Juliana Guarguati

Master’s Student in Safety Engineering

Mary Kay O’Connor Process Safety Center

Mexico City Disaster: A Thirty-Year Perspective

March 10, 2016

What have we learned?

2

Juliana Guarguati Ariza

I was born and raised in

Bucaramanga, Colombia

Bachelor’s degree in Industrial

Engineering at Pontificia

Universidad Javeriana,

Colombia

HSE Engineer at

Ecopetrol in Colombia

Master’s Student in Safety

Engineering at Texas A&M

University

3

Outline

Mexico City

incident

What have we

learned?

Conclusions and recommendations

4

Incident Overview [2,3]

November 19th, 1984.

San Juan, Mexico City.

A major fire and a series

of explosions in PEMEX

LPG Terminal.

Over 500 people were

killed, 7,000 injured and

200,000 people were

evacuated.

Fig 1. Mexico City explosion [3]

Fig 2. Terminal after the explosion [6]

5

Incident Background [1,2]

Storage & Distribution facility for Liquefied Petroleum Gas (LPG).

At the time of the disaster the storage was estimated to contain

11,000 – 12,000 m3 LPG.

Fig 3. Layout of the facility[8]

6 large spherical tanks

(2 largest - 2400m3)

48 smaller tanks of various sizes

Housing within 130 m

from the storage tanks

Private gas

distributors within

100-200 m from

the facility

40% of gas

supply of

Mexico City PEMEX Terminal Before PEMEX Terminal After

Fig 4. PEMEX Terminal Before[10] Fig 5. PEMEX Terminal After[10]

6

Rupture of 8 in.

pipe. A vapor

cloud was

formed

Ignition of gas

cloud. Violent

combustion.

First explosion

(BLEVE)

Second BLEVE

(One of the

most violent)

Police alerted

and civilian

traffic stopped

Last explosion on

seismograph

(BLEVE)

Series of

weaker

explosions

Rescue work at

its

height

Last

explosion

Flames

extinguished

on last large

sphere

5:30 5:40 5:45

Sequence of Events [4,10]

5:46 6:00 7:01 11:00 7:30 8:00

18:00 23:00

7

Incident Analysis

Vapor cloud:

Estimated size: 200m x 150m

x 2m high [5].

Ignition source:

Ground flare at the bottling

plant [3].

Explosions:

In total there were 9

explosions (The second and

seventh were the most

severe) [1].

Effects of missiles:

The majority of damage

occurred within 300m away [1].

300 m

200 m

100 m

Fig 6. Damage to housing area and fall of missiles [1]

8

Previous PEMEX incidents [2] S

an

Ju

an

Ixh

uate

pec

• Fire and explosion near storage tanks

• Residents evacuated

Acach

ap

an

, Tab

asco

• Gas pipeline explosion

• 11 dead and 44 injured

Co

lme

nas,

Ta

bas

co

• Gas pipeline explosion

• Settlement destroyed

Lo

s P

aja

rito

s,

Vera

cru

z • Ammonia

gas pipeline leak

• 4 dead and 29 injured

March

1984 April

1984

June

1984

July

1984

9

Contributing Factors Mexico City Incident [3,4,5,10]

Hazard

identification

Plant

layout

Land use

planning

No formal hazard identification process was carried out.

Lack of awareness of potential death toll if a BLEVE

occurred.

Victims were located within a 300m radius of the center of

the terminal.

Lack of effective planning and safety legislation.

Inadequate positioning of the tanks (Domino effect).

Management

of change

Additional relief valve was needed for the pipeline as the flow

had been increased. Additional tankage had been installed with much closer spacing.

10

Protective

systems

Emergency

response

Mechanical

integrity

Training

The water spray system was inadequate and disabled.

Lack of gas detector system.

Emergency isolation was initiated too late.

Lack of alarm systems and evacuation routes.

Lack of awareness of potential death toll if a BLEVE had

occurred.

Inadequate maintenance and inspection program.

