One of the major , a number of major incidents stand out – those that had a significant impact on my life and the lives of those involved in those incidents. Major lessons were learned by all involved that would have far reaching consequences.
I will not be able to disclose some of the details for legal and confidentiality reasons, but will describe these unfortunate and catastrophic incidents and their far reaching impacts as best I can, without compromising myself or any of the people involved.
The incident involved a large tank containing Ethanol – an alcohol fuel, but the same ‘innocuous’ liquid contained in a glass of wine! In this incident, the Ethanol exploded and burned furiously for nearly a day and night. This tank was located in a fuel storage terminal operated by a local fuel transport and storage operator.
The tank can only be described as being a ‘behemoth’ of a container (Google definition of ‘behemoth’ is ‘a beast mentioned in Job 40:15–24. Suggested identities range from a mythological creature to an elephant, hippopotamus, rhinoceros, or buffalo
I was at our office, when I was interrupted by the ringing of my mobile phone. It was the Health and Safety Manager who had engaged me to assist with the design of the fire protection systems and operation of that particular tank.
The urgency in his voice, close to panic, set the alarm bells ringing. I was instructed to “check the news, get down to the terminal as soon as possible and bring with you the risk assessment for filling the tank”. His parting comment was ominous;”You may have something to answer for!”
My reaction, I can remember clearly, was one of panic, and I can more easily say this now, overwhelming dread and disbelief. I kept thinking, over and over again; “This could not be happening to me…….!”
I followed the news throughout the day, preparing to travel down to Port Kembla as soon as possible. The news filtering in was that there was a blaze in a seven-million-litre Ethanol tank, sparked by an explosion at a site behind the Port Kembla steelworks, and that it was expected to burn well into the night. The blast had rocked areas up to 25 km away. The fire was massive fire with flames and and black smoke shooting 100 metres into the sky!
Hundreds of workers from a 500-metre radius around the site had been evacuated, for fear the blaze could spread to nearby tanks containing millions of litres of crude oil and marine fuel.
Apparently no-one had been killed in the blast, although a 56-year-old man was taken to Wollongong hospital with minor burns. One man had been feared missing, but was soon accounted for.
“Firefighters were battling the blaze with a defensive strategy of protecting surrounding tanks from radiant heat”, so the news went. The NSW Fire Brigade were shooting “water curtains” around the flames.
It later transpired that 100,000 litres of foam were shipped from Sydney to Port Kembla and an Ericksson Air Crane (helicopter) was deployed to dump firefighting foam into the tank. The New South Wales Fire Brigade Commissioner was later to report that this attempt at extinguishing the fire was unsuccessful – in that the fire was not “smothered”.
“The fire crews worked under conditions of blistering heat”, he said, “to the extent that cars parked on the other side of the road, the rear tail-lights and everything had melted off them – that gives people a bit of an indication of how hot it was, and the firefighters were a lot closer than that. So we had to rotate crews a lot during the night because of that heat problem”.
At its height, the fire shot more than 100 metres into the air and a plume of billowing black smoke could be seen kilometres away.
Eventually, it was reported, the firefighters managed to extinguish the fire “more than 20 hours after it (the tank) exploded into flames”. One man received minor burns, but hundreds of workers were evacuated as a result of the fire.
The blaze was put out early on Thursday morning, but fire crews continued to spray the tank to ensure it did not flare up again. Sixty to 70 firefighters were involved in protecting the six adjoining tanks and any metal surfaces that showed any signs of heating up.
The questions that kept running through my mind were – “had we missed anything?, did we capture all the possible causes for such a fire?; “did we have a feel for the extent of such a fire?”; “could it escalate and involve the entire tank farm?”; “would the community be involved?”; “were we sufficiently thorough in stipulating controls and safeguards and would these be adequate and sufficiently reliable?”
I read and re-read the documents we had produced, analysing each and every conclusion and recommendation, trying to determine whether there could have been any omissions that could have indicated negligence on our part, negligence that would have compromised public safety and the lives of the people working at, and in the vicinity of the terminal during the fire! I wondered if my Professional Indemnity Insurance was fully paid up and sufficiently comprehensive to cover me and our firm against a claim of negligence?
Such fires, by their nature, are to be experienced to be believed! During testing of fire fighting foams for extinguishing fuel fires, we had previously ignited large pans of fuel at an indoors fire testing facility, before pouring foam onto the fire. These relatively ‘small’ fires frightened all observers, including members of the fire brigade – it was impossible to get within 30 metres of such a fire due to the intense radiant heat and overwhelming plumes of black smoke that filled the building rapidly.
