Flixborough killed 28 people and an explosion and followed by fire at
an offshore platform “Piper Alpha” caused 167 people died. The risk of the major
accidents might be avoided by prevention and control measures and their consequences
can be minimized by ‘mitigatio’n. Under Control of Industrial Major Accidents
Regulations (CIMAH), Major Hazard Installations (MHI) are required to include
elements of prevention, control, and mitigation in their safety reports as stated in
Schedule 6 (1) “ information relating to a potential major accidents” . Prevention and
control are measures should be taken by installations to stop any event that has potential
to lead into a major accident hazards while mitigation is subsequent measures after
hazardous events to minimize the consequences.

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INDUSTRIAL PROCESS SAFETY

Normally there are 3 lines of defense in chemical process industries for

preventing casualty and damage to property and the environment and this depicted in
Figure 1 .

Properly designed/maintained/operated of
Primary equipments.
Controlled releases
(flares, scrubbers, surge tanks, etc.)

Fixed mitigation systems

Secondary ( fire fighting systems, dikes, drainage etc )

Emergency
Preparedness
Tertiary

Figure 1: Lines of Defense in Chemical Process Industries

The most significant incident prevention in the plants are(2)::

i) safe design and standards of construction of the plant

ii) operating daily and maintenance control (work permits)
i) audits of the plant operation, employee safety commitment and performance
review
ii) inspection and monitoring of equipments
iii) control of plant modification (technical compatibility of the original design
intention and safety standards)
iv) investigation thoroughly and eliminate the imminent threat

The plant or installation should be designed to withstand static loads, dynamic loads,
internal and external pressure, corrosion, loads due large differences of temperature and
loads due to external impacts (wind, settlement, flood)(3). To keep plant safe, its operation
must be controlled by various systems either using manual or automatic controls during
normal and abnormal conditions to keep the plant safely. It also needs to undergo
inspection, maintenance, audit and repair when necessary to maintain its integrity. The
result of investigations showed that mechanical failures and operational failure (or
human and organization errors) were two major causes of accidents of the chemical
plants (4). To ensure any process plant no harm to people, or damage the environment the
“technical integrity” (TI) of design, operation and maintenance of the plant must always

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place in highest possible standard at all time (5). Since the personnel actually involved in
the three activities therefore they need to be trained up to competent standards or only
well trained personnel are employed for any responsibility in operation, maintenance and
controlling the installations. Training and evaluation of workers will be more reliable if
quality assurance system inclusive in the activities because the system requires work-
procedures are documented and easily accessible.

Process variables such as flowrate, pressure, temperature and composition of mixture

at desired ranges or process conditions in normal operation determine safe plant
operations. Deviation from the safe operation or normal operation may cause an event
that may lead to an emergency situation and if uncontrolled might escalate to a major
accident or disaster. For example increasing temperature of LPG storage tank may cause
LPG discharge to atmosphere through a safety valve and then cause fire when its
temperature reachs at its flash point. There are three operating systems were
recommended to bring the abnormal condition back to the normal operation(6).:
i) First System-Alarm System and Manual Control
As soon as the process variable exceeds the set limit value the signal trigger
and manually action will be taken to control the process variable to safe
limit
ii) Second System- Automatic Control System and Protection System
When the variable exceeds the set limit, automatic controller reacts
automatically to bring process variable back to its controlled range. If the
automatic controller fail then other protection systems such rupture disk,
safety valve, flare, surge tank, scrubber and dike should be available for
minimizing the hazardous condition.
iii) Third System- Independent Automatic System and Response Team
If both systems available but the event still cannot be controlled. At this
point its needs a special response like independent automatic controller such
as a motorized valve to cut chemical supply besides water sprinkle to cool
the storage tank or reactor from overflow or propagate reaction. Provision
with well-trained personnel/operators who are conversant with normal and
abnormal operations and ready to response during an emergency situation
would be worthy.

Occurrence of an incident can not be eliminated at all although a plant is well

designed, operated, maintained and equipped with mitigation systems such scrubbing and
fire fighting system. When an accident happens on site, it may escalate to surrounding if
the mitigation fails. Thus, an emergency response plan (ERP) on-site must be developed
clearly and concisely in their references for best response in case emergency situation
arises. However, by knowing prevention, control and mitigation measure of the major
hazard installations the accident impact can be minimized.

