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Burns (1987) 13.

lZt,87-102

Prrnfedin

Gear Britain

87

The tragedy of San Juanico-the


LPG disaster in history
G. Arturson
Burn Centre, University

Hospital,

Uppsala,

Sweden

most severe

88

Burns (19871 Vol. 1YNo 2

INTRODUCTION
IN Swcdcn ;I <ommittcc for Disaster Mctlicinc
(KAMEDO)
ha hccn ~~t;d~lishcd since ll~OS. its
purpose king to collect information ;ritil cspcricncc of all kind5 of disaster:, all over tlic wilrld
;rnJ to nlitke the information
;tv;tilddc
to all
0rg;uiiz;itions
ciincsrncd with disaster mcclicinc
;ind to nil authorities
responsihlc
for disa~tcr
planning.
I was sent by KAMEDO
to the San Juan
Ixhuatepcc di~;I\tcr arca in or&r
to study the
following fcuturcs:
1. The scene of the disaster, including what
happen4
and the number ilnd types of casualtics.
2. The organiration
at the sccncof the disastsr. as rrg;u&
thr control. rcscuc. rekasc, triage
ad trirrlsport
of casualtics.
3. The organization at the hospitals dcsigmltd
for the handling of casudtics arising from the
disaster.
THE

SCENE

OF THE

DISASTER

San Juan lxhuatcpcc. also known ;IS San Juanico,


is a suhurh of Mexico City situated 9itH) m itbOW
SCil-ICVtl and Aout 10 lim north. just hcyond the

hortlcrlinc of Mcsico <ity and the Stiltc of Mcxice. S;III Juanico hclongs to the municip;dity of
Tl;ilncp;mtl;i.
onto of the most intlu~triiili~crl
arcas
of the country with 2 gnat number of 1.K;
(Liquid
Pctrolcuni
(iii\. mainly :I misturc of
propane and but;mc) storage and rli~tribution
ccntrcs, t!spcciiillv in San Juxtico.
The inkihitants of Mexico City number dlout IS million.

San Junnico has a population

of IOOlH)O. 4OOoU
of uhoni wcrc living in the immcdiatc arcit of the
di4atcr. The built-up iIre: of San Ju;rnico. which
was mostly affcctetl by the &astcr,
is situatd
south of the I.lYi facilities and with its horder\ at
it distance of about I?0 ni from the storage tailis
(Pig. I ). The ancient Sm Juanico villngc is Iocated in ;I small villlcy. 5 km in the cast-west
direction and 3 km xcrc)ss. Through
the valley
runs the Los Kcmcdios kivcr uxxl us ;I sewage
o\crllow dliinncl for the metropolitan ada.
fhr majority of the inhabitants of San Ju;mico
arc poor country people who went to Mexico
city in the hope of ;I hrightcr future. Their homes
arc mainly one-stormy houses constructed of concrctc pikirs filled in with bricks and with roofs of
iron sheets.
The lay-out of the LPG hulk storage and distribution tlcpot in San Juanico is given in Kg. 2.

amrson.

A LPG disaster

89

Burns (1987) Vol. 1YNo. 2

99

Table 1. Recordings by the seismograph of the


University of Mexico on 19 November, 1985

children
&+xi

[Under
the debris of the house the bodirs of
his wife Felisa, 30. and his four children. IO, 7, 4
and 2 yrars uld. wcrc discovered. In fhc next
house 3 family of ten had been killed.]

Recording
number

Intensity on the
Richter

Time
05h 44min
05h 46min
06h 15min
06 h 31 min
06h 47min
06h 49min
06h 54min
06h 59min
07hOlmin27s

52s
01s
53s
59s
56s
38s
29s
22s

scale

0.5

05

cloud was followed by an esten\ive tire in the


plant area.
The tirst explosion registcrcd on the seismograph al the University
of hlcxico wits at 05 h
44 min X 5. This
explosion
was
followed
by
another tight rxplosions
within 2 h (Ttrh/l* I).

THE

COURSE

OF EVENTS

During fhc weekend 17-18 Novcmhcr


I0S-l the
Pcmcx storage tanks wcrc hcing filled with l.P(i.
By early in the morning of Monday 19 the two
Iqcr
spheres and all the cylindrical tanks had
been liktl
up. During the feeding of the smaller
sphcrcs B suddsri prcssurc drop was obscrvcd in
the pipe lint at OS. IO h. The rrason for this wils ;I
Ic;tkagc: of LPG close to thr smaller spheres (No.
2 in Fig. 2), probably due to a pipe rupture
causrd by excess pressure. Eyewitncsscs
among
the military guards watching the LPG facilities
have confirmrd that they noticed ;I vapour cloud
nowing over the walis of about 1 m height which
surround the tanks. The smell of gas prior to the
disaster was also mcntioncd by several obscrvcrs.
The vapour cloud was slowly moved by the
north-east wind (0.4 m/s) towards the groundplrrcrd fkircpit (No. 7 in Fi,q. 2) aricl ignited. A
vapour cloud explosion
(IUVCI~) occurred.
From nn analysis of various rsports in the press.
it may be concluded that ignition of the vapour

