1.1 Background of the study case 1.1.

1 Event The incident took place on April 16, 1947, and began with a mid-morning fire on board the SS Grandcamp, a French registered vessel which was docked in the Port of Texas City. It was the deadliest industrial disaster in United States of America history. The incident occurred due to a fire that detonated approximately 2300 tons of ammonium nitrate and in result of a chain reaction that causes further fires and explosions that killed a minimum of 571 people. The Red Cross and the Texas Department of Public Safety identified 405 and 63 unidentified dead. Another 110 persons were classified as believed missing because no traces of their remains were ever found. Estimates of the injured were around 3500 persons. Although not all casualties were residents of Texas City, the total of the casualties were equaivalent to 25% of the towns estimated population The incident has triggered the first ever class action lawsuit against the government of United States of America under the recently enacted Federal Tort Claims Act (FTCA) of behalf of the victims which accounted of 8485 victims. 1.1.2 Involved Parties The Grandcamp was a 437-foot-long (133m) Liberty Ship that was recently reactivated. The ship was assigned to the French Line to assist in rebuilding of Europe after the World War II. Along with ammonium nitrate , a very common cargo on the high seas, the ship was also carrying small arms ammunition, machinery and bales of sisal twine on the deck. Another ship, the SS High Flyer was docked approximately 600 feet (200m) away from the SS Grandcamp. The High Flyer contained 961 tons of ammonium nitrate and 1800 tons of suphur. The ammonium nitrate in the two ships and in the adjacent warehouse was fertilizer on its way to assist farmers in Europe. The Grandcamp did not obtain permit from the port authority loading of ammonium nitrate had arrived from Houston.

1.1.3 Load to be Loaded onto Grandcamp During the 1940s, Texas City was a commercial hub and a booming metropolis. There were several chemical plants and refineries scattered all around the city. The 38% ammonium nitrate, used as fertilizer and in high explosives was manufactured in Nebraska and Iowa were shipped to Texas City by train before being loaded on the Grandcamp. It was manufactured in a patented explosive process, mixed with petrolatum, rosin, clay and paraffin to avoid moisture caking. It was packaged in paper sacks then transported and stored at temperatures that increased its chemical activity.

2.1 Issue/causes and problem Theres no certain cause of the fire but speculations spread that there was no special precautions on the dock nor the ships and workers were mostly oblivious of the volatile condition of highly explosive ammonium nitrate carried by the ships. It is also said that labeling and special handling of ammonium nitrate fertilizer were not carried out. When the ships carpenter noticed the smoke from the fertilizer on Grandcamp ship and wished to put it out with water, the ship captain forbade using it, fearful that it will destroy $500 worth cargo that was on fire. Instead the captain ordered steam introduced into the hold in an attempt to smother the fire. The pressure from the compressed steam blew off the hatch covers. This majorly led to the first tremendous blast.The second explosion resulted tore to High Flyer which carried sulfur and some more ammonium nitrate fertilizer and spread the fire to Wilson B. Keene which occurred some sixteen hours later. The standard procedure which is dealing with dangerously burning ship after the explosion should be towed by tug as far from the harbor as possible was not followed. This prompted the ships (High Flyer, Wilson B. Keene) into a deadly embrace with each other.The High Flyer caught fire but given the confused situation it was some time before the danger was realized. The industrial complexes around the area were connected by pipelines that caused the fires and explosions to quickly spread the flaming inferno to the surrounding plant. Texas City only had three clinics and no hospital which led to more deaths.

3.1 Effect of Texas Disaster

3.1.1Effect on Life and Property - Blast over pressure and heat disintegrated the bodies of the firefighters and ship's crew. -145 of 450 shift workers perished. - Ultimately, the Red Cross and the Texas Department of Public Safety counted 405 identified and 63 unidentified dead. - Another 100 persons were classified as "believed missing" because no trace of their remains was ever found. - Estimates of the injured are even less precise but appear to have been on the order of 3,500 persons. - Aggregate property loss amounted to almost $100 million, or more than $700 million in today monetary value. - This figure may be too low, because this estimate does not include 1.5 million barrels of petroleum products consumed in flames, valued at approximately $500 million in 1947 terms. - Refinery infrastructure and pipelines, including about fifty oil storage tanks, incurred extensive damage or total destruction. - One-third of the town's 1,519 houses were condemned, leaving 2,000 persons homeless and exacerbating an already-serious postwar housing shortage. - Over 1,100 vehicles were damaged and 362 freight cars were obliterated - Many victim suffered severe trauma. - Grief and bleak future confronting more than 800 grieving widows, children, and dependent parents.

3.1.2 Effect on Industrial - They developed technology to better control chemical process. - They developed standards to built safer facilities. - The result of the study was sweeping changes in how much material was stored in each facility. Many processes and lines of business were deemed too risky to continue and were shut down. - Monsanto also instituted new programs to train and equip local first-responders where its plants are and to reduce emissions.

