Table of Contents Case DescriptionCase InvestigationRecommendationsCase DescriptionOn October 23, 1989, a massive explosion occurred at the Phillips Petroleum Houston chemical complex in Pasadena, Texas. This 800-acre chemical plant produced plastics used around the world. It was a multi-level structure, with the tallest tower measuring 14 stories. The exterior portion of the facility was filled with heavy concrete and reinforced steel buildings. Say no to plagiarism. Get a tailor-made essay on “Why Violent Video Games Should Not Be Banned”? Get the original essay The day before the explosion, maintenance work had begun to remove three of six reactor installation legs. The decanting branch of the plug is stuck in the pipes. A team member went to the control room to ask for help. Shortly thereafter, 85,000 pounds of a flammable mixture containing ethylene, isobutene, hexane and hydrogen were unintentionally released into the product sampling system. About a few minutes later, a cloud of flammable vapor ignited. The large gas cloud formed immediately because the system was under high pressure and temperature. The gas mixture exploded with a force of 2.4 tons of TNT and was equivalent to an earthquake measuring 3.5 on the Richter scale. Additionally, there were more explosions after the first big explosion due to many pipes and tubes containing trapped gases. An alarm was sounded, but the explosion occurred 60 to 90 seconds later, leaving workers with little time to follow the escape plan and simply running for their lives in any direction, far from the explosion. The exact source of the explosion may never be known, but it is possible. were located throughout the plant, including fans, electrical switches and gas combustion flames. As a result, $715 million was lost, 23 people died and 314 others were injured. Metal and concrete debris were found up to six miles from the explosion site.Case InvestigationFailure in engineering systems occurs due to specific causes, whether planned or unplanned. Many causes are linked to specific procedures. Analysis of the incident revealed that numerous safety procedures were not followed, including the product sampling valve was removed, the one-piece valve (DEMCO) was opened and the lockout device was detached. These actions caused the release of flammable mixtures, and therefore the explosion. There was either a failure in the pipe or in the valve that carried the ethylene and/or isobutane. The pipe measured ten inches in diameter and supported a pressure of approximately 700 pounds per square inch. Polyethylene products typically settle in the settling leg and are removed from the product sampling valve. Sometimes, the decantation plug remains blocked due to a deposit of products, but it is repaired by maintenance. The normal and safe procedure is to close the DEMCO valve, remove the air lines and lock the valve. The buildings were equipped with sprinkler systems; however, the force of the explosion cut off the system's water supply. At the conclusion of the investigation on April 19, 1990, OSHA fined 566 willful and nine serious violations against Phillips Petroleum with a proposed fine of $5,666,200. OSHA found that no process hazard analysis was conducted at the plant and, as a result, many serious safety violations were overlooked..