1. Learning from Disasters and Emergency Preparedness
Presented by Mark Fields (Saudi Aramco, Loss Prevention Engineer)
6th Safety & Fire Protection Conference – 9-10 November 2016

2. Learning from Disasters….
Presentation Aims
Learning from Disasters….
Emergency Preparedness
UK Experience, including
How the Buncefield Fire started.
The efforts to put the fire out, (logistics involved).
The lessons learned following Buncefield.
What lessons can be learned
Local / Regional / National Arrangements (Emergency Response)
Human Factors in Disasters

3. Emergency Preparedness
Credible Scenarios!
When developing credible scenarios, some thought should be given to the analysis of Worst Possible Scenarios which may be extremely unlikely.
A greater effort should be on analysis of Worst Credible Scenarios.
According to Kash and Darling: “ it is no longer a question of if a business will face a crisis; it is rather, a question of when, what type, and how prepared the company is to deal with it. Whether it is a natural disaster, such as an earthquake, tornado, or flood, or a manmade disaster, such as a major accident”.
(Recent examples – Fukushima – BP Deep Water Horizon).
Isomorphic Learning – (Learning across businesses that have a similar structure or are involved in similar activities).
Kletz – Not that we don’t know how accidents are caused. More often, we haven’t applied the lessons learned.

4. Emergency Preparedness
Learning from Previous Incidents (Isomorphic)
(A Case Study)
Pre-2005, UK refinery had developed credible scenarios, had a COMAH Plan, and MAPP (Major Accident Prevention Policy).
Local and Regional plans were approved and drills carried out and assessed.
A Shared Fire Fighting facility (two refineries), with up to date hardware (Williams 6 Gun, Foam Trucks and truck mounted foam pods, and a shared fire main with large capacity and fire water reserves).
Well trained and professional team of firefighters equipped with the tools to tackle scenarios identified in the MAPP. The Worst Case Scenario was a full surface crude tank fire.
But Then ……

5. Buncefield Explosion at 0601 hrs 11/12/05 Heard 300km away
Measured 2.4 on Richter scale
43 Injuries – No fatalities
25,000 people displaced from work
2,000 people displaced from home
The UK’s most costly Industrial Accident

6. Emergency Pre – Planning
All planning in accordance with national guidance for this type of facility
Fixed foam installations on some tanks
Foam equipment and concentrate (26,000 litres) on site
Emergency water supplies on site
Fire main on site – charged using two pump houses
Plan had individual sheet for every tank detailing product, capacity, fixed installations and method of foam application
Local crews had been on site six times in the last six months
Planned for a low likelihood but high impact incident (Credible Scenario)?

7. Tank 912
Tank receiving unleaded gasoline from 1900 hrs at 550m3 per hour
At 0300hrs tank gauge remains static
Pumping in continues at 550 m3 per hour
Ultimate High Level alarm fails
At 0520hrs tank is completely full and petrol overflows into Bund A
At 0550hrs pumping in increases to 890 m3 per hour
Explosion at 0601 hours

8. Vapor Cloud Generation
Leak from overfilling
Fuel diverted to tank wall by deflector plate
Droplet fragmentation enhanced by intersection of liquid and vapor
Air loaded with Fuel vapor driven down by liquid spray
Increased surface area allows volatile fractions to evaporate and vapor gathers in the bund.

9. CCTV images of UVC
prior to the explosion

10. The Fire (12 hours after ignition)

11. The Fire (24 hours after ignition)

12. Firefighting

13. Putting the Fire out No fire fighting availability on site.
The fire water and pump houses were destroyed in the UVCE.
National Industry and Local Authority joint response.
24 hours after the initial explosion before the foam attack started.
National assets utilised to fight the fire.
Nearest suitable and available water source was 3 km away.
The logistics involved to be in a position to start fighting the fire went on through the night.