INDUSTRIAL PROPERTY

Monsanto Chemical Co. Property......$14,750,000 Use and Occupancy.... 7,000,000 Texas City Terminal Railway Co . 2,500,000 Southport Republic Terminal Co. ..... 325,000 Sid Richardson Refining Co. .... 300,000 Carbide and Carbon Chemical Co. (Terminal) . 250,000 Seatrain Lines, Inc. ..... 225,00 Pan American Refining Corp. (Oil Dock) . 300,000 Humble Pipe Line Co. ... 700,000 Republic Refining Co. .. 1,000,000 Railroad Rolling Stock ... 450,000 Grain Loss .. 300,000 $28,100,000 OTHER LOSSES Dwellings and Contents...$2,000,000 Mercantile Buildings and Stocks 1,000,000 Automobiles 750,000 City and School Property... 1,000,000 .. $4,750,000 .. Grand Total. $32,850,000

4.1 Action that has been taken As the surge of injured quickly overwhelmed the towns three small medical clinics, the city auditorium was pressed into service as a makeshift first-aid center. Within an hour doctors, nurses, and ambulances began arriving unsummoned from Galveston and nearby military bases. Serious casualties were taken to Galveston hospitals and later to military bases and even to Houston, fifty miles away. State troopers and law enforcement officers from nearby communities helped Texas City's seventeen-man police force maintain order and assisted in search and rescue. The horror was not over yet. As help poured into Texas City, no one gave much thought to another Liberty ship tied up in the adjoining slip. The High Flyer was loaded with sulfur as well as a thousand tons of ammonium nitrate fertilizer. The force of the Grandcamp's explosion had torn the High Flyer from its moorings and caused it to drift across the slip, where it lodged against another vessel, the Wilson B. Keene. The High Flyer was severely damaged, but many of its crew members, although injured, remained on board for about an hour until the thick, oily smoke and sulfur fumes drifting across the waterfront forced the master to abandon ship. Much later in the afternoon, two men looking for casualties boarded the High Flyer and noticed flames coming from one of the holds. Although they reported this to someone at the waterfront, several more hours passed before anyone understood the significance of this situation, and not until 11:00 P.M. did tugs manned by volunteers arrive from Galveston to pull the burning ship away from the docks. Even though a boarding party cut the anchor chain, the tugs were unable to extract the ship from the slip. By 1:00 A.M. on 17th April, flames were shooting out of the hold. The tugs retrieved the boarders, severed tow lines, and moved quickly out of the slip. Ten minutes later, the High Flyer exploded in a blast witnesses thought even more powerful than that of the Grandcamp. Although casualties were light because rescue personnel had evacuated the dock area, the blast compounded already severe property damage. In what witnesses described as something resembling a fireworks display, incandescent chunks of steel which had been the ship arched high into the night sky and fell over a wide radius, starting numerous fires. Crude oil tanks burst into flames, and a chain reaction spread fires to other structures previously spared damage. When dawn arrived, large columns of thick, black smoke were visible thirty miles away. These clouds hovered over Texas City for days until the fires gradually burned out or were extinguished by weary fire-fighting crews.

The Grandcamp's explosion triggered the worst industrial disaster, resulting in the largest number of casualties, in American history. Such was the intensity of the blasts and the ensuing confusion that no one was able to establish precisely the number of dead and injured. Ultimately, the Red Cross and the Texas Department of Public Safety counted 405 identified and 63 unidentified dead. Another 100 persons were classified as "believed missing" because no trace of their remains was ever found. Estimates of the injured are even less precise but appear to have been on the order of 3,500 persons. Although not all casualties were residents of Texas City, the total was equivalent to a staggering 25 percent of the towns estimated population of 16,000. Aggregate property loss amounted to almost $100 million, or more than $700 million in todays monetary value. Even so, this figure may be to low, because this estimate does not include 1.5 million barrels of petroleum products consumed in flames, valued at approximately $500 million in 1947 terms. Refinery infrastructure and pipelines, including about fifty oil storage tanks, incurred extensive damage or total destruction. The devastated Monsanto plant alone represented about $ 20 million of the total. Even though the port's break-bulk cargo-handling operations never resumed, Monsanto was rebuilt in little more than a year, and the petrochemical industry recovered quickly. One-third of the town's 1,519 houses were condemned, leaving 2,000 persons homeless and exacerbating an alreadyserious postwar housing shortage. Over the next six months, displaced victims returned as houses were repaired or replaced, and most of those who suffered severe trauma appear to have recovered relatively quickly. What could never be made good was the grief and bleak future confronting more than 800 grieving widows, children, and dependent parents.

