Professional Documents
Culture Documents
Aurelia MA., Kharaini LD. & Yasmin AOA
Aurelia MA., Kharaini LD. & Yasmin AOA
TABLE OF
CONTENTS
Background
The incident
No pressure No calculations
happened during
testing was carried were undertaken
start up when
out on the installed for the dog-legged
critical decisions
pipework shaped line or for
were made under
modification. the bellows.
operational stress.
FAILINGS IN TECHNICAL MEASURES
Operating Maintanance
Design Code
Procedures Procedures
use of flexible
number of critical recommisioning
pipes
decisions to be
made
AFTERMATH
Since the accident took place at a weekend
there were relatively few people on site: of
the 72 people on-site at the time, 28 were
killed and 36 injured. Fires continued on-
site for more than ten days. Off-site there
were no fatalities, but 50 injuries were
reported and about 2,000 properties
damaged.
LESSONS TO BE
LEARNED
Special care should be Plant should be
taken when decisions
designed and run to
have to be taken which
minimise the rate at
would normally be
which critical
taken by or on the
management
advice of the holder of
the vacant post decisions arise