Approximately
I min after the lirst explosion one
of the Iarpcst explosions of the whole scque~~cc
occurred (OS h JO min OI s). lhc explosions Nos
7 ;wd 7 wcru nw~t likclv CIIICto rupture of the
&llcr
spheres and they-wcl-c ;il1 of the HLEVLI
lypc (Ijoiliiig
I.iquid I:xp:intlinp
Vapour Explosion). According to the Scismlc Service of the
Univcr5ity of Mexico. they had 211 iritcnsity ofO.5
on the liichtcr scale. Unburnctl
and burning gas
critcrcd ths hi~tlscs south 0f the pl;mt artil ilntl scl
fire to cvcrythiag.
13l;ist WilVCS from Ihc explosions dcslroyctl ;I number of housch and shift4
scvcral cylindrical
tilnks
from their supports

Table II. The distance range of cylindrical


tanks and major fragments of spheres

Distance range

Bullets
(no.)

End tubes
(no.)

bullet

Sphere
fragments
(no.)

On supports
In their original
bund
Within 100 m
100-200 m
200-300 m
300-400 m
400-700 m
700-l 000 m
1000-l 200 m

11
17
4
3
2
1
1
1

Total

44

3
4
3
2
1
1
1

6
6
7
1
5

15

25

Two of them ruptured longitudmally.

91

Arturson: A LPG disaster

At the Llnig;i~ and (ia\oni;itic.o arcas ;thout 20


tank
trucks lxmicil
(Fix.
7) and many
thou~xd smallsr hottlcs of household gas lo;~ckd
on truck5 wcrc Jcstroyd
(bY,g. 8).

gas

fmgmcnts of cylilltlritill
Ir;rgnwits gStctf spccilic
kinetic cncrpy ;is ;I result of the physktl
cxplokn.
lhis kin&c
cncrgy turticrl the fr;tgnwnts
into ntis\ila which wtrc attered
over considcr;ihlc
dist;incea (7irhle /I antI i;is.s. 3, 4 anti S).
f.orty-four
tx~lis from ;I total of 48 could hc
traced. Mod likely ti)ur tmks
were fragrncntcd
into mailer picccs. The maximum distance over
which ;I hulkt txnk tr;tvcllctl was 12t)om south of
the site (Fig. 5). This hullct tank dcstroyctl two
houscb from which the inhabitants
had already
left due to the intcnkc heat. The weight of this
tdlct tank (cmptv) was c;ricul;ttal to hr 30 tons.
The m;lximum &t;mcc
to which fragments of
sphcrcs wcrc found to travel was btbt)m north of
hdlcl

huge nunihcr

of

I;irdi~ ;rritl qhw

the site. A total arc;1 of about ItM~tMM~m was


wvcrcly d;unagcd. including about 270 houhcs
(Fig. 6).

FYq. J. Wrerkagc ;II the Pcmcx plant steams as the Fire


Dqwrtmcnt cstinguisha the hl;~zs. Note the shift of
the c~lirrrlr~c~d~;mhs from their supports.

THE COURSE OF EVENTS AFTER THE


DISASTER
Initial action at the disaster site
Ilw chronological scqucnc~ of the rcscuc efforts
given by different authorities
and rclicf units ih
summarizrd
in 7iihk 111.
When the first tclephonc csll came to the fire
station at Ecatqxc
3 km cast of the disaster site
at OS.45 the ptxsonncl at the station had been
wakcmd by the lirst cxplokn.
The head of the
fircbrigade. convincal that a disaster had occurred, had nlrcady preporcd for turn-out
and
phoned police forces, ambulance crntrcs, and the
idarm ccntre of Tlalncpantlas.
Ten minutes later
the fire-fighting units from Ecatcpcc consisting of
IX firemen arrival BS the first rescue team to the
village of San Juxnico. On their way to the site
the iircmen obscrvcd a cylindrical bullet tank
llying in the air (Fig. S) and they noticd il loud

