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Scenario identification in oil and gas company: A case in Middle-East.

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Scenario identification in oil and petrochemical industry: A case in the
Middle East
Zahra Rezvani
Safety Science Group, Delft University of Technology, Netherlands
Paul Swuste
Safety Science Group, Delft University of Technology, Netherlands
Patrick Hudson
Safety Science Group, Delft University of Technology, Netherlands

ABSTRACT

The first element in effective safety management REFERENCES

is having enough knowledge about what and how
accidents happen. This article focuses on incident Ghazinoory, S., & Kheirkhah, A. S. 2008.
scenarios and potential causes of incidents in the pet-
rochemical industry. It is based on a review of acci- Transportation of hazardous materials in Iran :
dents in one oil and petrochemical company in the A strategic approach for decreasing accidents.
Middle east and compares them with world-wide ac- transport 23(2), 104–111.
cident scenarios in this sector (Sam, 2005; NISOC,
2011). The findings are consistent with the findings Hopkins, A. 2008. Failure to learn: the BP Texas
of other researchers (Sam, 2005; Ghazinoory & City Refinery disaster. CCH Australia Limited.
Kheirkhah, 2008). They utilize similar equipment
and facilities; therefore, fires and explosions form NISOC. 2011. Survey of Accidents in National South
the major types of major accidents. The main causes Iranian oil company Ahwaz, Iran: NISOC.
of accidents have been pipe failure, excessive pres-
Sam, M. 2005. Lees’ Loss Prevention in the Process
sure, and electrical failures. Pipelines are dead part
in the industry studied, because of a large spread of Industries. Elsevier.
the pipeline network which requires considerable ef-
fort for repairing and maintenance. Another reason is
contamination of oil and gas with either H2S, and
CO2 caused acidity that increases corrosion. In this
sector there is a repetitive pattern of accidents and
common root causes of events observed. As Andrew
Hopkins has frequently stated, failure to learn con-
tinues to happen, even in well-developed industries
which have documented their earlier failures
(Hopkins, 2008). Sharing of past major incidents
with other oil and gas industries provides valuable
input data for similar process industries in order to
encourage the active monitoring of critical barriers
and improvement in their safety process. It is sug-
gested that these oil and gas industries develop a
complete incident database with more precise and
complete information about the root causes of inci-
dents and share that information with other compa-
nies to learn and to prevent accidents.
Scenario identification in oil and petrochemical industry: A case in the
Middle East

Zahra Rezvani
Safety Science Group, Delft University of Technology, Netherlands
Paul Swuste
Safety Science Group, Delft University of Technology, Netherlands
Patrick Hudson
Safety Science Group, Delft University of Technology, Netherlands

ABSTRACT: The preliminary element in safety management is having enough knowledge about what and
how accident happens. Evaluation of protection layers is important in retrospective and predictive point of
view as well. This article focuses on incident scenarios and potential causes of incident in petrochemical in-
dustry and oil plants. It is based on literature review of accident scenarios in Iranian oil and petrochemical in-
dustries and comparing them with world accident scenarios in this sector. The result shows that accident sce-
narios in Iran oil and petrochemical industries are similar to accident scenarios in this sector in the world ,
because they utilize similar equipment and facilities. Also, the loss of containment and fire are the most popu-
lar accident in these industries. Finally , there is a repetitive pattern of accident in all over the World.