Pressure gauges were inaccurate and in bad shape.

Lack of training of workers and the community regarding

hazard identification.

Contributing Factors Mexico City Incident [3,4,5,10]

11

PEMEX thirty years later [16,17,18]

Veracruz explosion

2 dead and 13 injured

Gas and oil leak

20 dead

Leak at the Cadereyta refinery

1 dead and 2 injured

Gas facility explosion

30 dead

Central building explosion

33 dead and 125 injured

San Martin explosion

30 dead and 52 injured

Madero refinery

4 dead and 8 injured

Platform fire

4 dead and 16 injured

Pajaritos Terminal explosion

8 dead and 14 injured 2004

2005

2006

2007

2010

2011

2012

2013

2014

2015

Fire and explosion

7 injured and environmental impact

2016

3 dead and

7 injured

Fig 7. PEMEX Platform fire 2015 [21]

12

PEMEX thirty years later [16,17,18]

197 accidents

per year

21 fatalities

per year

231

188 164 164

211 239

223

149

203

2007 2009 2011 2013 2015

Number of incidents

36%

Fig 7 . Adapted from Mexico newspaper “El Horizonte” [13]

Mechanical Integrity: 64%

Land Use Planning: 44%

Emergency Planning: 44%

13

Land use Planning San Juan [6]

27 facilities in the area

(6 million LPG liters)

In 2009 only 34% of the young

population knew about the

incident

In 1984 the president issued a

regulation in which gas

companies had to leave the area

Fig 8. Land use planning San Juan, Mexico City [6]

Catastrophic recent incidents [14,15]

14

West Fertilizer explosion - 2013 Tianjin explosion - 2015

15 fatalities and more than

260 injured 173 fatalities and more

than 797 injured

Poor hazard awareness

Land use planning

Inadequate emergency planning

Fig 9. West Fertilizer explosion 2013 [22] Fig 10. Tianjin explosion 2015 [23]

15

Similar incidents in US [14]

Land use Planning

Plant Layout

Mechanical integrity Management of

Change

12 incidents

22 incidents 21 incidents

Fig 13. Land use planning [25]

Fig 11. Mechanical integrity [26] Fig 12. Management of change [27]

26 incidents

Emergency Planning

Hazard Communication

Fig 14. Emergency response [24]

16

Conclusions and recommendations

The chemical and petroleum industry should ensure that lessons learned

are communicated and implemented.

Companies must report significance accidental releases in the framework

of the RMP. However, how much of this information is used for further

prevention?

Companies should implement a corporate memory system to ensure

sharing knowledge within the company, especially with new employees,

and others companies.

Agencies and government should ensure that regulations are well

established and the compliance is inspected by qualified experts.

Governments have to ensure the implementation of process safety

courses in universities. As well as training in hazard awareness for

emergency responders and the community.

17

Conclusions and recommendations cont.

Expert authorities in the field should encourage the use and

understanding of databases and academic resources in order to

ensure that companies are up to date regarding process safety

practices.

Companies should ensure that incident investigations are

performed by qualified professionals and the identification of root

causes are not masked by intermediary causes.

Companies should implement effective process safety metrics,

analyze them and take actions of any potential failure. These

metrics must take into account near misses.

Companies should promote reporting of near misses by

employees with a culture of no blame or repercussions.

18

Acknowledgements

Dr. Mannan

Dr. Waldram

Dr. Pasman

All the members of the Steering Committee

All the members of the MKOPSC

19

References

[1] C.M. Pietersen, Analysis of the LPG-disaster in Mexico city, Journal of Hazardous Materials, Volume 20,

December 1988, Pages 85-107, ISSN 0304-3894.

[2] Johnson, Kirsten. "State and community during the aftermath of Mexico City's November 19, 1984 Gas

Explosion." (1985).

[3] Atherton, John Gil, Frederic. (2008). Incidents That Define Process Safety. Center for Chemical Process

Safety/AIChE.