4.1.2 RECOMMENDATIONS Anyone dealing with or handling ammonium nitrate should be fully advised of the hazardous nature of the chemical and fully instructed as to the proper methods of storage and handling. The proper labeling of the containers is of utmost importance. The label should be red in color with the words "Hazardous Chemicals" - :Ammonium Nitrate" - "Handle With Care" prominently displayed with any other notations in small type, preferably of some other color. Following are interim recommendations for the storage and handling of Ammonium Nitrate which should be followed pending publication of complete regulations to be promulgated in a forthcoming bulletin to be published by the National Board of Fire Underwriters.

4.1.2.1 STORAGE 1. Material should be stored only in masonry or fireproof sprinklered buildings on skids or pallets on concrete floors with at least on foot clearance from walls.

2. Storage should preferably be in separate fire divisions from highly combustible commodities or well segregated (but not necessarily in separate fire divisions) from not so highly combustible commodities such as sulphur, flour, sugar, cotton (compressed) and charcoal. Intimate contact with metals such as cadmium, zinc, copper, tin and lead must be avoided. A minimum clearance of 5 feet should be maintained between ammonium nitrate and other materials.

3. Piles of ammonium nitrate in paper bags in storage should not exceed 10 bags (bags to meet the requirements of the Consolidated Freight Classification) high, 6 bags wide (narrow dimension) with 3 foot separation between piles and with handling aisles of 10 feet every 100 feet. Separation specified is necessary for inspections and fire fighting operations. 4. Spilled material from broken bags must be re-sacked immediately and, to avoid contamination to the contents, must not include floor sweepings. Floor sweepings and discarded bags should be immediately removed from the building and burned at a safe distance. 4.1.2.2 HANDLING 5. Ships holds or boxcars must be thoroughly clean before loading operations are begun. 6. Spilled material in the hold, cars or on dock and discarded sacks must be removed immediately and disposed of in a safe manner as described in 4 above. Any spilled material on docks should be flushed off thoroughly with water. 7. Proper dunnage and sweat-boards must be used in ship's hold and boxcars to prevent friction and to allow for circulation of air. 8. Smoking or use of open lights must be strictly prohibited at any time. 9. Other cargo must not be place in the same hold with ammonium nitrate. 10. Keep material clear of all steam lines and wiring. 11. Fire fighting methods should be the same as recommended in No. 13 below. Pending the outcome of tests now in progress, it is suggested that steam not be used for fire fighting in compartments containing ammonium nitrate.

4.1.2.3 FIRE FIGHTING OPERATIONS

12. Any ship with hazardous material such as ammonium nitrate as cargo entering a port must notify the port facility who in turn should notify the chief of the fire department immediately. Also port facilities storing ammonium nitrate must notify the chief of the fire department of the location and amount of the commodity. 13. Fire departments combating ammonium nitrate fires should use only water in large quantities (applied gently so as not to scatter the material) as an extinguishing agent and all personnel entering the fire area must wear masks approved for use in such locations. Fire in ammonium nitrate usually generates large quantities of oxides-of-nitrogen gasses, which are extremely toxic. 14. Cities in which large industrial operations are present or which are in area subject to hurricanes, earthquakes, tornadoes and other like disturbances should have a well preconceived and organized Disaster Plan to include all relief, law enforcement, fire fighting, military and naval agencies.

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5.1 Lesson Learned 1) Focus on the operations.

The leadership teams should have time to focus on day-to-day operations and not distracted by too many competing demands. Managers need to know what happen in their control rooms and on the plant.

2) The need to capture the right metrics that indicate process safety trends, do not get seduced by personal accident measures, they have their place but do not warn of incidents such as this one.

3) Procedures are ineffective if they are not up-to-date and routinely follow.

4) Two-way communication.

We must keep our promises to each other. This is the first step in rebuilding trust and the only way to earn the respect and obtain the commitment of the workforce. This is about staying in touch, being aware, being responsible and listening.

5) Investigate process incidents

Investigating process incidents are the most important things. Loss of containment incidents the same way serious injuries are investigated. All incidents must document thoroughly. Share what you have learn.

6) Take a hard look at any potential blast impact zones. And if you must have temporary structures near process areas make sure they are blast resistant. The safest way to protect your people is to move them outside of blast zones. 7)Focused on environment and personal safety, not process safety. 8) The development of people was a low priority, with inadequate training. - Company should train the workers first on how to prevent from any incident. The way they must do is by giving speech about the safety during works to the workers.
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6.1 Reference
1. Stephens, Hugh W.: The Texas City Disaster, 1947. University of Texas Press, 1997

2. Fire Prevention and Engineering Bureau of Texas, Dallas, Texas; The National Board of Fire Underwriters, New York, New York. 1947.

Mark Pandanell,: The Texas City Disaster, April 16 1947 retrieved September 28 from http://www.local1259iaff.org/disaster.html
3.

4. Texas City, Texas, Disaster, April 16, 17, 1947: Fire Prevention and Engineering Bureau of Texas,
Dallas, Texas; The National Board of Fire Underwriters, New York, New York. 1947.

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