Buncefield Oil Terminal Explosion_1

Buncefield Oil Terminal Explosion_1

1. Design Life Cycle

   • Detailed Design
     • Storage Capacity
     • Controls
     • Pumps
     • Tank Lid
     • Materials used
     • Fuel tank storage and transportation
   • Construction
     • Materials
       • Tanks
       • Fuel pumps
     • Manufactoring
       • Workers
     • Function
       • Design Lifecylce
       • Usability of systems
   • Commissioning
     • Testing
     • Transportation of Storage Tanks
       • Via road tank or pipleines
     • Maintenance
   • Operating
     • Controls
       • Level Gauge
       • Monitoring systems
     • Operator Skill/Requirements
     • Function
   • Maintaining
     • Parts/Repair
     • Service Requirements
   • Decomissioning
     • Tanks
       • Only for qualified and competent technicians
         • tank must be fully drained, degassed and certified

2. What Happened

   • 19.00, Tank 912 started receiving unleaded motor fuel; pumping at about 550 m3/hour (***)
   • 3:00, Tank fuel levels recorded unchanged reading, yet still continued to be fuelled
   • 05.20 Tank 912 would have been completely full. It now began to overflow (***)
   • 05.38 vapour from the escaping fuel is first visible in CCTV footage
   • 05.46 the vapour cloud had thickened to a depth of about 2 m and was flowing out of storage site onto all directions
   • At 06.01 the first explosion occurred, followed by further explosions and a large fire that engulfed over 20 large storage tanks.
   • The fire burned for several days, destroying most of the site, 2,000 homes were evacuated and 92 neighboring firms were affected

3. Why it happened

   • Failures
     • People
       • Individual Factors
         • Designers and suppliers of independent level switch were poorly trained
         • The site operator did not exercise sufficient oversight of the ordering, installation and testing procedure
     • Workplaces
       • Workplace Factors
         • There was only one visual display screen for all the tanks which meant that the status of only one tank could be fully viewed at a time
         • lack of engineering expertise on site
       • Equipment Design
         • Automatic Level Gauge (ALG) did not function
         • Independent level switch was inoperative
           • Critical Padlock not fitted
         • On the tank screen mimic a red ‘stop’ emergency shutdown button was showed.
           • this was not working and had never been fitted into the system.
       • Work Environment
         • The ATG system hadn’t the set the alarm in the event of inconsistencies between tank level measurements and filling data
         • The lack of a maintenance regime
     • Management
       • Organisational/System Factors
         • None of the staff at the site was aware of the need for the padlock to be replaced
         • failure to implement management of change processes
       • Job Design
         • Poor shift working times meant workers were exhausted
         • poor communications at shift handover
       • Information transfer
         • Tank storage supervisors did not have access to monitoring screens - Lack of control of incoming fuel
         • No written evidence on which the tanks had to be filled

4. System Parts

   • Tank
     • Vents on Tank roof
     • Automatic Level gauge
       • measured the rising level of fuel and displayed this on a screen in the control room
     • Access Hatch
     • vertical, cylindrical, non-refrigerated, above-ground
     • side walls greater than 5 m in height
     • Tankers operating from Buncefield were of 44 or 18 tonnes capacity
   • Staff
     • Tasks
       • Operators monitored the arrival of the various grades of fuel and separated them out into dedicated tanks by fuel type
     • Training
   • Oil Pumps
     • Independent High-level switch
       • Alarm Circuit
       • Check Lever
       • Critical Padlock
   • Storage and transfer depot
     • e three pipelines all transported fuel products in discrete batches, separated by an interface or buffer of mixed product
     • interface of mixed fuel was diverted to special small tanks to be reinjected into the main large storage tanks
     • separated products left the depot either by road tanker or, in the case of the majority of aviation fuel, via two dedicated pipelines