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MOHIT SINGH
06116101413
CT(6TH SEM)
USCT
CONTENT
 When and where?
 Before and after?
 What happened?(*)
 How it happened?(*)
 Result?
 Lessons learned?
 Future action?
WHEN? WHERE?
Introduction
 November 19, 1984
 San Juanico; a suburb of Mexico City
 Pemex State Oil Company
 Storage & Distribution facility for liquefied
petroleum gas (LPG)
ď‚— LPG comes in from 3 different refineries
 54 LPG storage tanks- 16,000m3
ď‚— 6 large spherical tanks
ď‚— 48 smaller tanks of various sizes
 Built to API Standards
Right Before Explosion
 Being filled from a refinery 400km away
 Fall in pressure
ď‚— The cause of the pressure drop was unidentified
ď‚— no one initiated emergency shutdown
Pemex Before
Pemex After
WHAT HHAPPENED
What Happened
 About 0530 hours, 8 inch feed pipe near the
vapor phase of Horton Sphere F-4 ruptured
causing release of LPG.
 Official cause of rupture is unknown .
 Release of LPG continued for 5-10 minutes.
 Gas cloud (200x150 m, height 2 m) found the flare
and got ignited at 0540 hours
 The cloud caught fire over a large area, giving a
high flame and causing violent ground shock.
 Series of explosions followed as vessels suffered
BLEVE. 19 explosions over a period of one and
half hour.
 Numerous missiles generated by the bursting of
vessels. Many of these were large and traveled
far.
The mexico city explosion of 1984
Accident Timeline
 5:30am Rupture of 8 in. pipe;
Pressure drop in control room
 5:40am Ignition of gas cloud; Violent
combustion and high flame
 5:45am First explosion on
seismograph, a BLEVE; Fire
department called
 5:46am Second BLEVE, one of the
most violent
 6:00am Police alerted and civilian
traffic stopped
 6:30am Traffic chaos
Accident Timeline cont.
 7:01am Last explosion on
seismograph, a BLEVE
 7:30am Continuing tank explosions
 8-10:00am Rescue work at its height
 11:00am Last tank explosion
 12-6:00pm Rescue work continues
 11:00pm Flames extinguished on last
large sphere
 10:00am Last fires put out (next day)
HOW?????
Causes of Unsafe Acts and/or
Conditions
 Lack of : Experience , Training
 Poor Supervision
 Laziness
 Distractions
 Personal Pressures :
Your team playing tonight?
Problems at home?
 Human Errors : Forgetfulness
Root Causes
 Official cause of rupture is unknown
 One report cited
 Overfilled tank caused the inlet line to
rupture
 Failure of relief valve
Failings in Technical
Measures
 Plant Layout and positioning of vessels not proper.
 Emergency isolation means not available.
 The Terminal’s fire water system was disabled in
the initial blast. Also the water spray systems were
inadequate.
 The Plant had no gas detection system and
therefore when the emergency isolation was
initiated it was probably too late.
 The traffic chaos hindered the arrival of
emergency services.
The mexico city explosion of 1984
Results
 500-600 deaths; 300+ never identified
 5000-7000 severe injuries
 10,000-60,000 people made homeless
 31 million dollars of damages
 Destruction of 1/3 of the LPG supply to
Mexico City
Results
Results
Lessons Learned
 Old plant, too congested, poor
maintenance & poor operator training
were cited.
 Homes as close as 130m to plant.
Village should have been 1,500 meters
from terminal.
 Require many gas detectors and alarms.
 Emergency plan required
FUTURE ACTION
????
Future Preventions
 Timely inspections
 Maintain industrial standards
 Better maintenance
 Effective operator training
 Housing appropriate distance
away
Future Preventions cont.
 Proper layout of large LPG
storages
 Gas detection and emergency
isolation
 Extra water hydrants in the
streets
 Planned evacuation routes
“There is a saying in Tibetan, 'Tragedy
should be utilized as a source of
strength.'
No matter what sort of difficulties, how
painful experience is, if we lose our
hope, that's our real disaster.”
― Dalai Lama XIV
The mexico city explosion of 1984
References and links
 Arturson, G. (April 1987). "The tragedy of San
Juanico--the most severe LPG disaster in
history". Burns Incl Therm Inj. 13 (2): 87–102.
