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Retrospective of the Incident – Part 6: Fire Incident at the Propylene Loading Station Truck

2016-06-08View Original

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This post was last edited by Ma Boyou on 2016-6-28 at 15:21. 1. Account of the incident: Around 18:10 on July 24 of a certain year, the rainwater drain located on the east side of our company’s railway unloading quay suddenly caught fire. The flames spread rapidly along the rainwater drain toward the gasoline loading area, setting fire to 4 tank cars that were in the process of loading gasoline. Upon receiving the alarm, the company’s fire team rushed to the scene immediately to extinguish the fire and cool down the surrounding tank trucks. A few minutes later, the local fire department arrived and joined in the firefighting efforts; the fire was put out after 2 hours. Thanks to prompt response, no greater losses or casualties occurred. 2. Accident losses: 4 railway tank cars were destroyed, resulting in a loss of approximately 230 tons of finished gasoline, with direct economic losses amounting to around 4.5 million. Due to the intensity of the fire, it appeared from a distance as if the tank area was on fire, causing great panic among the residents in the vicinity and having a very negative impact on society. 3. Accident cause analysis: At 17:00 on July 24, the oil loading and unloading team received a dispatch instruction to transfer gasoline into 4 tank cars at Line 4 for light oil loading. The loading pump was started around 17:30, and the transfer operation commenced. When the operator on duty saw that the gasoline had been poured into the tank truck, he left his post without permission to go to the lounge for dinner, planning to resume the filling process once the approximate time he usually used for such tasks had passed. In the past, it took about 50 minutes to fill 10–12 tank cars, while this time it only took around 30 minutes to fill 4 tank cars. Post-analysis, around 18:00, the 4 tank trucks were filled to capacity, and the spilled gasoline flowed into the rainwater drain, moving northward along it. The gasoline in the drain reached a pipeline gallery about 400 meters away; acetylene cutting operations were taking place above that gallery, and hot molten iron splashed into the rainwater drain, causing debris there to catch fire. This ignited the gasoline, which then spread along the rainwater drain to the tank trucks, setting them on fire and resulting in the accident. 4. Lessons from the accident: Weak production management, as well as operators leaving their posts during the loading and unloading process, which led to gasoline spilling, were the direct causes of this accident ; Due to the lack of requirements for sealed loading at that time, during previous transfer operations, issues such as oil dripping from flexible hoses and spills of oil vapor often triggered alarms from the combustible gas detectors. Operators would shut down the alarm sounds on their own, which prevented timely detection of gasoline spills; this was also the main cause of this accident ; The cause of the fire in this accident was that the pipeline construction unit failed to cover the rainwater ditches in the construction area in accordance with safety requirements, and failed to extinguish promptly the small fires caused by debris in those rainwater ditches during construction.
Reply #22016-06-08
Moderator, do you find it complicated and difficult to post here? It’s even more complicated when trying to insert images – what on earth is that advanced mode?
Reply #32016-06-08
Posting in advanced mode is more convenient and comprehensive
Reply #42016-06-08
In advanced mode, after entering the title and content, clicking results in a message stating that there is no title or content
Reply #52016-06-08
Yes. By improving gradually, you will get used to it eventually
Reply #62016-06-08
I finally found the title bar that had been so carefully hidden in advanced mode, and I also typed several dozen characters of text, but when I clicked send, it prompted that the content was less than 2 characters!
Reply #72016-06-09
When such problems occur, they are always attributed to operator errors. Why not reduce the likelihood of human mistakes from a technical perspective, for example by installing high liquid level interlocks or limiting the amount of material that can be loaded based on the tank’s capacity? This time it was because of going to eat; next time it might be due to being busy with work and having to do other things, or it could be because of needing to use the bathroom.
Reply #82016-06-09
I’ve learned it, thanks for sharing! ^_^
Reply #92016-06-09
It’s clearly a violation of rules and regulations – so why is it being labeled as an operational error? Is it also a mistake to disable the combustible gas alarm without authorization?
Reply #102016-06-09
This post was last edited by Security Door on 2016-6-9 at 16:46. It’s normal for people to make mistakes; but can you guarantee that no mistakes will be made if you’re the one to carry out the tasks? Regarding the potential risks associated with these routine operations, designers or management should take more reliable measures instead of blaming people for making mistakes. Flammable gas detectors are a post-event measure, not a pre-event one; the management responsible for sound control bears no responsibility. Why was it not detected? Why were there no control measures in place? Stop blaming the operators all the time; they earn low wages and do the hardest work, so why should they bear all the responsibility when something goes wrong?

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