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TYPICAL PREVENTION, CONROL AND MITIGATION IN CHEMICAL
PROCESS INDUSTRIES

In Malaysia there are 149 of major hazard Installations. Following only four categories of
the major hazard installations namely LPG, water treatment plant and crude stabilization
and gas processing plant. Detail in terms of hazardous substances, potential hazardous
events, possible causes, prevention measures, design codes and standard, control and risk
mitigations of the installations as follows:

1) Storage and Distribution of LPG

i) Flammable substance : LPG

ii) Hazardous event : Ignited release of LPG resulting in:

• Pool fire
• Flash fire
• Jet fire
• BLEVE
• VCE

iii) Possible Causes :

• Leakage in the storage vessel
• Catastrophic failure of vessel due to:
- External damage
- Overpressure
- Corrosion
• Failure of pipework
• Leakage of loading hose

iv) Prevention Measure

• Gas detectors have been designed and installed in accordance with approved
codes and standards including BS 4693.Pt 2 1971 and SFA 3009:1972
• There are two loading hoses used to transfer the LPG from the tank ships to
the storage tanks. One of the loading line is used for LPG liquid transfer line
while the remaining loading line is used for LPG vapor return line. The
purpose of a vapor return line is to maintain the pressure in the ship’s cargo
tanks to prevent backflow while LPG in unload from the ships.
• The closed vapor handling system will ensure that no vapor is released to the
atmosphere and that the concentration in the ship’s cargo tanks is always
100% LPG vapor. The latter eliminates the possibility of an internal tank fire
or explosion, as there is no air present to form a flammable mixture.
• The LPG pipelines are fitted with a non-return valve the wharf to prevent
backflow in the line in the event of a leak in the connection between the ship
and the shore facilities.

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 • Each sphere has a safe fill level, its maximum allowed liquid level being at
80% of volume thus leaving 20% vapor space. This safe fill level always
ensures the existence of the vapor space and allows for temperature changes
such as might occur when the storage container is exposed to strong sunlight
in which might resulting in overpressure of spherical tanks.
• All tanks have been installed within the required separation distances between
tanks and within the plant boundary.
• All tanks have lightning protection including earthling bonding to
minimize the risk of leaks igniting due to electrostatic discharge.
In handling liquid of high coefficient of expansion such as LPG, butadiene
and etc, the process equipment, vessel, pipeline and storage tank must be
provided with adequate ullage or pressure relief valves to prevent it
becoming overpressure as a result of temperature increases.
• Daily inspection and verification includes gas cylinders and cylinder
filling machine, gas evacuation unit, devalving machine, weighing
machines, storage vessel, compressor and pumps. Other machineries and
equipment inspected, checked or maintained weekly or monthly.
• Maintenance and servicing routines have been based on manufacturer’s
instructions and operating experience and they are tracked by computer to
ensure that the maintenance is carried out in a effective and timely
manner.
• Plant Operating Manual and Work Procedure Manual, which deal with the
plant operation philosophy, work/operating procedures, plant routines,
isolation procedures and requirements for equipment change out and

v) Codes and Standards

Plant Layout and Equipment Separation M.S. 761 and M.S. 830
Electrical Equipment and Wiring IEC 79
Bulk Storage Vessel ASME Sec. VII, Div.I
Pipeworks, Valves and Fittings ANSI B 31.3
Fire Protection System NFPA
Design and Construction of LPG Installation API 2150
Storage and gas Handling NFPA 58, M.S. 830
Gas Cylinders DOT 4B 240,4BA,4BW

vi) Control Measure

• Spherical tanks, unloading bay and tanker truck loading area are provided with
fixed water spray protection.
• Portable dry chemical fire extinguishers are strategically located throughout
the plant.
• Gas detectors are located near the sphere connections; LPG bottling area, .The
detector will actuate alarms in case of LPG leakage.
• The support legs on each sphere are fireproofed.

vii) Risk Mitigation/Minimization

• Emergency response plan(ERP)

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 • PPE (Type)
Eye : Chemical goggles or face shield optional
Skin : Use leather gloves to prevent frost bite or cold burns
Inhalation : Use positive pressure air respirator if vapor concentration
exceed permissible limits
Ventilation : Adequate to meet permissible concentration

2) Water Treatment Plant

i) Toxic substance : Chlorine

ii) Hazardous event : Release of chlorine

iii) Possible Cause : • Catastrophic failure of delivery lorry

Catastrophic failure of chlorine drum dropped
during drum movement Pipeline failure
• Failure of chlorinator outlet
• Human error
- improper connections
- incorrect maintenance

iv) Prevention Measure

• The chlorine feed bank is equipped with a pressure relief valve.