I was horrified throughout the day, as the incident unfolded. I knew that such fires can rage for days on end, spewing huge amounts of toxic, pitch black smoke into the environment. Although it was Ethanol burning, I was aware of the potential for escalation. The fire could spread to the adjacent tanks which contain fuels that would generate highly toxic thick black smoke. Such smoke will cocoon the fire so that flashes of orange flame appear unexpectedly and grotesquely. When this occurs, intense radiant heat flashing through the cloud can produce the most dreadful burns and injuries!
During the day, my thoughts turned back to the assessment we had completed a few weeks before the fire. We had painstakingly worked out the procedure for filling the large tank with Ethanol. Every care had been taken to ensure that the risk of filling such a tank was acceptably low to all the people involved in the exercise. I facilitated the hazard assessment – included were experts in fire safety, terminal operating personnel and fire brigade personnel. I had found that the fire brigade were indispensable during such occasions – as they would be the front line fighters during such a fire event.
I remembered the reply of an operations manager, made a number of years previously, when I was working at an LPG terminal, when asked “What will you do in the event of a fire in your refrigerated storage tanks”. His wry answer, as he gazed into the distance, his eyes following the road up the hill, “We will run, (expletive) run and let the ‘firies’ worry about it”.
We had laboriously looked at every conceivable thing that could go wrong in filling such a tank. We asked ourselves – “how could energy ‘get out of control’?”. Even though this is a rather simple and basic means of identifying hazards – it appeals to the imagination. Anyone who has tried to light a fire where the amount of combustible material is underestimated, will quickly understand the concept! We used exhaustive checklists and referred to the Standards and Codes of Practice in our hazard assessment. Given the facts, and an explanation that a tank fire will be ‘bigger than Ben-Hur’, we believed that we had come up with suitable and appropriate safeguards and controls.
During our assessment we knew that our procedure for filling the Ethanol tank required special tactics and a strategy for contending with an event, rarely experienced. We knew that none of us, including the fire brigade people present, had ever dealt with such an event.
I remembered being smugly satisfied with the good procedure that we had developed. We’d involved a lot of experienced people who knew a lot about protecting tanks that could be involved in a fire. I thought we had considered everything.
I gave no further thought to this until the tank was being filled with the Ethanol on that fateful day when the phone rang.
As with such events, all accounts of the sequence of events that followed were highly subjective and, in most cases, based on the distorted perceptions and interpretations of reality.
With the help of the operators at the tank farm, I later pieced together the following sequence. The filling of the tank appeared initially to proceed as planned, with all operators at their posts around the huge metal cylindrical structure which reached into the blue sky above them. The reassuring sound of the filling pumps reverberated through the still morning area, as the level of liquid gradually rose inside. Operators monitored the level in the tank meticulously, on the alert for anything untoward that could occur, though unlikely.
The firefighting foam systems that would deliver foam into the top of the tank were checked with the large firewater pumps that would deliver firewater for cooling, ready on standby.
One of the operators, perched on the spiral stairway leading up to the top of the tank, heard a strange rumbling sound within the tank. In the next instant, pandemonium. The ground shook, the roof of the behemothic tank opened in an instant, like the open mouth of a fish, accompanied by a deafening explosion. As the tank erupted, the operator was hurled from the stairway, landing on his back on the concrete slab surrounding the tank. The roof of the tank swung upwards, swaying precariously at the side of the tank, before being flung off, crashing into the ground 250 meters away; a crumpled heap of steel.
Flames shot high into the sky, fueled by the flammable, boiling contents which were still contained in the tank, which then progressively collapsed into a distorted heap of steel.
A pall of black, toxic smoke started to envelope the whole area. Operators, usually familiar with every nook and cranny at the terminal, became disorientated, trying to find their way around in the black swirling cloud, punctuated by orange flashes of flame as the cloud opened up and closed again. Operators were mercilessly exposed to the radiant heat from flames that periodically pierced the black pall.
The wailing of the fire brigade sirens grew ever louder. Fire tenders bore down on the terminal, criss-crossing the heavy traffic which had slowed down, and in some places stopped, to let the tenders through. Tenders came from all directions, deploying around the tanks which were almost invisible in the ever thickening pall. These were joined by ambulances, which added to the chaotic scenes around the terminal and adjacent areas.