csplosion
(OS.40).
When
the
lir~hrigaclc
ilpplIKlCllCLl tllc site. the vikkgc WilS burning and
the lcmcx facilities wcrc coved
by tlamcs to
Due to
the height of &out 6(N) 111;llxwc ground.
the intcnsc hat the tire forces had to dop south
of the village. llalf of the lircmen st;lrtcd to
rescue the pcoplr running from the village with
their clothcs on lirc and the other half began to
fight the ncarcst burning houses and tried to
reach the Irmcx facilities from the south. The
hcilt was enormous. A huge number of frxgmcnts
of cylindrical bullet tanks and hphcrc fragments
wcrt sc;~ttcrcd all ovcr the plxcc. I louses collapsed. Black heavy smoke ;~ncl dust tklrkcnccl
the whole vdlcy. In these very dangerous and
dramatic circumstances the lirxt lirumcn on the
spot did heroic rtxuc work (Fig. 9). Only two of
them sustained thermal injuries.
In the mcantimc. tho highway patrols had been
alcrtd
and
they
implcni~ntctl
Opcr;ition

Acurson

A LPG disaster

93

Tab/e 111.The chronological sequence of events including the rescue efforts tn the San Juan Ixhuatepcc
dtsaster. 19 November 1984

05.00
Omin

05.10

30 min

05.35-05.40

05.44.52
05.45
05.46.01

lh

05.55
06.00
06.10
06.15
06.54.29

2h

07.00

3h
4h

08.00
09.00

5h

10.00

6h
-. 10h
-15h

11.00
15.30
20.00

Feeding with LPG of the four spherical storage tanks (volume 1600n?)
Pressure drop in the pipeline to Pemex. Leakage of LPG and a vapour cloud
flowing over the bund walls
The vapour cloud reaches the flare p11.200 m from the LPG leaking point, and is
ignited. A vapour cloud explosion (PUVCE) occurs followed by an extensive fire
at the plant area
Flrst explosion registered on the seismograph at the University of Mexico. A
BLEVE probably due to the first rupture of one of the four smaller spherical tanks
First telephone call to the fire station at Ecatepec, 3 km east of the disaster site
First major explosion (registered) probably due to BLEVE of two smaller
spherical tanks
First fire-fighting units from Ecatepec reach the San Juanico village
Police close roads
Various emergency services such as ambulances and rescue teams arrive
together with additional firebrigades
The Secretary for National Defence proclaimed the disaster DN-111-E Plan (an
earthquake plan) to be put into action
A second major explosion (registered), probably due to BLEVE of the fourth
small spherical tank
Panicking, caused especially by information via radio and TV from the area of
the disaster
All roads from San Juanico congested by refugees
Nearby hospitals overcrowded by patients. The Governor of the State of Mexico
arrives at the site
Most injured from the disaster have been taken care of and transported to a safe
place
Last registered explosion. Fire in San Juanico village extinguished
Fire within Pemex under control
Fire extinguished. Environmental sanitation. Removal of debris etc.

Burns (1987) Vol. 1YNo. 2

94

Volcano.
In conformity
with this operation
schcmc. cvcry highway that led to the diaastcr
;nxx W;I\ closed
to ;dI private traffic (0(x00 h).

untlcr control
had heen put

Only ~rl~oiil I h cl;ipscd hcforc the


emergency service\.
such
as ;lmblllance~

Evacuation of people from the disaster site


LlOst pcoplc living in the Villil~C
of S;ln
.flI;inico

cue

tcams

gndcs

(F@.

IO

and policemen

and

I I).

arrived

on

v:irioir5
and

ild~fiti0ll;ll
the

spot.

rc\-

firchri-

lhc tire

prcvkWcif from sf)rc;ding


;inif
lirst aid w;iS
u here ncccsxkry. During
thcx xtion4 the
sccoii~lmajor csfdosion took pl;icc. liycwitncbscs
SpOkC Of il W;lfi of tire ill111 IlC;it th;lt WA3 cloain~ in
on them ;lnd forcccf stiiergcncy
pcr5cwicI into il
tcnilxxiry
withdrilwal.
was

given

for N;ltiond
Lkfcncc
f>rod;lim~~f the I>i\atcr l)N-I I I-I! lfi1tI to bc plot
into ;iction. This fkln is 0fxrr;itcd by the ilrrlly
;intf
At

00.

15

the

llscd

m;linlv

time

on

3s

;I ev;~St

Sccrctilry

an
;lnil

C;lrthcfllilkC

pl;lrl.