• The facilities were designed to the codes and standards as practiced by the
British Works Department. The relevant established codes and standards for
the water treatment facilities are listed below:
Drum/Piping/Fitting

v) Codes and Standard

Pipe identification: pipes carrying chlorine BS 1710/1984
painted lemon yellow
Steel for use in the chemical and allied industries BS560:Pt:1
Steel pipes flanges and fittings BS 1560
Piping and flanges to drum ASA 150, BS 1560
Under Pressure Chlorine Tubing Silver coated copper tubes
Valves (different components) forged steel bodies/monel/
stainless steel spindles. Other
components are made from
swelling and corrosion
resistant material

• A Permit to Work System is practiced in the facilities. The system helps

identify any potential hazards in the plant and take preventive measures before

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 any work are authorized to be done either by maintenance personnel or
contractors.
• Work instruction manuals are in place. It provides instructions for operators
on any specific work task relating to the operations and production activities
of the plants.
• All equipment are maintained according to the preventive maintenance
checklist which was determined in accordance with manufacturers
recommended specification and guidelines, statutory requirements and
company’s policy.
• All staffs are subjected to a training course to ensures that all staffs who
performs the work activities are adequately trained and competent to carry
out the respective functions safely and effectively.

vi) Control Measure

• An ammonia bottle test kit is made available throughout the process of
connection operation of chlorine to give indication of any leaks.
• Chlorguard system is provided for chlorine drum feed bank. The system
functions to shutoff chlorine supply from the drum to prevent escalation of
chlorine release. It will be activated upon detection of the gas sensors.
• Scrubber system is installed to extract major chlorine release and to
neutralize it through caustic soda system before venting it out to the
atmosphere.
• Chlorine warning system in install. The warning system consists of a siren
and an emergency light. The system is designed to provide prompt audible
and visible warning during chlorine releases.
• Gas sensors/Detection System is provided where there could be possibility
of gas leakage.
• Fire fighting system consists of fire extinguishers (carbon dioxide, dry
powder and water-based), fire blanket and hydrant point are provided at
strategic locations within the plants.

vii) Risk Mitigation/Minimization

• ERP
• PPE are provided for the personnel at the plants. PPE available consist SCBA, full
face respirator, goggles, gloves, safety shoes, rubber boots, dust mask, dust
catridge, life jacket, safety helmet, ear plugs/muff and emergency shower.

3) Crude Stabilization and Gas processing Plant

i) Flammable Substance : Crude oil, gas condensate and dehydrate natural gas

ii) Hazardous Event : Ignited release of hazardous substances resulting in:

• Pool fire
• Jet fire
• VCE

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iii) Possible Cause :
• Overpressure of piping and process vessel
due to:
- upstream floe control device fails
- blocked or restricted outlet
- gas blowby (upstream component)
- overflow (upstream component)
- pressure control system failure
- thermal expansion

• Under pressure due to:

- control valve failure
- inlet line blocked during withdrawal
- thermal contraction
- open liquid outlet

• Rupture of process vessel and piping due to:

- deteriortion
- erosion
- corrosion
- mechanical failure
- impact damage

iv) Prevention Measure

• The floating roof on these crude storage tanks minimize vapor losses due to
tank breathing because the tank vapor space is virtually eliminated. The
floating roof travels up and down the tank with the crude liquid surface. At the
lowest operating position, tank breather vents will open in floating roof. These
prevent vacuum formation if the liquid level drops further. They also release
vapor as the liquid level returns to this minimum roof operating level.
• Corrosion rates in the gas pipelines are reduced by the dehydration facilities
which eliminate water dropout in the pipelines. Free water dropout could be
corrosive in the presence of CO2, which is in the gas stream. Corrosion rates
in the condensate lines are reduced by the condensate dewatering facilities,
which remove most free water from the lines and continuous corrosion
inhibitor injection.
• On all vessel and piping, external corrosion is prevented by application of
painting/coating.
• Procedures are in place to ensure that the changes considered essential for sale
start-up are implemented prior to start-up so that plant and organizational
readiness for operations may be confirmed. The system requires that all
procedures must be in place and operations personnel adequately trained prior
to start-up.
• A careful managed inspection program, which provides a continuous
overview of the conditions of piping, equipment, safety valves and critical

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 instruments essential in order to ensure the continued integrity of the
hardware.
• Work permit System is strictly enforced to ensure that all hazards and risks
have been eliminated and/or managed from the work area prior to
commencement of any work.
• Post-process design engineering relies on Exxon Basic Practices, which
defines minimum acceptable requirements for engineering, materials,
fabrication, procurement, erection, inspection and testing of plants and
equipment.
• Ventilation
Ignition of a combustible gas requires that the concentration of the gas mixed
with air reaches the lower explosive limit. The primary method employed to
prevent a combustible mixture is to minimize the amount of hydrocarbon
released by using the safety system to shut off the hydrocarbon source upon
detection of an abnormal condition. Therefore, the process area are as open as
possible to allow rapid dispersion of any released hydrocarbons.
• Electrical Codes
The primary source of ignition for a combustible mixture is from electrical
devices, motor, switches and wiring within the plant. The electrical
component has been design in accordance with the relevant Malaysian and
North America electrical codes and enhanced by using industry practiced such
as API RP500, to minimize of an electrical device becoming an ignition
source.
• Fireproofing
Fireproofing of certain structural items is employed to provide protection
against failure of fire exposure.
• Vibration/Mechanical Impact Protection
Leaks and failures are frequently associated with failures of small bore piping,
usually caused by vibration or mechanical impact. Exxon standards recognize
this and require of small bore connection throughout the plant.