14. 100 million litres of oil product on site
Logistics
100 million litres of oil product on site
25 appliances on site at height of incident
300 appliance movements
1000 different staff
786,000 litres foam concentrate used
68 million litres of water used
53 Million litres clean water and
15 million litres recycled
30km hose laid

15. Logistics Scale of incident beyond capability of a single authority
Needed Regional and National co-ordination
Alternative bulk water supplies
Mobilisation of bulk foam supplies

16. Logistics Mobilisation of National Assets 14 High Volume Pumps
National Command and Control Centre

17. Logistics

18. The Aftermath

19. Some of the Impacts

20. Lessons learned
A detailed and lengthy investigation and clean-up followed the fire. Co-ordinated by the HSE (UK Government body). It took years to complete.
The UK Regulator issues several public reports following the Buncefield Fire, and highlighted 3 main areas of concern.
Design and Operation of Fuel Storage Sites
Environmental Protection Measures
Emergency Planning Scenarios

21. 1. Design and Operation of Fuel Storage Sites
Electronic monitoring of tanks and pipe-work
Detection of flammable vapours near tanks
Warnings for abnormal conditions
Remote operated shut off valves
Storage tank design

22. 2. Environmental Protection Measures
Bund capacity and integrity
Liquid tightness of Bund walls
Effects of intense fire on sealants
Effects of hydraulic pressure on sealants
Plans to control fire water run off
Arrangements for removing rain water
Kerbs and raised areas

23. 3. Emergency Planning (Learning Points)
Review existing Emergency Plans
Include Vapour Cloud Explosions
Identify Resources
Incorporate Regional Resources (where required)
Develop a national framework Document (Fire service). A national major emergency preparedness plan.

24. REGIONAL RESILIENCE FORUMS
Shown Simply
NATIONAL RESILIENCE
REGIONAL RESILIENCE FORUMS
MUTUAL AID AGREEMENTS
REVIEW EMERGENCY PLANS
LOCAL PRE PLANNING

25. UK Response
Fuel storage sites had to respond to the regulator with how they planned to meet the expectations from the Buncefield report, (and they did).
2010 (5 years on) – Not all sites had arranged for the detection of flammable vapours near tanks.
Emergency plans reviewed and Local and Regional arrangements improved (Humber Region).
Difficulties in establishing a National Framework Agreement.

26. What should we learn from this, and other similar Disasters
Vapour Cloud Generation at Fuel storage areas.
It is not unique. Disasters of this type occur every year in the Oil and Gas Industry.
Not all companies/countries are prepared for such disasters, the result =
Multiple Fatalities & Full Facility Loss!
(Jaipur, India 2009).

27. Have the Buncefield lessons been learned
How prepared are you to deal with Major Emergencies at your sites? Buncefield learning – do you have flammable vapour detection near to hydrocarbon storage tanks.
Do you have remotely operated shut off valves.
Warnings for abnormal conditions? (Hi / HiHi alarms).
N.B. Even all of the above does not guarantee that a disaster will not occur – it reduces the probability.
If, or when, (according to Kash & Darling) a disaster of this scale occurs within your organization, how prepared are you?

28. Emergency Planning Some Must Do’s.
Train your organization’s leaders in emergency planning and the development of emergency response plans.
Have local emergency plans, and conduct realistic drills across the sites regularly.
Drill against pre-determined credible scenarios, (including worst case scenario).
Have well trained fire teams with specific / suitable equipment.
Arrange for regional planning, (Consider Mutual Aid Arrangements).
Corporate level – have trained crisis management teams.

29. Human Factors Contributor in almost all Disasters
Tank 912 level was static since 03:00hrs.
Pumping was increased from 550 m3 to 890m3
at 05:50hrs.
Who was monitoring the tank levels?
Only two, (2) operators were covering all operations
at the depot throughout the night.
Initial investigation report was critical of the operators actions, (lack of). And it was suspected for some time that personal prosecutions may follow for the operators involved.

30. Human Factors
The ensuing HSE investigation revealed that “A culture had developed where keeping operations going was more important than safe processes, which did not get the resources, or priority status, they required.”
This re-affirms the point that most major failings can be taken back to management failings.
Management commitment to safety processes (including human factors and competency) is essential in avoiding disasters.
‘Competence is the continuing ability of individuals and teams to perform reliably the MAH elements of their roles, responsibilities & tasks, and for this to be demonstrable against standards’ – Taken from COMAH.
There was no prosecution of individuals, but 5 companies, including Total and HOSL were prosecuted by the HSE, with fines and costs totaling 9.5 million pounds.

31. Iceberg theory in Accident costs
Direct Costs – 9.5 Million pounds
However, the aftermath of the fire had a significant impact on the local economy, with some business closing and others having to relocate. Hundreds of workers lost their jobs. Some families lost their homes.
Total Cost – >1 Billion pounds.
(6 Billion SAR)

32. And Finally – to end on a lighter note…
An army marches on its stomach……….

33. Thank You – Any Questions