I:fonl

coinf~fcs lirclwigxfc

at

fkmts

in the

nciphbouring plant\ had hccn brought under control. wcrc


the lirchrifack~
at>lc to vcnturs out into the
ground\ of the burning I_l(i dor;qc illltl tlistrihu[ion

ccntrc.

whcrc

they

tricil

the

to

put

out

the

cool the untl;un;~gd


t;inks.
As the water pipes iincf sprinkler SyStclllS
ilt [hc
Site
wcrtz clcstroycd ;y the lirst q~lo\ions and no
water pipe5 csistd
m the
viflagc. all the water
nccdcd for the lirc-lighting
hxl hc hc brought to
the arc;1 hy lorrick. About 1000 ~ch lorries wcrc
ofxrating
on
hfonday
19. The lirc w;i)r brought
rcniaining

fire

on

the

hills

by

and

3f.00

south

rrniaining

all

fire

h.

of

IIIC

village

took

Ilight

highwily.
Avcnuc
lnsurgentcs Nortc. amI \urrountlin~
hills soon ;Iftcr
the q~lo.Gons ;uid lircs startcif. f hc lird rdugccs
tow;lrds

the

nearby

ILId ilfrGltly
;lrrivcd
at Oh. I5 h at Indies
subw;iy station situ;ltcil 2.5 kill ;lWilV I
villqc.
Ch;iotic sccnc~ iloniin;itcd and
no

orpni~cd

cv;lcuation

during

the

VcrJcs
from

the

thcrc

was

IirSt

Icw

IiourS.
At

OS.tH)

congcstcd

t11;lt
tc;mi

(lMncp;mtl;~ ;u~f Fsdcr;d dktrict fircfightcrh and


firchrigdc5
from Mexico
<i(y). togcthcr with
pcrsonncl from the f&l Croa, Mexican Inatitutc
of Socid Security ;incl Govcrnnicnt
I lospitalx.
wcrc rcxxing
and
trxnqxxting
the injured to
provi5ion;il
rdicf
ccntrcs
;lIltf
10
hOSpitillS.
Altopcthcr
250
fircmcn
wcrc
working on the
spot. After sonic time they were able to install
jctsfxxyh to cool the storage tanks
vicinitv. Not until the Gtuation at

ilnd

at I.F..Ufh
out

According

ccntrcs

rcf)orts

alrout

the

from

hOtHNf

to makeshift
and

from

Jui~nk<) wcrc

S;m

rcfilgccs.
to

altogcthcr

ported

rods

h a11 the
by

of

;luthoriticS.

wcrc

sports

camps,

klsifica

the

cv;~cuccs

trans-

antI hcitlth

~iu;~tl;~lupc,

;I

rclicf

;intl 7000
pcoplc sfxnt the ni@
inside the prcmiscs of the
National Polytcchmc fnstitutc.
Most of this oft
triition WiIS organird
by voluntccrs. ~spccinlly
stutfcnt3. Mainly due to fxddicity in the ncwspaper reports. different
sorts of collections for
food. clothing ;mtf footwe;lr.
etc.
startctf
Within
a
few
hours.
The gocds wcrc clircctly transported
to the makeshift rclicf ccntres.
Approximately
3SW)
hot meals wcrc provi&d each tl;~y with an overall total of apfxoxiniately 17StMM).

ccntre

some

5 km

away.

fktwcen

StNfO

;incl

Primary medical care and transport of the


injured from the site of the disaster
For

the first

site

of

thcrc was total chaos at the


and
all the
rcscuc
work was
imf>roviscrl ;lnd without guidance ~UC to the Iitrgc
Sc:lfc
of cvcnls.
Attempts
to S;IVC pcoplc
from
the

hour.

tliS;lstcr

Arturson- A LPG disaster

To allow for smooth tr;iii~),c)rt;ltioii


id the iniurcd ;I liugc
p;irking arc;1 for ;I~~INII~I~~~~ Ixlimping 10 the various rclicf scrviccs w;i\ rrc;itctl
off the river 1.0s I<cmctlios. in thi* way. spcc
was
;ilso rcscrvctl for w;i(cr-arrving
lorries 2s
well ;is vcliicks
xid
hclicoyMcr5. i:cbr tr:inyort;ttion purpox3
the cmcrgcncy scrviccs u~l
30.3
;unbul;lncc\ ilntl 5 hclicoptcrs in shuttle traflic.
Scvcii
thouxind two hundrctl md thirty pcoldc
nc~Acil mdicd
help. Of thcw.
1070 of 1hcni
wcrc 30 scvcrclv iniurctl
that tlicv hd
to Ix
hqdaiizd.
;mci 025 of thchc hd s&x
t hcrmal
injuries. The injured wcrc t;rkn
to 33 tlilfcrcnl
hospit;ils,
most of thcni Iocatal within Mcuico
Citv.