v) Control Measurement
• The firewater system consists of a firewater tank, an auxiliary firewater pond,
firewater pumps and an underground network distribution with hydrants,
monitors and hose reels.
• Fire water equipment such as deluge system, and dry chemical fire
extinguishers are provided throughout the process areas.
• Fire detection system to detect heat from fire, smoke or combustible gas
concentration are available.

vi) Risk Mitigating/Minimization

• Emergency response plan(ERP)

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4) Oil Refinery Plant

i) Flammable Substances : LPG, butane, isopentane, crude oil, naphtha,

gasoline reformate, ethyl-mercaptan, methanol,
gas oil, kerosene, diesel, LSWR, dyes

ii) Oxidizing Substances : trichloroethane, calcium oxide, dyes

iii) Hazardous Event : Ignited release of hazardous substances resulting in:

• Pool fire
• BLEVE
• UVCE

iv) Possible Cause :

• Gasket failure
• Leakage from pipes
• Wall failures in vessel, which may be
caused by an overpressure inside the
vessel resulting from control valve
failures. (Note: corrosion may also
lead to catastrophic failure of the vessel
wall)
• Rupture of gas carrying pipes
• Failure of compressor mechanical seal
• Rupture of process vessels

iv) Prevention Measure

• All new employees are required to attend an induction training prior to
starting work. They are briefed on general working and safety procedures that
are practiced in the plant.
• The Permit to Work system as practiced in the plant is governed by Permit to
Work procedure to ensure all non-routine work in the refinery is carried out in
a controlled and safe manner.
• Operating manuals that covered all processes within the facility are in place.
• Measure taken to prevent releases are covered by the process safety
management system as applied to the design and construction standards with
the actual operation of the refinery and the inspection, maintenance and
quality assurance systems. Examples of the codes and standards applied to the
facility include:

v) Codes and Standards

ASME : American Society of Mechanical Engineers
ASTM : American Society for Testing and Materials
API : American Petroleum Institute
ANSI : American National Standards Institute
AIA : American Issuance Association

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 IEEE : Institute of Electrical/Electronic Engineers
IEC : International Electrotechnical Commision
ISA : Instrumentation Society of America
OSHA : Occupation Safety Health Administration
NFPA : National Fire Protection Association
EPA : Environmental Protection Agency

vi) Control Measure

• Automatic Gas Detection
The plant is fitted with Automatic Gas Detection System with Automatic
Sensing Heads. Should there be a gas leak or gas accumulation within the
plant, the alarm automatically sounds alerting the plant personnel.
• Heat and Smoke Detection
All vital areas are protected by heat and smoke detectors, which gives an
alarm to the Main Fire Panel in the event of a fire.
• Deluge System
The LPG storage spheres and butane bullets are fitted with a deluge system
with a remote control operating panel.
• Refinery has stocks of dry chemicals and CO2 fire extinguishers, set-out in
strategic locations.
• All storage tanks, both cone roof and floating roof types, are protected with
fixed foam installation. The fixed foam systems are designed in accordance
with NFPA Standards and are capable of tackling storage tank fires
effectively.
• A fire water reserve level is maintained in the fire water tank with backup
water supply from utility water tank.

vii) Risk Mitigation

Emergency Response Plan(ERP)

CONCLUSION

Although prevention, control and mitigation measures in place in a safety report

but probability of occurrence of an accident cannot be eliminated at all. However, the
information is useful for preparation of an emergency response plan (ERP) besides
information about accident scenario and individual/team capability. Regular safety audit
and review inclusively assessment of workers commitment toward safety and
equipments/plant performances tests can prevent an event from escalate to a major
accident. Furthermore regular tests/exercises of the established ERP can mitigate the
accidents.

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REFERENCES

(1) Occupational Safety and Health ( Control Industrila Accident Hazards) Regulations 1996.
(2) John Eberlein, “Emergency plans-the industry approach”, CIMAH in Action,
Chemistry and Industry, 2 February 1987, pp. 77- 89
(3) Major Hazard Control , A Practical Manual, ILO
(4) D A Crowl, J F Louvar, Chemical Process Safety: Fundamentals with Application,
Prentice Hall, 1990 pp. 12-13.
(5) E A Bale and D W Edwards, Technical Integrity-An Engineer’s View, Process safety
and environmental Protection, Vol 78 Number B5 2000, pp.355-361
(6) Major Hazard Control , A Practical Manual, ILO pp. 17-18

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