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Flixborough

Summary

The Flixborough disaster was an explosion at a chemical plant close to the village of Flixborough, North Lincolnshire, England on Saturday, 1 June 1974. It killed 28 people and seriously injured 36 out of a total of 72 people on site at the time. The casualty figures could have been much higher, if the explosion had occurred on a weekday, when the main office area would have been occupied.

Key Learnings / Issues

  1. Absence / deficient Management of Change (MOC).
  2. Incident occurred during start-up (critical decisions made under operational stress).
  3. Lack of operating procedures to assist in making critical decisions.
  4. Lack of onsite engineering support.
  5. Plant layout (positioning of occupied buildings) and control room design (to withstand major hazards events).

Quote

“Never here. Never here. And where I’m going to go I don’t know. We don’t have a home.”
A community member when asked about rebuilding her home.

Resources

Wikipedia
Investigation

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