Transportation

of corpses and identification

Duriy
the lirst thy _W ccqscs wcrc found at the
cik id the iliastcr
(/*;S. II!). h&N of the hodics
\ccrc grcatlv
chart-cd xd
unrcco~iiiz~rl~lc.
Attcnq~s
at Sitlcntilication
were mark cithcr at
rhc site or Ixkzr itI :I spccial morruary near San
Juanico. lhc idcntilkxtion
work W;IS primarily
mxlc both hy an cxprf
in forensic mctlicinc and
by rcl;itiva.
A qkd;il
group con\iating of ;I
forensic palhologisl.
il prosecutor
and sanit;iry

pcrsonncl

~inishcd the iclcntific;1tion

\rt)rk williin

3, h. Only 15 out of the 1W corpc\ could IW


itlcntilictl. Tlic authorities thcrcfr,rc dcdctl
11i;b1
the burial of the hodics should hc m;rtk in ;I nwss
gr;ic. at ;I nearby coiickry
in I.os
(ilr;lCOiC\.
the
d:ry

;iflcr

the

dkistcr.

Hospitals designated for the handling of


severely burned patients
Out of the 730 pcoplc who wcrc (r;mq)ortccl (0
3.1 diffcrcnt
hospids,
1070 hatI to hc hospitalizcd. The most plausihk
numhcr of inp;iticnt\
with scvcrc thermal injuries i5 625. This ligurc
differs 3onicwh;d in rhffcrcnl reports for scbcrd
reasons. The lists of patients with hurnc av;iil;ihlc
at tliffcrcnt
hospitals wcrc not alwavs correct.
Sonic pMient5 wcrc sent honic or Ait
to orher
hospit;rls without changing the lists. (onfusion trf

Burns 11987)Vol. 13340.2

96

Table /V. Distribution


different hospitals

Hospitals

of

pattents

Hosp.
No.
Hosp.
Hosp.
No.
Hosp.

thermal

injuries

to

inpatients
5 days after
the
disaster

Specral
burn beds
{IlO.)

Patients
admitted
Ino.)

32

175

67

32
48
20
20
32

175
88
70
60
28

40
37
64
40
23

5
5

5
5

3
2

3
2

.- 625

300

Magdalena de las Salinas


Hosp. de Traumat Lomas
Verdes
Centro Medico*
La Raza Hosp.
Hosp. 10 de Octubre*
Hosp. 20 de Noviembre
Hosp. Adolf0 Lopez
Mateus
Hosp. General
No. 29

with

de Zona

General de Zona
57
Tacuba
General de Zona
58
lgmaris Zaragora

Total number

Illc tr;ttl\~~ort;ttit,rl
ol ptictih
\r.itli
hi-ii5
u;is
soniclimcs ni;itk rlircctlv to the lin;il dcstinalioti;
sc~tiictinics ;i1 lirst to ii l)rovision;ll
burn carc
Ixilil\
;incl later 10 ii hurii unit Ior spkdiml
c;irc. fhrcc ilab illlCF the ilisastcr Ihc 015 burn
paticrits were tlktributcd
at 12 iliffcrcnt hospitals
with gocxl burn fkilitics
(/k/)/t- IV). lhcsc hospitill! ilrC gcl~gr;lpllicilll~
hitu;itccl over ;I Idrgc
ilrC;l in ;I tlcnwly
i~optthtcd
pirt of Illcsiso City
with hmvy. ollcn co,n~cstcd. trdtic. Due 10 this it
was inyossiblc
to visit more than ;I few of them
\hithin ;I rc;~son;ihlc t&c.
In or&r
to get iin
ovcrvicw ofthe gcner;d stmclarcl of c;m at these
hospitals. I visitctl four of thcnl (ndicil
with
st;lr> in Iirhk IL). All thsbc hospit;lls
hxl :I
surprisin_cly iargc nurnhcr ol pcrsonncl. enough
spxc arid wcrc, in gcmml. well cquippxl.
All
burn piticnb
wsrc isikirctl cithcr in privq
ifi
I;lrgc room or ;~lonc in cubicdid
w:lrtls. The
gcncral trc;itmcnt
was ch;trxtcrizcil
by Wilrnl
hunimi care with ;ill kinds of conifort for the
piticnts. lhc reiativcs ucrc :illowcd to visit ;iI all
times anal any without rclxtivss hxl ;I close friend
at his klc helping him with kliiy prohlcms and
supporting
him in dilfcrcnl
W;I~S. Sornc of the

