LESSON LEARNT FROM GEORGE SUGAR REFINARY ACCIDENT
1. PERFORM A CAREFUL REVIEW OF MATERIALS USED IN CONSTRUCTION; CREATE A RECORD
CHANGE NOTIFICATION - A careful review of design specifications and material selection should
be conducted because use of the wrong grade of material could have adverse results and lead to
disastrous incidents.
2. MAINTENANCE AND INSPECTION SHOULD BE PERFORMED PERIODICALLY TO ENSURE
EQUIPMENT RELIABILITY - The goal is ongoing mechanical integrity rather than breakdown
maintenance.
3. MANUFACTURERS SHOULD DEVELOP EFFECTIVE WORKER TRAINING PROGRAMS - Many
incidents have occurred in the process industries because operators or supervisors or even
managers did not understand the hazards of chemicals or technology. While training in hazard
communication will help employees to be more knowledgeable about chemicals they work with,
additional training should be conducted on operating procedures and safety work practices,
emergency evacuation and response, safety procedures, and other areas pertinent to process
safety and health.
4. MAJOR HAZARD INSTALLATIONS (MHI) SHOULD BE INSTALLED TO MINIMIZE THE IMPACT OF AN
EXPLOSION - These industries utilize complex processes operating at high pressure and
temperature, employing continuous use of hazardous substances. Major industrial incidents
occurred in the past and are likely to occur again in the future if no initial attention and
precautions are taken to manage and control these installations.
5. PLANT LAYOUT AND SITING SHOULD BE DESIGNED FAR AWAY FROM THE RESIDENTIAL AREA Large quantities of dangerous substances, especially explosive or toxic gases, are often
processed or stored in hazardous installations. If the substance is accidentally released to the
atmosphere, it will have an adverse impact to the nearby area. Therefore, the siting of a plant
should not be placed near the populated area
6. COMPLETE PLAN AND APPROPRIATE PROTECTION SYSTEM SHOULD BE IN PLACE IN CASE OF
EMERGENCY - Emergency planning is an important part of company operation. Since
emergencies will occur, preplanning is necessary to prevent possible disaster. An urgent need
for rapid decisions, shortage of time, and lack of resources and trained personnel can lead to
chaos during an emergency. The stress of the situation can lead to poor judgment resulting in
severe losses. Additionally, the emergency response is characterized by the urgent need for
rapid decisions; therefore the protection system should be in place and in operable status. The
lack of an emergency plan could lead to severe losses such as multiple casualties and possible
financial collapse of the organization.
7. PROCESS HAZARD ANALYSIS MUST BE IMPLEMENTED PERIODICALLY In process safety, a hazard
is considered to be the potential for an incident with undesirable consequences (Baybutt, 2003).
Processes can contain different types of hazards, for example, chemical hazard such as toxic
material, reactive chemicals, mechanical hazard such as rotating equipment, physical hazard
such as high pressure, electrical hazard such as high voltage power supply.
8. ACTIONS MUST BE TAKEN TO PREVENT POTENTIAL HAZARDS ACCORDING TO LESSONS LEARNED
FROM SIMILAR INCIDENTS IN THE PAST What has already happened cannot be changed, but
lessons should be learned from previous incident investigations to prevent future losses. To
prevent similar tragedies from occurring, many legislative and industrial changes were invoked
to prevent incidents and save lives by improving process safety with the lessons and
recommendations learned from the incident investigation.
9. APPROPRIATE PROTECTION SYSTEM SHOULD BE ALWAYS IN PLACE IN THE CASE OF AN
EMERGENCY The probability of incident occurring is always larger than zero. So emergency
planning and response (EPR) should always be developed and implemented consistent with
federal rules and good engineering practice, and applied to mitigate the impact of an incident
on the public and the environment. All the safeguards and protection systems should be
maintained on a regular basis to ensure their functionality when needed in an emergency
situation.
10. APPROPRIATE OPERATION PROCEDURES MUST INCORPORATE ALL SAFETY PROCEDURES AND
STANDARD INDUSTRY PRACTICES When studying the incident cases, it was found that safety
procedures and standard industry practice should be incorporated into the operating
procedures to help eliminate injury to personnel, minimize incapacitating damage to facilities
and maintain steady process.