Baker & O'Brien, Inc.

Case Studies

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Is There Such a Thing as a “Foolproof” Process Design?

International Arbitration, London

October 1, 2013

A major chemicals company licensed a proprietary catalytic process to manufacture a chemical intermediate used in the production of commodity chemicals.  One part of the process involved an exothermic (heat-generating) reaction in which too much catalyst can lead to an out-of-control reaction. Two years after start-up, that part of the unit suffered an explosion and fire.  The owner alleged the cause to be a design flaw in the emergency shutdown system (ESD), which, it claimed, was supposed to be100% “foolproof.”  The owner and its insurers filed an arbitration for damages against the plant’s design contractors.

Baker & O'Brien was engaged by the contractors to investigate the “root” cause of the incident, whether the ESD system had functioned correctly, and whether the plant operators had been properly trained in operation of the unit—especially during unstable conditions.  Several reports were prepared and submitted as evidence in the arbitration and our consultants were cross-examined at the hearing.

On investigation, it was revealed that the owner had made a number of design and operational changes that materially contributed to the incident.  For example, mandatory laboratory analyses had been dispensed with, and some process control instrumentation had been decommissioned.

Also, the owner’s operators had deviated from the standard operating procedures that were an important part of the design basis. Finally, the explosion and fire had occurred during start-up—when the ESD system had been bypassed and locked out.

The incident demonstrated that no safety system can be considered “foolproof.”  Such systems rely on properly trained operators who understand the process, can observe and identify abnormal and/or dangerous conditions, and respond with appropriate actions.