hc)spit;ils h;rtl iiliti;illy


10 t;ilic c;irc olii very I;irgc
ntrnibcr of p;ilicnt\ ~roiii the dki\tcr. Iliis probkin was. howcvcr. scrlvc~l cithcr by c;irlg di+
trihutiou idsonic pticiits
10 olhcr hcbpit;ils or by
cdling
up sxtr;l
p_xs~mncl in I;irgc nunibcr\.
Sonic of the iJig hc+Lils
wcrc ahlc. within :I
short tiiiic. to c;ill iip :i grc;lt nunibcr of ldiysickins ;inil nurses who wcrc well tr;iincd in the c;irc
of traumxk
tliscxscs. Ihcsc hospitds ilIsl> hild
;~dcqu;~te operating thcatrcs. wml rooms. CW. for
ail tlic p;iticnts.
All ;bgc-groups were rcprcscntctl aiiion~ the
burn p;iticnts. A qua1 nunihcr of chilclrcn kitI
susl;iinctl
burns.
fortunately
most of thcni of
;iiid of only Ixirtiiil
rhickncss
smxllcr
sxtcnt.
tlcpth (Fig. I-!). In gencrd thcrc wcrc rather few
very estcrisivc illlll tlccp burns and very few H hi)
ncctlcd trc;itnicnt
with ;I respirator
(kY<q. 15).
Prim;iry excision and grafting of n10\1 deep burns
kv;is pcrformcd.
when the cstcnt w;is Icss thxn
dx)ul 30 per cent of the tot;il ho+ surfxc
:irea.
I:ivc d+s after the disaster only IO0 out of the
hz.5 burn p;iticnts atlniiltcd
wcrc still in burn
units. Oric hundred xi~l forty kitI did (22 per
ttnt niort;ility
rate) ;intl IS.S kitI hccn sent hcWc
or tr;ursferrctl
to sm;lllcr hospit;lis.
A more ilctailcd tlcscription of the trcatnicnt
;ipplicil will hc reportccl frocii two burn units with

Arturson

A LPG

d~ssster

98
Table

W.

Boiling-liquid

expanding-vapour

explosions:

1951-84

Date

State/Country

Scene

7 July 1951

Explosion and fire of 70 tanks at tankyard

19 July 1955
29 July 1956
22 October 1965
8 January 1957
28 May 1959
4 January 1966
25 January 1969

Post Newark, New Jersev,


USA
Ludwigshafen. Germany
Amarillo. Texas. USA
Cottage Grove, -Oregon, USA
Montreal, Canada
McKittrict, California, USA
Feyzin, France
Laurel, Mississippi, USA

21 June1970
19 October 1971

Crescent City, Illinois. USA


Houston, Texas. USA

9 February 1972

Tewkesburv, Massachussetts,
USA
Rio de Janeiro, Brazil
Kingman, Arizona, USA

30 March 1972
5 July 1973
11 January

1974

12 February 1974
17 April 1974
2 December

1974

1 September 1975
31 August 1976

West Saint Paul, Minnesota,


USA
Oneonta. New York, USA
Bielefeld, Brackwcdde.
Germany
Haarlemmermeer-Rijsenhout,
Holland
Des Moines, Iowa, USA
Gadsen, Alabama, USA

26 November
1976
6 February 1977

Belt, Montana,

20 February 1977
23 April 1977
19 May 1977
22 February 1978

Dallas. Texas, USA


Long Island, New York, USA
Pocono Mountains,
Pennsylvania. USA
Waverly, Tennessee, USA

11 July 1978
30 May 1978

Los Alfaques, Spain


Texas CitY, Texas, USA

16 May 1979
8 September
1979
5 January 1980
8 January 1980

Vlaardingen, Holland
Paxton, Texas, USA

3 March 1980

Los Angeles, California,

26 November
1980
1980

Oosterwolde,

13 July 1981
16 August 1981
1981

USA

Boynton Beach, Florida, USA

Rotterdam, Holland
Erlecom, River Waal, Holland

Holland

Krcis Borken-Weseke.
Germany
Beunigen, Holland
Oldeholtpade, Wolvega,
Holland
USA

USA

Fatality/
injuries
-Ill

Explosion and fire of tank car


BLEVE of 3 oil tanks
BLEVE of LPG storage tank
Overflow butane. Sphere
Explosion in storage tanks
Explosion of tanks at refinery
Derailment of train tank cars, explosion
and fire
Derailment and explosion of 9 tank cars
Derailment of 18 tank cars, explosions and
fire
Collision tank vehicle with pipelines
causing BLEVE of storage tank
Explosion and BLEVE of aball tank
BLEVE of tank car caused bv exolosion
and fire of LPG distribution plant
Explosion of tank

-I2
20132
12112
l/-12
18140
2133
-166
1150
2121
37153
13196
4/6

Derailment and explosion of tank cars


Derailment of 36 tank cars, fire explosion
and BLEVE
Fire at car repair

-125
--l

Derailment and rupture of tank cars


Explosion tank vehicle and storage tanks
during transshipmenl
Derailment and explosion of several tank
cars
BLEVE of LPG cylinders caused by
derailment of freight train
Derailment of tank cars
BLEVE cylinders on truck
Leakage supply line caused explosion of van

