ABSTRACT
On October 23, 1989, a massive release of polyethylene and combustible gases resulted in an explosion and fire at a large polyethylene production facility in Houston, Texas. The fire and explosion caused the deaths of 23 workers and resulted in damage and lost revenue of over two billion dollars (Figure 1). The resulting investigation ultimately focused on maintenance operations as the cause of the release. Because two of six workers who were directly involved in the maintenance operations were killed, and the others could not recall significant details, the exact facts and circumstances of how the release occurred will never be completely known. However, the physical facts and accident investigation point to human error as the most probable cause of the release of explosive gases. This paper discusses the engineering investigation and findings of the facts and circumstances pertaining to the incident. Also, the concept of Crew Resource Management (CRM) is introduced as a means of eliminating or reducing the frequency of these incidents. CRM also provides an analysis tool for investigating accidents that may involve human error.
