Investigation and Analysis of a Hazardous Chemical Accident in the Process Industry: Triggers, Roots, and Lessons Learned

This paper performs an in-depth investigation and analysis on a catastrophic hazardous chemical accident involving domino effects in China based on an emerging accident causation model-the 24Model. The triggers and roots of the incident from the individual and organizational levels have been identified and several useful lessons have been summarized to avoid similar mistakes. This accident began with a leak of vinyl chloride caused by the failure of the gas holder's bell housing and the operators' mishandling. Leaked vinyl chloride was ignited by a high-temperature device in the process of diffusion and the fire quickly spread to the illegally parked vehicles. Several organizations were involved in this accident, and the chemical company should bear the main responsibility for it, and shall establish and implement an effective safety management system in its organizational structure and staffing, facilities management, hazards identification, emergency disposal, etc., to improve safety performance in a systematic way. Enterprises in the chemical industry park shall enhance the communication to clarify major hazard installations in their domains, and conduct regular safety evaluation for the plant as the external environment changed. Government agencies shall plan the layout of the chemical industry park scientifically and ensure safety starts with the design stage. The case study provides a practical procedure for accident investigation and analysis, and thus, preventive measures can be made according to the various causations at different levels.