-I3
3128

Derailment of several tank cars caused by


broken wheel
BLEVEs of LPG storage tanks
11 tanks exploded by unknown cause in
45 min
Fire in van and explosion of gas
Derailment of 33 train cars with chemicals,
explosion and fire for 2.5 days
Fire in bus station, LPG tank exploded
Collision of tanker Kombi 21 and Vessel
Rodort 6. explosion
Overturn and explosion of tank vehicle
loaded with gasoline
Explosion of tank in car during assembly

-/l

-I22
--l
-I1
ll-11
16143

102/140
7110
-I2
-18
-I1
-I2
212
-/l

Fire and explosion of tank vehicle

-12

Explosion of gas cylinder in house


Explosion of gas tank in car by collision

-/l
-11

BLEVE of cvlinder in converted coach

13117

Arturson: A LPG disaster

99

Date

State/Country

Scene

21 June 1982
1982
23 July 1984

Grootbroek, Holland
Suez, Egypt
Romeoville and Lemont,
Illinois, USA
San Juanico, Mexico

Cyclist hit fatally by fragment of cylinder


Fire and explosion of gas pipeline
Explosion and fire at refinery

19 November
1984

After treatment in the intensive care unit for 3


days all the iatrogenic problems were solved and
he recovered

rapidly.

Emergency organization and services


As soon as the magnitude of the disaster was
obvious, that is. at 06.15 h. the so-called National
Defence,
DN-I II-E Plan was put into action,

BLEVEs of LPG storage tanks

Fatality/
injuries
l/49
15l22
550/7000

c, Last stage of the programme covering the


period Y0 days to I year was aimed at the total
recovery of normality, including follow-up of the
previous stages especially the medical care. In
this case the construction of a technical school
will be included as well as a new health centre
and a kindergarten school.

DISCUSSION
Catastrophes caused by accidents in handling
dangerous goods have increased in number durinstance an earthquake.
ing the past few years (OECD. 1985). Out of 43
The Governor of the State of Mexico decided very severe industrial accidents during a IS-year
at this moment to appoint the State General period (IY70-8-t). 34 involved dangerous goods
Attorney to act as the executive coordinator in and 25 of these accidents were caused by noxious
assisting the civil population. When the Gover- or intlammable gases. The world consumption of
nor arrived at the disaster arca 4 h after the liquid petroleum gases has increased every year
accident hc commanded that the necessary meas- which is also reflcctcd in the statistics of accidents
ures be established according to five predetcr- (Tub/t* V).
mined criteria:
During the 15-year period IY5.%Y about 20
BLEVEs occurred causing 60 deaths and around
I, Assistance to the affcctcd population.
ltto severe thermal injuries. During the IS-year
2. Supply of material and economic support.
period lY70+
more than 30 BLEVEs occurred
3. Establishment of a public opinion and
with WH) deaths and 22tMjsevere burns. The most
affected population communication system.
serious of these accidents was the Los Alfaques
4. Adoption of sound measures to prevent
disaster in Spain in 197X, when a road tanker exsimilar catastrophes. and
ploded in a camping area and killed I02 people
5. Determination of responsibilities.
and caused I40 severe burns (Arturson. 19x1).
All these actions were set in a plan to be exWhat causes a BLEVE?
ecuted in a specific time-frame:
a, Immediate action, first 15 days after the In a BLEVE two events occur simultaneously
disaster. This action included temporary evacua- resulting in an enormous release of energy. If the
tion from the area, rescue and transportation of container is punctured or torn apart in pieces at
the injured to hospitals. prevention of epidemics the same time as the liquid in the container has a
(vaccination. fumigation, environmental sanitii- temperature over its boiling point at normal
tion, medical supplies, etc.), removal of debris, atmospheric pressure, a BLEVE occurs. Since all
removal of the dead and their identification, legal flammable gases are stored and transported
and funeral assistance for the bereaved.
under pressure, they can always contribute to a
b. Short-term action, lbY0 days after the dis- BLEVE. If the liquid is heated. for example by
aster, was aimed at totally restoring normal com- fire, it vaporizes. Mechanical causes can also
munity life. This action included environmental
underly a BLEVE. Collision or puncturing are
sanitation. distribution of canned food, recon- two such possible mechanical causes. Flammable
struction of the affected houses and urban infra- liquids not under pressure cannot cause a
structure.
BLEVE merely through collision. The container
This plan is operated by the army and includes a
broad coordination of different institutions of the
health sectors in case of a major disaster, for

100

Burns (1987) Vol. 13N0.

can of course break, but it does not explode.


