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July 17
th
,2014

July 17
th
,2014 LATE DATE

MATRIC No. 1310028
SURNAME GADDA
FIRST NAME(S) SALIM
COURSE & STAGE
Eg MSc Oil & Gas Engineering
MSc Drilling & Well Engineering


Full Time
MODULE NUMBER & TITLE ENM302 / SHERA
ASSIGNMENT TITLE
Case Study of DuPont Explosion
discussion of the explosion as an accident waiting to happen
LECTURER ISSUING COURSEWORK Mr. Mohammed Kishk

I confirm: (a) That the work undertaken for this assignment is entirely my own and that I have
not made use of any unauthorised assistance.
(b) That the sources of all reference material have been properly acknowledged.
[NB: For information on Academic Misconduct, refer to
http://www.rgu.ac.uk/academicaffairs/assessment/page.cfm?pge=7088]


Signed .. .....SALIM GADDA........................ Date........... July 17
th
,2014..................


Markers Comments















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ENM302/SHERA Coursework
By: SALIM GADDA
1310028


July 2014

i

Table of contents
























1. Introduction................................................................... 1
2. Safety Management System & Industrial Disasters........ 1
3. Accidents Causation.
2
4. Case Study: DuPont Explosion...
2
4.1 Accident Date & Site............................................................ 2
4.2 Sequence of Events Description............................................. 3
4.3 Accident Results................................................................. 4
4.4 Root Causes of the Explosion................................................ 5
4.5 Was DuPont Explosion an Accident Waiting to Happen?
Could it have been avoided?...............................................

6
4.6 Lessons Learned from DuPont Explosion................................ 7
4.7 Recommandations................................................................ 7
5. Conclusion.....................................................................
8
References...........................................................................
9

ii



List of figures




List of abbreviations

CSB U.S. Chemical Safety and Hazard Investigation Board
U.S United State of America
VF Vinyl Fluoride
SMS Safety Management System

















Figure 1: Storage tanks.............................................................. 3
Figure 2: The two contractors began the repair activity on tank 1.... 3
Figure 3: During the welding activity; Vinyl fluoride was flowing
inside tank 1 (a), and welding sparks were falling into the same tank
(b)..............................................................................................


4
Figure 4: A sudden explosion occurred......................................... 4
Figure 5: Work place before and after the explosion...... 5

iii






Executive summary

This short paper deals with a case study proposal about an industrial
disaster which is discussed as an accident waiting to happen. The
discussed disaster is DuPont Explosion; this is an explosion of a
flammable vapour in DuPont plant near Buffalo in New York that
happened on the morning of November 9
th
, 2010 when a hot work
activity was taking place (welding operation). The explosion involved
death and injuries.
The case study is developed and discussed in the context of an industrial
accident(s) in such a way that the report first covers; a safety
management system, its key elements, what should it do, and then
followed by developing accidents causation. Next, this report covers the
proposed case study in terms of explosion date & site, events description,
root causes, was DuPont explosion an accident waiting to happen?, could
it have been avoided?. At the end, some recommendations are covered
including those made by the CSB (U.S. Chemical Safety and Hazard
Investigation Board) are covered.



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1. Introduction
Safety Management System can be established for all sorts of sectors
(business and/or industry) and the safe functioning of each organisation
from these sectors is based upon its overall management. A good Safety
Management System cannot stop the accidents from happening because
it is not perfect. However, learning from previews accidents and then
reviewing the safety management system itself can at least minimize the
accidents from happening. Most of these accidents are caused by the
human being who is not perfect as well, most of the investigations have
proved that human errors were the root causes.
In this report, a proposal of case study will be discussed highlighting the
causes making the explosion as accidents waiting to happen leading to
accidents, and if so how could these accidents have been avoided.