 Explosiones en San Juanico - YouTube video on
the disaster showing casualty response, burning
LPG spherical tanks, among other things
 PEMEX LPG Terminal, Mexico City, Mexico. 19th
November 1984 - Health and Safety Executive

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The mexico city explosion of 1984

  • 2. CONTENT  When and where?  Before and after?  What happened?(*)  How it happened?(*)  Result?  Lessons learned?  Future action?
  • 4. Introduction  November 19, 1984  San Juanico; a suburb of Mexico City  Pemex State Oil Company  Storage & Distribution facility for liquefied petroleum gas (LPG) ď‚— LPG comes in from 3 different refineries  54 LPG storage tanks- 16,000m3 ď‚— 6 large spherical tanks ď‚— 48 smaller tanks of various sizes  Built to API Standards
  • 5. Right Before Explosion  Being filled from a refinery 400km away  Fall in pressure ď‚— The cause of the pressure drop was unidentified ď‚— no one initiated emergency shutdown
  • 9. What Happened  About 0530 hours, 8 inch feed pipe near the vapor phase of Horton Sphere F-4 ruptured causing release of LPG.  Official cause of rupture is unknown .  Release of LPG continued for 5-10 minutes.  Gas cloud (200x150 m, height 2 m) found the flare and got ignited at 0540 hours
  • 10.  The cloud caught fire over a large area, giving a high flame and causing violent ground shock.  Series of explosions followed as vessels suffered BLEVE. 19 explosions over a period of one and half hour.  Numerous missiles generated by the bursting of vessels. Many of these were large and traveled far.
  • 12. Accident Timeline  5:30am Rupture of 8 in. pipe; Pressure drop in control room  5:40am Ignition of gas cloud; Violent combustion and high flame  5:45am First explosion on seismograph, a BLEVE; Fire department called  5:46am Second BLEVE, one of the most violent  6:00am Police alerted and civilian traffic stopped  6:30am Traffic chaos
  • 13. Accident Timeline cont.  7:01am Last explosion on seismograph, a BLEVE  7:30am Continuing tank explosions  8-10:00am Rescue work at its height  11:00am Last tank explosion  12-6:00pm Rescue work continues  11:00pm Flames extinguished on last large sphere  10:00am Last fires put out (next day)
  • 15. Causes of Unsafe Acts and/or Conditions  Lack of : Experience , Training  Poor Supervision  Laziness  Distractions  Personal Pressures : Your team playing tonight? Problems at home?  Human Errors : Forgetfulness
  • 16. Root Causes  Official cause of rupture is unknown  One report cited  Overfilled tank caused the inlet line to rupture  Failure of relief valve
  • 17. Failings in Technical Measures  Plant Layout and positioning of vessels not proper.  Emergency isolation means not available.  The Terminal’s fire water system was disabled in the initial blast. Also the water spray systems were inadequate.  The Plant had no gas detection system and therefore when the emergency isolation was initiated it was probably too late.  The traffic chaos hindered the arrival of emergency services.
  • 19. Results  500-600 deaths; 300+ never identified  5000-7000 severe injuries  10,000-60,000 people made homeless  31 million dollars of damages  Destruction of 1/3 of the LPG supply to Mexico City
  • 22. Lessons Learned  Old plant, too congested, poor maintenance & poor operator training were cited.  Homes as close as 130m to plant. Village should have been 1,500 meters from terminal.  Require many gas detectors and alarms.  Emergency plan required
  • 24. Future Preventions  Timely inspections  Maintain industrial standards  Better maintenance  Effective operator training  Housing appropriate distance away
  • 25. Future Preventions cont.  Proper layout of large LPG storages  Gas detection and emergency isolation  Extra water hydrants in the streets  Planned evacuation routes
  • 26. “There is a saying in Tibetan, 'Tragedy should be utilized as a source of strength.' No matter what sort of difficulties, how painful experience is, if we lose our hope, that's our real disaster.” ― Dalai Lama XIV
  • 28. References and links  Arturson, G. (April 1987). "The tragedy of San Juanico--the most severe LPG disaster in history". Burns Incl Therm Inj. 13 (2): 87–102.  Explosiones en San Juanico - YouTube video on the disaster showing casualty response, burning LPG spherical tanks, among other things  PEMEX LPG Terminal, Mexico City, Mexico. 19th November 1984 - Health and Safety Executive