INTRODUCTION be classified into control (e.g. automation) failures,

The definition of accident scenarios lies at the
heart of the safety management process and the
study of safety related decision-making in which
individuals in high-hazard industries are engaged. A
scenario is a generalized description of the actors,
their goals, sequences of actions and events, and
background information (Go & Carroll, 2004). First
(2010) proposed that in any accident scenario the
fact that they form an unplanned event sequence
which could cause unwanted consequences. He
argued that one or more conditions besides the
immediate sequence of events are necessary in an
incident scenario. Fecht et al. (1982) added the
concept of initiating events and intermediate events
into the concept of an accident scenario. An
initiating event is the first event (cause) of accident
scenario but there are also intermediate events that
form an enabling event or “condition which does not
directly cause the scenario”. For example, loss of
containment is an accident scenario for major
hazards such as gas or liquids. It can be caused by a
direct event (an initiating event) like a rupture in a
vessel or by an indirect (intermediate event) such as
the occurrence of a runaway reaction that
subsequently results in releases through pressure
relief devices or then cause a rupture. In total,
Initiating events are typically failures that exceed the
boundaries of normal process conditions .They can
mechanical integrity failures (e.g., corrosion or
erosion of materials ensuring containment) and
human error (e.g., inadvertent opening or closing of
valves, setting incorrect control values etc.). Also,
the operational conditions themselves should be
considered as forming a potential for failure (First,
2010).
From a human error perspective, Guerrero et al.
(2008) stated that an incident scenario is a
composition of actors, objectives, instruments,
action sequences, errors, error causes and error
consequences, and context elements.
In summary, a scenario provides an analysis tool
for strategic planning in safety management. The
typical usage of scenarios in safety involves the
description and analysis of the current system, the
analysis of the problem domain, provision of a
model of the real world, envisioning uncertain
feature environments, analysis of user tasks,
development of a rationale design and finally
provision of a communication tool (Go & Carroll
2004). In fact, based on a review of the literature,
there is no firm consensus for scenario definition and
its application because the range of topics covered is
so wide and the concept does not provide much in
the way of theoretical focus. It is as a result of a wide
range of influencing factors such as a variety of
disciplinary backgrounds and various perspectives
(retrospective versus predictive). However, this
paper focuses on uncovering the common accident
scenarios in a Middle Eastern oil and petrochemical
company based on historical data – using data about
what happens in a specific environment rather than
very general considerations of what might be
appropriate scenarios. The question is then posed
whether there any differences between accident
scenarios in this Middle Eastern case and accident
scenarios in the world’s oil and petrochemical
companies? What are the main causes of accidents in
these industries and do they differ from a potentially
unique isolated environment?
METHOD
A documentary analysis was carried out to
investigate accident scenarios from both a
retrospective and a predictive point of view. In this
study, data from published incident reports
(accident cases) from the oil and petrochemical
industries were used to clarify the concept of an
accident scenario and identify the causes of
accidents in this sector. Also, risk analysis which
have been conducted by researchers and have been
documented in this scope were utilized.
Oil and gas plants and petrochemical industries
use the same basic equipments (pumps, tanks,
vessels columns , etc.) because the chemistry of
hydrocarbon and petrochemical processing is the
same everywhere. Therefore the scenario types for
various types of equipment might be categorized by
risk analysis, accident history and operational
experience. Accidents in oil and gas plants and the
wider petrochemical field in one region of the
Middle East over a time period between 1985 to
2009 were assessed. The data was gathered form a
book which was published by National South oil
company and published studies were carried out
using this scope of reference. Although this is not
the complete source of data, since usually incident
histories are not published publicly as a result of
confidentiality issues and it has been evident that
this document focused on major events, those that
caused loss of life, damage to property or harm to en-
vironment. It is nevertheless useful for our purpose,
which is identification of the main accident
scenarios in this sector because such major incidents
can be treated as representative of the major
scenarios that are likely. If some scenarios are
missed they will appear to be either associated with
lesser consequences of be much less frequent. We
then compared incidents within this specific area
with incidents of the same industry in the world as a
whole over a time period between 1938 and 2010.
The focus was on process incidents which
resulted from plant operation and process activities
rather than on any personal accidents that were
unrelated to the process in the plant. Because
personal safety incidents are more common the
personal accident scenarios can easily swamp the
less common process scenarios, even though the
latter will inevitably have much higher potential for
disaster involving more people and larger assets.
RESULTS
Overall the use of a scenario approach has some
advantages. For example, scenarios can help to
distinguish which are the important events which
should be taken into account. Morover, using a
scenario approach can clarify the inter-relationship
between different aspects such as individual,
psychological, social and political factors. From a
predictive point of view, structured techniques such
as Process Hazard Analysis (PHA), HAZOP and
What-If analyses have been used for identification of
scenarios in this area and are used world-wide.
These methods can find connections between
deviations (process upsets), the possible causes
(initiating events) and outcomes (consequences). For