The fire raged for at least 24 hours, until all that remained was the semi-circular vestige of what was once a proudly designed and stately fuel tank. All attempts to activate the installed extinguishing system failed, as the operators tried to find the ‘push buttons’ for the foam system in the pitch dark surroundings. When an operator stumbled onto the push button panel, no amount of violent jabbing at push buttons or banging on the panel had the desired result! The foam system had disappeared. This was supposed to put such a fire out in less than an hour!
Fortunately the cooling water pumps were switched on in time by an operator who dashed out of the smoke to the control panel where she activated all the cooling systems on the surrounding tanks and equipment. A great hiss of steam could be heard as the cooling water streams hit the side of the tanks that reflected the flames from the burning tank. Some of the flames licked the rims and shells of the closest tanks, fanned by wind gusts which formed eddies in the spaces between the tanks.
Statistics and probabilities were on our side that day – the fire fortunately did not spread beyond the single burning tank; nor were there any deaths. Injuries were very serious though.
Most operators sustained serious burns to their arms and faces – to any exposed areas. The radiant heat was fearful and intense throughout – there was no escaping the periodic bursts of radiant heat that people were exposed to, as the smoke cloud thinned and opened. Some people sustained injuries as they slipped and fell in the mad rush to escape the flames and smoke. The operator flung from the tank managed to crawl to safety.
The aftermath of the event was as expected. Any person involved with the management of the terminal, design or operation of equipment and the management of safety, became a target for the myriad of police, regulatory and workplace safety personnel. That’s why I got the call!
I sat in an office at the terminal, where I could see the hideously blackened remains of the tank, burned down to the ground and the blackened sides of all the surrounding tanks. Across the table sat the representatives from WorkSafe.
The questions were blunt and accusatory. “Did we identify all the hazards and risks in the filling procedure?”; “Did we have all the safeguards and controls in-place?”; “Were these all working at the time – effective and reliable?” I pored over the report with them, huddled around the table. I knew I was nervous and afraid as my voice shook when I answered the continuous stream of questions. The haunting thought kept arising, “Will they find a flaw in the procedures we developed?”.
Fortunately, we had prepared well and had addressed all of the hazards, which we had a clear understanding of. We made sure that the people involved in our assessment, had the appropriate experience and understanding of the nature of petrol fires in large storage tanks.
Our report had comprehensively listed details of all that could wrong in the Gasoline filling process – including the disastrous consequences if anything did go wrong. Releases of petrol into the air become highly dangerous where there are sources of ignition – a naked flame, tools striking against metals, an illegal cigarette or devilish arson!
The function of the pipe was to deliver fire-fighting foam to the tank via a ‘foam box’, mounted high on the outside of the tank. The foam box is supposed to be fitted with a frangible disc, which is designed to burst under the pressure of foam pumped into the system, allowing foam to flow into the tank. When in place, the disc prevents ethanol vapour from the tank entering the foam box and the attached piping.
One of the three foam boxes installed on the tank had never been fitted with its frangible disc. This allowed ethanol vapour to enter the box and the attached piping. Welding on this piping ignited the ethanol in the pipe and caused the tank to explode.
The coroner could not determine the reason for the absence of the disc, but presumed it had been supplied. According to the coroner’s report, the supplier of the box ‘declined to assist with this inquest, relying on legal advice’.
Coroner McRobert found that no check had been made to ensure the disc had been fitted, and considered this negligent, as the disc was ‘an essential part of the system’.
The supervisor for the fitting of the foam box was a qualified carpenter. The coroner commented, ‘I fail to see how a carpenter is qualified to supervise what was primarily a metal working operation.’
The welding operation
The welder was appropriately qualified. Where work could not be removed to a safe location for welding, a ‘hot work’ permit could be issued. The coroner found that ‘the procedure for obtaining a hot work permit was not followed as a matter of course’, and ‘the existence of a hot work permit for the job which caused the explosion is unlikely to have effected the outcome’.
Chain of command
The coroner found the chain of command within the seven or eight employees at the site ‘confusing’. The person who directed the welding on the pipes described himself as ‘a labourer, a leading hand, and a supervisor’. This person stated that he gave direction that the work was to be removed to the workshop for welding. The coroner considered that in performing the welding in place, the welder ‘simply followed a commonly adopted practice’.
No check was made for the presence of ethanol in the pipe before welding. Testing equipment was available.