| Case Name |
Fire of methanol leaked from piping removed accidentally due to welding sparks |
| Pictograph |
|
| Date |
December 26, 1991 |
| Place |
Sayama, Saitama, Japan |
| Location |
Chemical factory |
| Overview |
On December 26th, 1991. In an adhesives manufacturing plant, methanol was returned as usual from a reactor to a tank. However, because the piping was open, methanol flowed out, and it was ignited by welding sparks. The cause was removal of the wrong piping during revamping work. A mistake during lineup directly led to the accident. |
| Incident |
At a plastic glue manufacture plant, methanol was returned as usual from a reactor to a methanol tank. However, the piping was removed accidentally and a joint was opened. Methanol flowed out, was ignited by neighboring welding sparks, and there was a fire. Refer to Fig2. |
| Processing |
Manufacture |
| Individual Process |
Maintenance |
| Process Flow |
Fig2.Sketch of the facilities
|
| Substance |
Methanol, Fig3 |
| Type of Accident |
Leakage, fire |
| Sequence |
On December 21st, 1991. The person in charge of construction directed the revamping for equipment extension. At this time, he accidentally ordered that the wrong piping should be removed. Consequently, necessary piping was removed.
About 11:30 on December 26th. The pump started to return 1500 L of methanol in the reactor to the methanol tank for washing. The tank was temporarily used for revamping. Methanol flowed out of an open joint (100 L per minute). Methanol arrived at a welding site about 4 m apart. It was ignited by welding sparks, and a fire occurred.
As initial firefighting with a fire extinguisher was not successful, a foam extinguishing system started after employees evacuated.
11:42. The fire was extinguished.
11:43. The fire was reported to the public fire fighting department by an emergency call. |
| Cause |
The person in charge of construction accidentally ordered the wrong piping to be removed.
Line-up before work was neglected.
Line-up: Checking opening and closing of all valves of related piping and apparatus before starting work. It is one of the most important basic tasks. |
| Response |
Initial firefighting with a fire extinguisher. Employees evacuated. The foam extinguishing system started. Notice to fire fighting department was given. |
| Countermeasures |
There should be more than one responsible person working together for the revamping work. Communication during transfer work should be improved. A joint must not be opened even if the piping is unnecessary.
The most important measure is to practice and understand the lineup. |
| Knowledge Comment |
When changing construction of piping, it is indispensable to make a record and correct piping drawings.
The end of piping is closed in principle.
Those who try to understand the whole system tend to doubt whether directions in a document or work orders are correct. |
| Background |
1. Although revamping work was executed in two buildings, the situations of both buildings were not grasped. The administration of construction was a problem.
2. In spite of transferring combustible material to a place where hot work was being done, line-up was not fully performed.
3. Piping, which should not be removed, was removed by mistake. The person in charge would have noticed the error, if an operating staff was present. |
| Incidental Discussion |
It is hard to expect incorrect directions written in a document to be corrected. Caution is required when making a document.
Naturally, there will be a witness of the operation side. Even then, if the piping to be removed is mistaken, he has to study the difference between the witness and only a person at the place. |
| Reason for Adding to DB |
Example of leakage and fire caused due to piping removed by mistake at revamping work |
| Scenario |
| Primary Scenario
|
Organizational Problems, Poor Management, Slackness of Management, Misjudgment, Misperception, Mis-Convincement, Poor Value Perception, Poor Safety Awareness, Inadequate Risk Recognition, Usage, Maintenance/Repair, Wrong Indication, Regular Movement, Careless Movement, Wrong Line-up, Secondary Damage, External Damage, Leakage/Fire, Loss to Organization, Economic Loss, Direct Monetary Damage 54 million yen
|
|
| Sources |
Fire and Disaster Management Agency, Main accident case, Methanol fire. Methanol spouted from detached piping due to error, was ignited by welding spark, Accident cases of dangerous materials. pp.33, 62-63.
|
| Physical Damage |
A building including a methanol tank was partially damaged by fire. Facilities, a power cable and measuring devices were damaged by fire and water. |
| Financial Cost |
¥ 54 million. (Accident examples of dangerous materials) |
| Multimedia Files |
Fig3.Chemical formula
|
| Field |
Chemicals and Plants
|
| Author |
ITAGAKI, Haruhiko (Japan National Institute of Occupational Safety and Health)
TAMURA, Masamitsu (Center for Risk Management and Safety Sciences, Yokohama National University)
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