instance, the principal goal of PHA is to specify
scenarios resulting from failures to manage major
hazards.
The paper is focused on a list of common incident
scenarios in this industry, identifying and using case
histories in the Middle-East case in particular and in
the world in general, in this sector. Although the
probability of some scenarios are low, certain
initiating events and conditions may still happen and
cause catastrophic scenarios. Table 1 shows a list of
major accidents, scenario types, and initiating events
in a Middle East case. It is based on First
classification (First, 2010) who considered 16
scenario types for incidents for various equipment
types.
DISCUSSION
As can be seen in Tables 1 and Figure 1, these
findings are somewhat similar with findings of other
analyses. The similarities are probably the result of
using the same basic equipment (pumps, tanks,
vessels columns, etc.) and similar processes. So,
fires and explosions, when including Vapour Cloud
Explosions with other explosions, are the major
accidents with which the pterochemical and oil
industry are faced. The most common is fire,
however explosion has more potential damage in
terms of fatalities and loss of property (Khan &
Abbasi, 1999).
The main causes of large fires and explosions in
oil industries are release or overflow of flammable
liquid or gas, overheating or hot surfaces, fitting or
pipe failure, electrical breakdown, and overpressure
or pressure vessel failure, explosion in equpment
chemical reaction, and inapropriate operation (Khan
& Abbasi, 1999).
Explosions form the second most important and
common incident scenario in this sector and become
the most frequent when different types of explosions
are combined. Explosions often cause fatalities,
damage to property, shoutdown of the plant for some
days, often months, and serious negative impact on
the reputation of the industry. There is not enough
information to allow coparisons of how long it took
for control to be recovered and return of the
damaged assets to normal conditions after accidents.
It needs to be noted that the conditions may be
different in this case as compared to other countries.
The evidences from recent years indicate that it
usually takes more time to recover in studeied case
than developed countries. Consequently, one
potential scope to significantly improve safety
management in this case is uncovering the obstacles
to recovery and improvement of the planning for
development an emergency response.
Initiating events or major causes in both cases are
plant failure e.g. equipment failure, process
problems, material movement problems, control
failure (ineffective loss prevention program,
inadequate material evaluation). Major contributing
factors or intermedidate events in this industry are
formed by the human element, faulty design, long
replacement times and inadequate explosion relief
(Sam, 2005).
It is obvious that incidents like pipline leakage
occur more frequently than has been reported . This
report contains accidents with consequences being
injuries or fatalities, while accident doccumentation
should include every incidents or near-misses
without consequences. Unlike accidents with
significant material or personal damage, near misses
and smaller incidents are much harder to discover,
even though they may be caused by the same
conditions and therefore be represented by the same
scenarios. Identification of holes in barriers requires
more details of input rather than was reported here.
Loss of containment is the most frequent scenario
type in this case. Pipelines have cosiderable potential
for accident in this industry. The frequency of
accident in this part of utility are the highest
(Ghazinoory & Kheirkhah, 2008). There are some
reasons. Firstly, this cases have very long pipelines
as part of their plant. For example, one Iranian oil
and gas plant has almost 5000 km of pipeline.
Considering 5 similar oil and gas plants in this
region, the total length of pipeline would be about
25000 km. Maintenance and repairing such a large
spread network of pipelines needs considerable
effort by operations, plant management and adequate
financing. Defects in every one of the factors
mentioned above have the potentiol for and incident
which can sometimes have catastrophic
consequences. Secondly, the crude oil in this plant
contains H2S, and CO2 either of which cause acidity
and thereby increase corrosion. Finally, usually, all
pipelines have a limited useful life. They should be
in limited service but because of a number of
limitations, these pipelines were not replaced and
have had to continue in operation after their useful
design life.
Sharing of past major incidents with other oil and
gas industries provides useful input data for similar
process industries in order to identify the most
critical barriers and improve their safety processes.
One poignant example highlights this matter. In
1998 there was an accident in the gas compression
stage of a Middle East oil and gas plant which
caused 7 dead as a result of fuel accumulation and
vapor cloud explosion which was very similar to the
Texas City Refinery disaster on March 23, 2005 in
which a distillation tower was overfilled and an
uncontrolled release of hydrocarbons led to a major
explosion and fires. Fifteen people were killed and
180 were injured in the worst disaster in the United
States in a decade. In both incidents, excess
hydrocarbons were diverted into a pressure relief
system that included a blow-down stack. In the
Iranian case, it was equipped with a flare, but one
which the operator didn’t ignite; in Texas City the
blowdown stack was not equipped with a flare to
burn off hydrocarbons as they were released. As a
result, the flammable overflow from the tower
entered the atmosphere. Ignition of the escaped
hydrocarbons was enabled by startup of a nearby
vehicle resulted in the explosion and subsequentfires
(Hopkins, 2008). This example shows the repetitive
patterns of accidents, and root causes of events in all
over the world in this sector. The lesson of this paper
is that accidents in one coutnry, where the scenarios
are very similar, can serve as lessons to prevent the
same scenario being actualized in other countries.
Table 1. A list of major accidents in a Middle East oil company between 1983 to 2009 (refered from
NISOC, 2011).
Death (d)
Accident Plant/ Scenario
Year Unit Event Chemical injuries Initiating event
type transport type
(i)