2. Safety Management System & Industrial Disasters
The SMS(s) term stands for Safety Management System(s), which refers
to a comprehensive integrated system which ensures that all work can be
performed safely (i.e. considering the safety of people, equipment,
environmentetc.) based upon its key elements which are as follows:
Policy: set a clear directions to be followed by the organisation.
Planning: an effective arrangements to deliver the Policy key
element.
Implementing: policies & procedures are put in place.
Assigning: measurement of performance & improvement.
Management Review: lessons learned and apply them.
All these aim to identify, prevent, deal with and mitigate risks before,
while and after doing any activity. So, the SMS should do:
Define safety roles and responsibilities;
Ensure adequate skills;
Maintain awareness of hazards and risks;
Plan, implement and evaluate;
Develop performance requirement and set targets for improvement;
Manage changes;
Manage and maintain knowledge; and
Review and improve the SMS itself.
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3. Accidents Causation
Different causes can contribute to accidents, some can be considered as
primary causes which are known as Root Causes, and others can be
considered as secondary causes. This does not mean that only the root
causes are sufficient for the accident to happen, but any cause, a root
cause is or not, can be sufficient to cause the accident alone or
contributing with other causes together.
The causes of accidents can be categorized into three main groups; these
can be a technical failure, human errors or organizational failure and all of
them can lead to dangerous situations. Among the causes within these
groups the following:
Technical failure: poorly designed equipment, poor preventive and
systematic maintenance and whatever is the equipment, service
companies try to makes it reliable and last as long as possible, but it
is like the human being, it might break down and no one know
when.
Human errors: these can be divided into be intended or
unintended actions:
Within the intended actions violations and mistakes, and within the
unintended actions lapses and slips. Within all these; work under
pressure, overwork (doing too much), lack of training, violation of
legal requirement, communication problems, intention, conflicts,
exhaustion, memory lapses, noisy work place, ignorance,etc.
Organizational failure: bad safety management system, poor
management of change, lack of leadership competence within
groups.etc.

4. Case Study: DuPont Explosion
4.1 Accident Date & Site
On the morning of November 9
th
, 2010, a flammable vapour explosion
took place at an E.I. DuPont de Nemours and Co. Inc., Yerkes chemical
facility near Buffalo in New York. The explosion happened when a welding
activity was being performed on the top of one of the storage tanks
(10,000 gallon) containing flammable Vinyl fluoride (VF). Two contractors
were involved in the welding activity, when they were so doing welding
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Figure 1: Storage tanks
Figure 2: The two contractors began the repair activity on tank 1
sparks entered into the tank, ignited the contained flammable vapour and
caused the explosion.

4.2 Sequence of Events Description
On the morning of November 9
th
, 2010, at around 9 am two contractors
(a welder and a foreman) began the repair activity; the welder started
the grinding and welding repair work on the top of tank 1 and the
foreman was looking at him from the nearby catwalk. At approximately
11 am when the welder was working, (using an electric arc welder)
sparks were falling inside the tank and suddenly the flammable vapour
ignited and exploded. The explosion blew the tank cover 100 feet away.
Minutes later, the fire self-extinguished after consuming all the
flammable vapour.






















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(a) (b)
Figure 3: During the welding activity; Vinyl fluoride was flowing inside
tank 1 (a), and welding sparks were falling into the same tank (b)
Figure 4: A sudden explosion occurred




























4.3 Accident Results
The explosion was tragic; firstly, it involved death and serious injuries
(killing of a contract worker and injuring another). The welder was killed
instantly and the foreman was seriously injured; his arms and head were
burned, one of his eardrum was burst and one of his eyes was scratched.
In addition to the death and injuries the vinyl fluoride tank destroyed and
the DuPont plant stopped producing for a period of time.

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Figure 5: Work place before and after the explosion












4.4 Root Causes of the Explosion
- The DuPont technician only monitored the atmosphere around and
above the tank and did not monitor its interior. Therefore the failure to
monitor the interior of the tank was the main root cause that lead to the
explosion as said CSB.
- The vinyl fluoride was leaking from the U- shaped pipe existing inside
tank 2 and found the pathway to reach tank 1. This can be considered
as an equipment failure and poor maintenance cause leading to the
explosion.
- The compressor used for scripting vinyl fluoride was not functioning
properly, the amount of slurry was much more than that of gas. The
personnel were not aware about the improperly functioning of the
compressor.
- Poor maintenance and checking of the equipment according to DuPont
safety procedures.
- A poor safety management system related to hot works was used at
DuPont facility, because the system was not amended learning from
other similar hot works which caused explosions.
- Non rigorous training and permitting procedures were applied by DuPont
plants.
- Use of welding spark producing methods during performing a hot work
activity.

