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15915 Chemical accident in Kuwait with hydrocarbons (gas)
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General accident information
Class/Quality * * * *
Year 2000
Summary When trying to isolate a gas leak from a
Condensor at a refinery a huge explosion
Occurred causing at least 55 casualties
Country KWT
Chemicals Benzine (fp<21/C) (gasoline), Crude oil, Hydrocarbons (gas)
Cause Unknown-cause
Fatalities/Injuries 5-6 / 50
Occurrences or events Blast-wave/Shock-wave, Block-of-system, Blow-away, Damage,
Explosion, Fire, Fire fighting/Emergency response, Release
Full accident information 
download accident report Click here to view a document containing the full accident information

Country: KUWAIT (KWT)
Date : 2000 0625

At 0424 hours, when the refinery staff were attempting to isolate a gas leak on a condensate line of condensor (condenser) between the NGL plant and the refinery an huge explosion occurred. Smoke and flames rose from the gasoline unit hours after the explosion. Fire trucks parked on ground littered with broken glass. At least one concrete structure appeared destroyed and the force of the blast shattered windows in office buildings at the complex.
It was the second explosion to Kuwait's oil industry in a week: 2 people were killed by a gas leak at another refinery on 18 June 2000, after attemps to restart operations at a jet fuel unit shut since the 1990-1991 Gulf war. (See acc.nr.#16300).
The explosion caused extreme damage to the refinery's 2 gasoline production units, which had a combined capacity of 36000/bpd, leaving Kuwait with 1 gasoline production unit of 15000/bpd. Other reports described that it would appear that reforming and crude units of the old part of the refinery were destroyed. Some reports also stated that 2 benzene units were destroyed.
The No.5 130000/bpd crude unit suffered major damage and the No.3 120000/bpd crude unit moderate damage. No.4 200000/crude unit remains intact.
The Kuwaiti oil minister has offered to resign over the explosion. He told the parliament he was not criminally responsible for the blast, but was taking political responsibility for it. The refinery, build in 1948, employed 1450 workers, produced petrol, diesel, aviation fuel and naphtha, had a total capacity of 485000/bpd. A force majeure has been declared for some products. The refinery was completely closed following the blast, some units may not be operational for many months. Some reports also stated it would probably be necessary to spend 400E+6 USA dollars and 2/years replacing the damaged installation.
Five workers were killed and 50 were injured. Most of the injuries suffered either suffocation, burns and cuts from flying glass. The following day only eight were still in hospital.
The damage was estimated at 412E+6 USA dollars.
The FCCU (fluid catalytic cracking unit), which also makes polypropylene, resumed operating 10 August 2000.
The crude distillation unit (CDU), with a capacity of 200000/barrels a day (bpd), resumed production on 7 October 2000 after passing trial operations.
A unit for production of aviation fuel also resumed operation on 9 October 2000.

Lessons learned
These accidents triggered an investigation by the Kuwaiti Parliament and the Ministry of Oil. Both organisations concluded that the companu had to develop robust safety systems.

Since the accidents, the company has moved swiftly to improve health and safety, revolutionising its approach to risk management. The company commissioned a consultant to help optimise SHE management systems on its three refineries and a gas processing plant. The work includes behavioural analysis, risk assessment, change management, training, environmental support and management systems development.
In October 2000 the company invited the company to assess the status of their management of safety, health and environment aspects and to plan appropriate enhancements. The assessment was needed promptly to allow planning to start, and work to proceed.
A five-man assessment team was assembled.
The team developed a special protocol, visited each refinery, the marketing company
and the head office. The team interviewed a vertical slice of the personnel, reviewed
critical documents and observed behaviour. The team found that HSE in the company was
driven by a compliance culture to a set of prescriptive SHE rules.
There were 79 recommendations related to Safety and Health, and 25 recommendations
relating to environmental management. The consultant also concluded that while the company was good at setting policies and planning, it lacked robust auditing and reviewing mechanisms.
This meant that implementation was not consistently applied throughout the organisation, and improvement was more sporadic than purposeful.

The first phase of the risk management solution was to ensure the executive management
team agreed the priority of this initiative and took ownership for it. This was
done through the exemplary behaviour of the Chairman and Executive Assistant
Managing Director for Manufacturing, who clearly signalled that the (safety, health and environment) SHE management system (MS) was their top priority and that they expected no less from their colleagues. The top team worked with the consltant to create the policy, having reviewed a series of policies by leaders in the global process industry.
From the policy a series of expectations were developed, and these formed the basis for a series of workshops held with teams leading each of the elements of the management system. They defined the system that existed and the gaps that needed filling. Once the gaps were identified a risk-based system was deployed to identify priority actions. One highlight of these priority actions was the introduction of a mandatory system of management tours. Each tour took 1-2 hours and all resulted in 3 priority actions that the organisation tracked until closure. For the first time, the work force was seeing
Executive managers in their own area to observe acts and conditions, to talk about SHE issues and to encourage the workforce in their SHE actions.
The development of the SHE Management System was supported by a parallel activity to assessment risks associated with the process units from a flammable and toxic events point of view, with a further emphasis on the technical integrity of the equipment. To this end, a coarse Quantitative Risk Assessment (QRA) was carried out covering all of KNPC???s operations to focus particularly on offsite risks, and with a detailed QRA and Risk Based Inspection project implemented at the refinery. The output from these assessments showed the impact of the SHE Management System made on risk reduction.

SHEMS implementation so far, has shown results in a downward trend of lagging indicators, including accidents and near misses. The company is also seeing active engagement in the SHEMS initiative by their contractors who naturally wish to align their objectives with company???s changing culture. Positive effects are also being felt in the operations.
For the consultant, the process has been a good test of their skills and ability to manage complex and comprehensive risk management solutions. And while the SHEMS will not be fully completed until 2006, the company has already learned that the ability to handle risk effectively pays dividends in terms of improved SHE performance, direct
savings and enhanced public confidence.

Une explosion, due ?? une fuite de gaz non ma??tris??e dans l???unit?? de gaz liqu??fi??, se produit dans la plus importante des 3 raffineries du KOWEIT; 6 morts et 50 bless??s sont ?? d??plorer. La d??flagration brise de nombreuses vitres. Des camions-citernes explosent dans un parking. Le feu est circonscrit apr??s plusieurs heures d???intervention. La raffinerie est arr??t??e en attendant les conclusions de l???enqu??te. Les dommages mat??riels sont importants: 2 des unit??s de production d???essence, d???une capacit?? de 36000 baril/j ont ??t?? d??truites, l???unit?? no. 5 de raffinage de p??trole brut de 122000 baril/jour est fortement endommag??e et l???unit?? no. 3 est moyennement touch??e. Les centrales ??lectriques locales ont baiss?? leur production. Les besoins du pays seront satisfaits gr??ce aux r??serves et ?? la production des 2 autres raffineries. Le montant des d??g??ts est d???ores et d??j?? ??valu?? ?? 298 millions de $. Les travaux de reconstruction commencent en f??vrier 2001. La premi??re unit?? est en fonctionnement sous 10 mois et l???ensemble de l???installation sous 28 mois.

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