Mexico City Disaster: A Thirty-Year Perspective
What have we learned?
Juliana Guarguati
Master’s Student in Safety Engineering
Mary Kay O’Connor Process Safety Center
March 10, 2016
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
2
Outline
Mexico City
incident
What have
we
learned?
Conclusions and
recommendations
3
Incident Overview [2,3]
November 19th, 1984.
San Juan, Mexico City.
A major fire and a series
Fig 1. Mexico City explosion [3]
of explosions in PEMEX
LPG Terminal.
Over 500 people were
killed, 7,000 injured and
200,000 people were
evacuated.
Fig 2. Terminal after the explosion [6]
4
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.
6 large spherical tanks Private gas
(2 largest - 2400m3) distributors within
48 smaller tanks of various sizes 100-200 m from
the facility
40% of gas
supply of
Mexico City Terminal Before
PEMEX PEMEXHousing within
Terminal After130 m
from the storage tanks
Fig 4. PEMEX Terminal Before[10] Fig 5. PEMEX Terminal After[10]
Fig 3. Layout of the facility[8]
5
Sequence of Events [4,10]
Rupture of 8 in. Police alerted Series of Rescue work at
pipe. A vapor First explosion and civilian weaker its
cloud was (BLEVE)
traffic stopped explosions height
formed
8:00
5:30 5:40 5:45 5:46 6:00 7:01 7:30 11:00 23:00
18:00
Flames
Ignition of gas Second BLEVE Last explosion on Last
cloud. Violent seismograph extinguished
(One of the explosion
combustion. (BLEVE) on last large
most violent)
sphere
6
Incident Analysis
Vapor cloud:
Estimated size: 200m x 150m
x 2m high [5].
100 m Ignition source:
Ground flare at the bottling
plant [3].
200 m
Explosions:
In total there were 9
explosions (The second and
300 m
seventh were the most
severe) [1].
Effects of missiles:
The majority of damage
occurred within 300m away [1].
Fig 6. Damage to housing area and fall of missiles [1]
7
Previous PEMEX incidents [2]
• Fire and • Gas • Gas • Ammonia
Los Pajaritos, Veracruz
Acachapan, Tabasco
Colmenas, Tabasco
explosion pipeline pipeline gas
San Juan Ixhuatepec
near explosion explosion pipeline
storage leak
tanks
• 11 dead • Settlement • 4 dead
• Residents and 44 destroyed and 29
evacuated injured injured
March April June July
1984 1984 1984 1984
8
Contributing Factors Mexico City Incident [3,4,5,10]
Hazard No formal hazard identification process was carried out.
identification Lack of awareness of potential death toll if a BLEVE
occurred.
Additional relief valve was needed for the pipeline as the flow
Management had been increased.
of change Additional tankage had been installed with much closer spacing.
Plant
Inadequate positioning of the tanks (Domino effect).
layout
Victims were located within a 300m radius of the center of
Land use the terminal.
planning Lack of effective planning and safety legislation.
9
Contributing Factors Mexico City Incident [3,4,5,10]
The water spray system was inadequate and disabled.
Protective
Lack of gas detector system.
systems
Emergency isolation was initiated too late.
Mechanical Inadequate maintenance and inspection program.
integrity Pressure gauges were inaccurate and in bad shape.
Lack of alarm systems and evacuation routes.
Emergency
Lack of awareness of potential death toll if a BLEVE had
response
occurred.
Training Lack of training of workers and the community regarding
hazard identification.
10
PEMEX thirty years later [16,17,18]
Fire and explosion
7 injured and environmental impact
Pajaritos Terminal explosion
2004 8 dead and 14 injured
2005
Leak at the Cadereyta refinery
2006 1 dead and 2 injured
2007 Gas facility explosion
Veracruz explosion 2010 30 dead
2 dead and 13 injured
2011 Madero refinery
Gas and oil leak 2012 4 dead and 8 injured
20 dead
2013
San Martin explosion
2014
30 dead and 52 injured
2015
Central building explosion
2016
33 dead and 125 injured
Platform fire 3 dead and
4 dead and 16 injured 7 injured
11 Fig 7. PEMEX Platform fire 2015 [21]
PEMEX thirty years later [16,17,18]
Number of incidents
Mechanical
231 239
Integrity: 64% 211 223
203
188
164 164
149
Land Use 36%
Planning: 44%
2007 2009 2011 2013 2015
Fig 7 . Adapted from Mexico newspaper “El Horizonte” [13]
Emergency
197 accidents 21 fatalities
Planning: 44% per year per year
12
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]
13
Catastrophic recent incidents [14,15]
West Fertilizer explosion - 2013 Tianjin explosion - 2015
15 fatalities and more than 173 fatalities and more
260 injured than 797 injured
Fig 9. West Fertilizer explosion 2013 [22] Fig 10. Tianjin explosion 2015 [23]
Poor hazard Inadequate
Land use
emergency
awareness planning
planning
14
Similar incidents in US [14]
Mechanical integrity Management of
Change
22 incidents 21 incidents
Fig 11. Mechanical integrity [26] Fig 12. Management of change [27]
Land use Planning Emergency Planning
Plant Layout Hazard Communication
12 incidents 26 incidents
Fig 13. Land use planning [25] Fig 14. Emergency response [24]
15
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.
16
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.
17
Acknowledgements
Dr. Mannan
Dr. Waldram
Dr. Pasman
All the members of the Steering Committee
All the members of the MKOPSC
18
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%2019
84%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]
19
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]
20
Thank you
Juliana_guarguati@tamu.edu