Before,
Everything is OK
After,
Death, injury and
tank destruction
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4.5 Was DuPont Explosion an Accident Waiting to Happen?
Could it have been avoided?
According to CSB investigation on DuPont explosion, all the elements
necessary to cause the explosion were present and the accident was
expected to occur (i.e. the explosion was an accident waiting to happen)
if the preventive measures were not considered at the right time.
Therefore the DuPont explosion could have been avoided if:
- DuPont technician had monitored all the atmosphere around, above,
inside and outside the tank before and even during performing such hot
works. Therefore the failure to monitor the interior of the tank would
not have been the main root cause that lead to the explosion.
- Good maintenance and checking of the equipment had been included
within DuPont safety procedures, there would have been no vinyl
fluoride leaking from the U- shaped pipe existing inside tank 2. Also, the
compressor used for scripting vinyl fluoride would have been functioning
properly; there would have been no much more amount vinyl fluoride
than that of the gas. The personnel would have been aware about the
properly functioning of all the equipment at the DuPont facility
particularly those equipment that have links with the hot work.
- A good safety management system related to hot works had been used
at DuPont facility, analysis and assessment of all potential risks would
have been performed before starting the concerned hot work.
- All process connections, outlets and inlets, on tank1 had been
disconnected and/or completely isolated by closing the adequate valves
before tackling such hot work activities, thus all known and/or possible
sources of flammable materials would have been prevented from
entering the slurry container.
- Enforcing rigorous training and permitting procedures had been
ensured.
- A welding spark producing method had not been used.




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4.6 Lessons Learned from DuPont Explosion
While performing any hot work activity that involves welding, cutting, or
grinding on surface of flammables containers, heat and sparks will be
generated and these can ignite flammables present inside these
containers. Also, before authorizing such activities, a continuous
atmosphere monitoring inside any container previously containing
flammables should be performed regardless to its size.
Any process connection on flammable materials containers or similar
containers can let these materials enter the container at any time if it is
not completely isolated by installing blanks, closing valves and
disconnecting pipes.

4.7 Recommendations
Here we try to give one recommendation or more correspondent to each
cause of the accident (the given recommendations include those made by
CSB to DuPont facilities);
- Atmospheric monitoring is required inside tanks before and while
performing any hot work activity.
- All process piping on tanks are required to be totally isolated before
authorizing and permitting any hot work activity.
- Enforcing rigorous training and permitting procedures.
- Analysis and assessment of all potential risks and hazards should be
performed before starting any hot work.
- Constantly monitoring of the atmosphere for flammables while
performing any activity that involves welding, cutting, or grinding on the
flammable substances containers.
- Create a policy which determines criteria and factors that require a
continuous or periodic testing for the duration of hot work activity.
- Avoiding the use of welding spark producing methods when performing
any hot work.
- Auditing of the whole hot work process including hot work permitting
systems should be ensured before initiating any hot work by
establishing and enforcing corporate-directed policies and procedures.
- High quality maintenance procedures should be established

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5. Conclusion
Based upon the case study (DuPont explosion) which has been discussed
in this report we can conclude that a high efficiency safety management
system can ensure high prevention level of industrial disasters including
hot work activities. And this should include high quality trainings for all
the personnel members including motivations and free work spaces at
acceptable levels in order to minimise and why not to prevent human
errors which are always involved in such disasters.
Overall, although the SMS can be established for all sorts of sectors
(business and/or industry) and it has the importance of reviewing the
accidents and the contributing causes, but having it is not enough even if
it has a high prevention level because it is not perfect and it will never
cover everything. Thus, all of us are responsible for safety, with different
levels of course, we should put in our mind the saying prevention is
better than cure and we should not let and/or ignore anything that can
lead to accidents or make them just as accidents waiting for us to
interfere and prevent them, but in lots of cases it is too late as the case
of DuPont explosion and other similar accidents.


Word-Count: 1746 words.





9

References

CSB Safety video, http://www.csb.gov/e-i-dupont-de-nemours-co-fatal-
hotwork-explosion/, accessed on July 05
st
, 2014.

CSB E.I. DuPont de Nemours & Co Inc. Case Study, January 2011,
Chemical Safety and Hazard Investigation Board (CSB), report No.
2011-01-I-NY.

RGU ENM302 courses with tutor instructions (Mr. Mohammed Kishk).