Leakage of Leakage of Failure in con-

wellhead
1991 wellhead Operation TOX (H2S) Oil- Gas wellhead sep- 2d trol valve, hu-
separator
separator arator man error

Electrical and
Fire of oil mechanical con-
Oil- water Fuel accumu-
1983 water separa- Operation Fire oil 1i trol failure of
separator lation ,
tor Vertical pump ,
human error

Drain of gas-oil
Fire of gas gas oil Improper
1993 Operation Fire gasoil 1d with gasoline
oil tank tank drain
pump

Fire of oil oil supply Uncontrolled

1994 Operation Fire oil - Control failure
supply tanks tanks reaction

Fire of Physical
degasing Control failure,
1997 degasing Operation Fire Oil- Gas damage of 1d
tank human error
tank flange

Electrical low volt-

fire of low age Hurricane , con-
2008 Operation Fire - - -
voltage switch trol failure
switch room room

Gas loss Seal leak, hu-

1991 Operation LOCA Pipeline Oil- Gas LOCA 1d
(LOCA) man error

LOCA of gas Failure in me-

gas well
1993 well pipe- Operation LOCA Gas LOCA - chanical integri-
pipelines
lines ty

Rotating of
crude oil
floating roof Physical
1995 Operation - storage oil - Control failure
of crude oil damage
tank
storage tank

Filure control(
Fire of fuel fuel tank- Improper drain without
1987 Operation Fire oil 1d
tanker (oiler) er (oiler) drain bonding fire),
human error

Pipeline &
LOCA dur- Human error ,
1988 mainte- LOCA pipeline oil LOCA 1d
ing pigging control failure
nance Unit

Pipeline &
1989 LOCA mainte- LOCA pipeline Gas, H2S LOCA 1d Control failure
nance Unit

Pipeline & 1d,

1999 Loss of gas LOCA pipeline Gas LOCA Control failure ,
mainte- some i
 Death (d)
Accident Plant/ Scenario
Year Unit Event Chemical injuries Initiating event
type transport type
(i)
nance

Pipeline & Human error,

LOCA in 18"
1990 mainte- LOCA pipeline NGL LOCA 4i physical dam-
pipeline
nance age

Pipeline &
Fire, LOCA, Control failure ,
1996 LOCA mainte- Pipeline Oil, Gas LOCA -
Fire human error
nance

Pipeline &
19602 Control failure ,
1989 LOCA mainte- Fire Pipeline Oil LOCA
barrel human error
nance

Oil release
Pipeline &
LOCA in Control failure ,
1988 mainte- Pipeline Oil LOCA -
12"pipeline Oil dis- human error
nance
charge

Oil release 1d,

Pipeline &
Sour oil Excessive >1500 Control failure ,
2008 mainte- Pipeline Oil, H2S
leakage Oil dis- pressure 0 bar- human error
nance
charge rel

Fire of gasoil Fire & ex- Gas-oil Human error,

1993 NGL plant Gasoil Reaction -
tanker plosion tanker control failure

Physical
Gas loss in Fire Control failure ,
2002 NGL plant manifold Gas, LPG damage (cor- 1i
20” manifold &Explosion human error
rosion)

Electrical switch
fire in switch room of
1981 NGL plant Fire - _ 2i Human failure
room of pro- propane
pane cooling cooling
Physical
damage (cor-
1995 Berners fire NGL plant Fire Burners NGL - Failure control
rosion) of
burner tubes
Human failure ,
Vopor cloud NGL Rupture &
1992 NGL plant VCE Gas, NGL 2d mechanical fail-
Explosion plant vent open
ure
NGL Loss of con- Human error ,
1990 Gas loss NGL plant Rupture Gas, NGL 1d
plant tainment control failure
explosion Fire, Explo- Fuel accumu-
1998 NGL plant - - 7d Control failure
and car fire sion lation
Fire and ex- Gas com- Physical
high gas
plosion in pression Fire, Explo- damage ,Loss
2000 compres- Gas Control failure
high gas sta- sion of contain-
sion
compression tion(GCS) ment
Gas com-
Human error,
pression
2000 Gas leakage Leakage Pipeline Gas Drain open, 1d Mechanical
sta-
failure
tion(GCS)
 Death (d)
Accident Plant/ Scenario
Year Unit Event Chemical injuries Initiating event
type transport type
(i)