[4] Mannan, Sam. (2005). Lees' Loss Prevention in the Process Industries, Volumes 1-3 (3rd Edition).

[5] http://www.hse.gov.uk/comah/sragtech/casepemex84.htm [Retrieved: 02/15/2016]

[6] http://archivo.eluniversal.com.mx/graficos/especial/EU_sanjuanico/index.html [Retrieved: 02/15/2016]

[7] https://www.youtube.com/watch?v=nngeCe8Kni8 [Retrieved: 02/15/2016]

[8] López-Molina, Antioco, Richart Vázquez-Román, and Christian Díaz-Ovalle. "Aprendizajes del Accidente de San Juan Ixhuatepec-México." Información tecnológica 23.6 (2012): 121-128. [Retrieved: 02/15/2016]

[9] G. Arturson, The tragedy of San Juanico—the most severe LPG disaster in history, Burns, Volume 13, Issue 2,

April 1987, Pages 87-102, ISSN 0305-4179.

[10] http://www.unizar.es/guiar/1/Accident/San_Juan.htm [Retrieved: 02/15/2016]

[11] http://archive.constantcontact.com/fs037/1102467289629/archive/1102479634308.html [Retrieved: 02/15/2016]

[12]http://web.mst.edu/~dludlow/classes/ChE%20285%20Sp12/The%20Mexico%20City%20Explosion%20of%201984%20Final.pptx [Retrieved: 02/15/2016]

[13] http://elhorizonte.mx/mexico/estados/598171/pemex-y-su-negro-historial-en-2015[Retrieved: 02/15/2016]

[14] http://www.csb.gov [Retrieved: 02/15/2016]

[15] http://www.bbc.com/news/world-asia-china-33844084 [Retrieved: 02/15/2016]

20

References

[16] http://eleconomista.com.mx/sociedad/2013/01/31/cronologia-accidentes-pemex [Retrieved: 02/15/2016]

[17]http://www.jornada.unam.mx/ultimas/2015/04/01/pemex-reporta-promedio-de-153-accidentes-con-21-muertes-por-

ano-7763.html [Retrieved: 02/15/2016]

[18]http://elhorizonte.mx/mexico/estados/598171/pemex-y-su-negro-historial-en-2015 [Retrieved: 02/15/2016]

[19]http://www.tcetoday.com/latest%20news/2016/february/three-killed-in-pemex-rig-

fire.aspx#.VsNXqMeprFI[Retrieved: 02/15/2016]

[20] http://www.excelsior.com.mx/2013/02/01/882272 [Retrieved: 02/15/2016]

[21] http://www.zerohedge.com/news/2015-04-01/pemex-oil-platform-explodes-injuries-reported-hundreds-evacuate

[Retrieved: 02/20/2016]

[22] http://abcnews.go.com/blogs/headlines/2013/04/live-updates-west-texas-fertilizer-plant-explosion-injures-more-

than-100/[Retrieved: 02/20/2016]

[23] http://www.telesurtv.net/english/opinion/Tianjin-Explosion-Highlights-Profits-over-People-20150823-

0011.html[Retrieved: 02/20/2016]

[24] http://www.niehs.nih.gov/health/topics/population/response/[Retrieved: 02/20/2016]

[25] http://www.dailymail.co.uk/news/article-2311379/West-Texas-fertilizer-plant-explosion-Death-toll-rises-disaster-

near-Waco.html[Retrieved: 02/20/2016]

[26] http://www.csb.gov/-csb-releases-analysis-showing-cause-of-rupture-and-hydrogen-blast-in-2009-silver-eagle-

refinery-accident-in-woods-cross-utah-pipe-walls-thinned-due-to-corrosion-that-went-uninspected-for-years-/[Retrieved:

02/20/2016]

[27] http://www.grimsbytelegraph.co.uk/VIDEO-Body-following-yesterday-s-explosion/story-11532025-

detail/story.html[Retrieved: 02/20/2016]

Thank you

Juliana_guarguati@tamu.edu