9th Latin American Conference on Process Safety

When Emergency Response Goes Fatally Wrong: Lessons Learned from Investigating Two Major Incidents

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Emergency response plans are an essential, yet oftentimes overlooked, layer of protection for facilities where all other safeguards failed to prevent an incident. While catastrophic accidents such as large releases of chemicals, fires or explosions are devastating for the process industry, experience investigating numerous incidents has shown that a lack of an effective emergency response plan can lead to an unnecessary and tragic escalation of the initial incident. More specifically, investigation of two recent incidents: (1) 2013 West Texas Explosion and (2) 2015 explosion on the FPSO Cidade São Mateus; will demonstrate how fatal consequences resulted from the lack of emergency planning in the first case study and from deficiencies in the emergency response plan or implementation of the plan in the second case study. More specifically, the FPSO explosion resulted in 9 fatalities, eight of which were responding to a leak of a light-end hydrocarbon, and the West Texas explosion that resulted 15 fatalities, most of whom were responding to the fire that preceding the devastating explosion. Lessons will show that the fatal consequences could have been avoided with the proper emergency planning. In addition, while emergency response plans consider “maximum credible” scenarios, past events have shown that low probability high consequences should also be at least considered.