E.36 - Operating Blind—Training

A supervisor attempted to rescue the worker, but he too was overcome with fumes and barely escaped. A second worker also attempted rescue and was also overcome. A third worker normally on site was offsite for personal reasons, leaving no one at the site to initiate further control actions. By the time response personnel arrived, vapors from the leak had engulfed the entire site. Recognizing the danger of explosion, they retreated. One hour and fifteen minutes later, the vapor cloud exploded, creating a fireball that engulfed entire site and broke windows in the surrounding community up to 2 km away. The ensuing fire soon spread to all the other tanks on the site and continued to rage for eleven days. Due to the scale of the fire, responders decided to allow the fire to burn itself out rather than try to control it. Ultimately six workers and five in the community lost their lives.
The investigating commission (Ref E.6) determined the accident was caused by valves being operated out of sequence and was exacerbated by the absence of a remote isolation valve and/or remotely operated shut-off. The commission noted there were no operating instructions for making the transfer, leaving the procedure up to the operators who were not well trained in this procedure.
While the commission did not comment specifically on company process safety culture, several recommendations show they were clearly thinking about it. Among the recommendations, the commission recommended creating an independent process safety function reporting to the Chief Engineering Officer and that line management practice conduct of operations to ensure all process safety functions are carried out. What other culture factors could the commission have considered?