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Public Report of the Fire and Explosion at the Conocophillips Humber Refinery on 16 April 2001

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Public Report of the Fire and Explosion at the Conocophillips Humber Refinery on 16 April 2001 PUBLIC REPORT OF THE FIRE AND EXPLOSION AT THE CONOCOPHILLIPS HUMBER REFINERY ON 16 APRIL 2001 Prepared by the Health and Safety Executive CONTENTS FOREWORD...........................................................................................................................................3 EXECUTIVE SUMMARY ........................................................................................................................4 1 THE HUMBER REFINERY.........................................................................................................5 Ownership of ConocoPhillips Limited ........................................................................................5 History of the Refinery................................................................................................................5 Management structure ...............................................................................................................5 Market Conditions ......................................................................................................................6 Risks associated with the Humber Refinery ..............................................................................6 Refinery products .......................................................................................................................6 2 THE SATURATE GAS PLANT (SGP) ........................................................................................7 Description .................................................................................................................................7 Figure 1 - Diagram of the SGP ..................................................................................................7 3 THE FIRE AND EXPLOSION INCIDENT AND EFFECTS.........................................................7 Incident details ...........................................................................................................................7 Figure 2 –The fire and secondary fireball - photo courtesy of Andy Trott..................................8 Initial release and explosion.......................................................................................................8 Effects on site.............................................................................................................................9 Figure 3 – Damage to the SGP after the explosion (W413 column to the right) .......................9 Figure 4 – Damage to adjacent Plant ......................................................................................10 Figure 5 – Close up views of damage to the SGP...................................................................11 Figure 6 – Close up views of damage to the SGP...................................................................11 Effects off site...........................................................................................................................12 Emergency Response..............................................................................................................12 4 OUTCOME OF HSE’S LEGAL ACTION ..................................................................................14 5 INCIDENT INVESTIGATION BY HSE......................................................................................14 Scope of the incident investigation on the SGP.......................................................................14 6 WHAT HAPPENED – THE BACKGROUND OF EVENTS LEADING TO THE EXPLOSION AND FIRE ...........................................................................................................15 Figure 7 – The failed elbow recovered from the plant .............................................................16 Water washing provision on the SGP ......................................................................................16 Design of the Injection point - Pipe P4363 (the pipe that failed)..............................................17 Figure 8 – Diagram of the pipework.........................................................................................17 Figure 9 – In-situ failed elbow and injection pipework connection (broken off) .......................18 Corrosion and Inspection history .............................................................................................18 7 CONOCOPHILLIPS SAFETY MANAGEMENT SYSTEMS .....................................................19 Management of corrosion ........................................................................................................19 Management of pipework inspection .......................................................................................20 Risk based inspection ..............................................................................................................23 Compliance with legislation and standards..............................................................................23 Management of change ...........................................................................................................24 8 CONOCOPHILLIPS RESPONSE AND ACTION .....................................................................25 Immediate ................................................................................................................................25 Longer Term.............................................................................................................................26 9 CONCLUSIONS AND KEY LESSONS ....................................................................................27 Management of pipework inspection .......................................................................................27 Management of change ...........................................................................................................27 Management of corrosion ........................................................................................................27 Communication ........................................................................................................................28 10 KEY LESSONS FOR THE COMPETENT AUTHORITY ..........................................................28 11 HSE SAFETY ALERT...............................................................................................................29 Pipework failure at an oil refinery.............................................................................................29 12 GLOSSARY OF ABBREVIATIONS..........................................................................................30 2 FOREWORD A message from Kevin Allars, Head of Hazardous Installations Directorate Chemical Industries, Health and Safety Executive: The fire and explosion at the Humber Refinery on 16 April 2001 was a very serious event and should serve to illustrate the potential for harm that arises from major hazard plant. As confirmed by Judge Reddihough, when passing sentence on ConocoPhillips Ltd for breaches of health and safety legislation, this incident had the potential to be catastrophic. The immediate area of the refinery was devastated, many other buildings on site were badly damaged and there was widespread damage to surrounding properties, particularly in the village of South Killingholme. Fatalities and serious injuries were avoided only because the incident occurred on a Bank Holiday and at shift changeover time when there were very few people out on site. The investigation revealed a systematic failure to understand the conditions that pipework was operating under, and to appropriately inspect pipework in the Saturate Gas Plant of the refinery. This confirms the vital requirement for companies who operate high-hazard sites, such as oil refineries and chemical plants, to ensure that they have in place rigid, robust and appropriate systems for inspecting pipework to detect corrosion and other defects. The investigation also revealed failings in ConocoPhillips management of change arrangements in that it had not correctly analysed the effects of an operating mode change, and had not recorded it, leading to operators, inspection staff and monitoring staff not being as one to the actual operating arrangements on the plant. ConocoPhillips have co-operated with the Health and Safety Executive in the preparation of this report and so I commend it to a wide audience. In particular people living and working in the vicinity of the refinery will be able to see why the incident occurred and how the company has responded both on the day and with measures to prevent a re-occurrence. There are also lessons in the report for people who manage high-hazard activities, especially those in the oil refinery and chemical industries. In response in particular to questions raised by local Members of Parliament and by professionals working in the petrochemical industry it was agreed that a report of the incident be prepared. This public report into the incident is designed to summarise the events and the investigations carried out by the Competent Authority and by ConocoPhillips. A full description of all the detailed investigative work and legal work are not presented in this report. The report seeks to reassure the public that a thorough and detailed investigation into the cause of the incident has been carried out by all parties concerned. In addition the report is intended to demonstrate that a number of lessons have been learned, both by ConocoPhillips and by the regulators, and actions have been taken in order to improve safety
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