Well Blow- Excessive Control Failure ,

2001 Drilling Blowout Well Oil, Gas 1d
out pressure human error

Electrical Electrical fail-

Distilla- Electrical Electrical
1993 fire of D.C Fire Unit 1i ure, Human
tion Plant board failure
room failure

Electrical
high volt- Welding and
fire of high Oil Boost-
1991 Fire age D.C - cutting igni- - Human error
voltge D.C er station
room tion
room

Driving with-
Transpor- Human error,
1989 Car accident Car accident - - out permis- 1
tation control failure
sion

Minibus ac- Transpor-

1989 - - - Overcome 3 Human failure
cident tation

muck trailer Parking a

Transpor-
1992 accident in - Well oil muck trailer 1 Human failure
tation
well location in sharp ramp

car accident Transpor- Car acci- Deviation to

1993 - - 1 Human failure
and fire tation dent, Fire left side
Fire caused
by bulldozer Transpor- Physical Human failure,
1985 Fire pipeline oil -
crash with tation damage control failure
10" pipeline
Fire caused
by bulldozer Transpor- Physical Human failure,
1992 Fire pipeline Oil -
crash with tation damage control failure
16" pipeline

rig carring
Transpor- Truck acci-
1990 trunk acci- - - Deviation - Human failure
tation dent
dent

Coil tubing
Transpor- truck acci-
2000 truck acci- - - Deviation - Human failure
tation dent
dent

Operation Transpor-
1999 Fire pipeline Oil Deviation 1d Human failure
pipeline fire tation

Crane boom
Crane crash Crash with
crash with Transpor-
with high - - high voltage 1d Human failure
high voltage tation
voltage wire wires
wire

Chlorine
Water Seal leak, Mechanical
Chlorine leakage
1985 treatment - Chlorine physical - failure , control
leakage from cylin-
plant damage failure
der
 Death (d)
Accident Plant/ Scenario
Year Unit Event Chemical injuries Initiating event
type transport type
(i)

Pharmaceu-
Water Pharma-
tical stor- General Control failure,
1981 Fire treatment ceutical Reaction -
age(supply) accident human error
plant Chemical
fire

Spontaneous
Chemical General Utility failure
1996 Fire Storage Chemical ignition, Re- -
storagefire accident and human error
action

General Smoking Ig- Control failure,

1996 Storage fire - Storage -
accident nition human

Figure 1. Comparison of major accidents in Middle Eastern case with world accidents in oil and gas
industry
Abrreviation: F: Fire; EX: Explosion; FB :fireball; BLEVE :boiling liquid expanding vapor explosion; DET :detonation (internal explosions
only); HEX :high explosive explosion; IE :internal explosion; REL :release ;TOX :toxic release ;VCE :vapor cloud explosion ;VCF :vapor cloud
fire; VEEB :vapor escape into, and explosion in, building, B:blowout
developed industries which documented and
published their earlier failures (Hopkins, 2008).It is
CONCLUSION
better to start to think about accidents in another
In summary, the existence of scenarios is an aid perspective. Blaming people and considering the
to reduction of uncertainty. They provide a way of technical casues of accidents in isolation is a blind
dealing with different aspects of a problem alley for the prevention of accidents. It is necessary
simultaneously. By utilizing scenario, the analyst to consider the role of other important factors such
might be able to explore systematically and as culture, organization decision making and
managers and stakeholders think about new management in different level of company, all of
possibilities (Wack, 1985). these can be captured in the scenarios that do no
Oil and gas plants are a major strategic industry contain individuals or specific machinery, but rather
in all over the world. Every country has emphasize the causal conditions and sequences that
confidentiality about public reporting about or even lead to incidents or even catastrophes As an example
of accidents and this is one contributing factor for of how to improve matters such as informstion
repeating accident with the same root or contributing sharing it is noted that the oil and gas Ministry has
causes in other plants. As Hopkinsmentioned, failure started to have a complete incident database or at
to learn occurs even though there is a ”depressing least incident investigation report with more precise
sameness” in the scenarios. It is more unfortunate and complete information (NISOC, 2011)
that this failure continues to happen, even in
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