Accident: BP Amoco Thermal Decomposition Incident
Location: Location: Augusta, GA
Accident Occurred On: 03/13/2001 | Final Report Released On: 05/20/2002
Accident Type: Oil and Refining - Reactive Incident
Investigation Status: The final report on this investigation was approved on May 20, 2002.
On March 13, 2001, three people were killed as they opened a process vessel containing hot plastic at the BP Amoco Polymers plant in Augusta, Georgia. They were unaware that the vessel was pressurized. The workers were killed when the partially unbolted cover blew off the vessel, expelling hot plastic. The force of the release caused some nearby tubing to break. Hot fluid from the tubing ignited, resulting in a fire.
Communicate the findings of this report to your membership.
Communicate the findings of this report to your chemical and plastics manufacturing facilities in North America.
Examine the manufacturing businesses acquired from
BP Amoco Performance Polymers and ensure that a systematic safety review procedure is developed and implemented for identifying and controlling hazards from unintended chemical reactions. Additionally, ensure that reactive hazards are identified and evaluated:
- During product R&D, during conceptual design of a new
process, and during detailed design of a new process.
- Before changes are made to existing equipment or process
- Communicate the results of this review to the workforce.
Ensure that a program is in place at facilities acquired from
BP Amoco Performance Polymers to systematically review the
hazards associated with new and modified processes and equipment as operating experience accrues. Ensure that facilities correct all identified design, operation, and maintenance deficiencies. Verify that operating experience does not invalidate the design basis for equipment.
Revise the Material Safety Data Sheet (MSDS) for Amodel to warn of the hazards of accumulating large masses of molten polymer. Communicate the MSDS changes to current and past customers (who may retain inventories of this product).
Implement a program to conduct periodic management reviews of incidents and near-miss incidents. Look for trends and patterns among incidents. Address root causes and implement and track corrective measures.
Revise process safety information to include:
- Information regarding the decomposition reactions of Amodel.
- Design intent, basis, capacity, and limitations of equipment.
- Hazards and consequences of deviations from design intent and operating limits.
Revalidate hazard analyses for the Amodel process to address:
- Credible deviations from process intent and their
- Hazards associated with startup and shutdown operations.
- Prevention of accumulations of potentially hazardous masses of polymer.
Revise your lockout/tagout program to ensure that equipment is
rendered safe prior to opening for maintenance. At a minimum,
ensure that equipment opening procedures contain a stop work
provision that requires higher levels of management review and
approval when safe opening conditions, such as equipment
depressurization, cannot be verified.
Ensure that your management of change policy applies to operational and procedural modifications.