There do not appear to have been any accidents
involving chilled gases in transport.
One of the
first options for the tire-fighters within the Pemex
depot was to cool the storage tanks with jetsprays.
A BLEVE
which involves large containers creates a shock wave so powerful that people 75IM)m away can be knocked down. Windows at a
distance of several kilometres can be broken.
The
tank involved
in connection
with
a
BLEVE
becomes a dangerous projectile.
The
trajectory of the container is determined by the
size of the tank. A tank containing
1Sm of
condensed gas will fly at least 30%600m.
sometimes up to Xo0m. In San Juanico a 4Sm3 tank
Hew I200 m.
The very high temperature
connected with
BLEVE
causes severe thermal injuries. The risk
zone for serious burns from small containers in a
BLEVE
is a IO-IS m radius. Flammable liquids
in barrels and containers filled with condensed
gas have a danger radius of 75 m. A tanker truck
involved in a BLEVE
entails a risk of serious
burns within a ISOm radius, while railroad cars
have a risk radius of about 2SOm (Arturson,
IYXI).
A BLEVE
generally produces a fireball upon
ignition.
The actual sizes and duration
of the
fireballs in the San Juanico disaster are diflicult to
estimatC. From the documentation available the
lirc looked more like a huge Ilare. ascending
hundreds of mctres into the sky and with a
diamCtCr ranging from 2trO to 3tM m. The tompcrature around the Ilare rcachcd about 1So0C. and
in the pcriphCral areas of the plant, as well as
2ot)m into the habitations,
between 300 and
S(H)C. The videotape of the San Juanico accident
reveals a BLEVE-type
explosion with a fireball
lasting at ICast 90s.
The fire was most likely fed
by a huge release of LPG,
indeed the largest
amount every involved in a BLEVE
went up in
smoke at the Pcmex distribution
plant.

Why such an enormous

disaster?

The San Juanico tragedy is one of the largest


disasters in industrial history and the most severe
LPG accident ever to occur. The reason for the
large number of fatalities and injuries is because
the built-up area, with a very high population
density. was situated close to the site.
When the plant. now struck by disaster, was
erected 25 years ago. the distance from the
habitations
was about 3(M)m. Under
pressure
from the large number of people moving in, the

authorities had been unable to prevent a relatively primitive


settlement from pushing ahead toward the depots. The shortest distance from the
rows of houses was
reduced to 13Om. In each
little dwelling lived at least five people. There
were also numerous livestock such as horses, pigs
and poultry.
Part of the area had houses built illegally,
without proper regard to regulations and facilities. Thus the streets were bad and narrow. No
water pipes existed. All water needed for the
fire-fighting
had to be brought to the area by
lorries. These circumstances. together with the
tremendous energy release causing the enormous
heat. fires with black heavy smoke. shock waves
and a huge number of fragments of pas cylinders
and spheres scattering all over the place. delayed
the rescue work and thereby increased the severity of the disaster.
What were the reasons for the disaster and
what preventive
measures
could have been
taken? There were several additional factors contributing to the disaster.
The accident started early on Mo~lry
nrornbig. All the time during the filling of the tanks a
ground level /lure WiIs burning in a device submerged in the ground for the burning-off
of
CXCCSS
gas.
The Ilare was burning below ground
level instead, a~ is usual, high above ground. It
WaS aISo pIaCed IOO CIOSC~IO lhe RUV de/~>~. The
s/rorfK witids preViiiling in the Villley Could easily
extinguish a Ilame above ground.
At 05.30 h u rupnrre in WI X in (31.3 cm) JiBecling
pipeline occurred above ground inside the Pcmcx
tank area and a pressure fall was registered.
From the control room of the retinery an attempt
was made to lind the reason for the fall in pressure, but without any result; nor was anybody able
to get in contact with the six-man staff in the
depot that night. The reason for this was that live
of the workers were found iti various areas within
the plant, dead and badly burned. The only worker
from the Pemex depot who survived ran out to
his car and drove to another depot nearby to
fetch help. Thus there was no contuct between rhe
corm-ol room utrd the outside of the plum. Other
important facts are that the disfunce between rhe
dvferent spheres und cylimlers wus IOO short. The
San Juanico plant did not huve uny PUS ulurms,
nor any wuter sprinkler system. There was no
emergency plun und no plum for muinrenance and
control in this large gas depot. The plants Health
and Safety Committee had severely criticized the
maintenance of some components of the plant in
documents written on several occasions before
the accident in November 19X4.

Arturson:

A LPG disaster

What lessons can be learned from the


tragedy of San Jurnico?
Even if we do not have all the facts it is possible
to analyse the events and learn some important
lessons. Some are so dramatic that a reevaluation of previous rules for distance and risk
areas should be undertaken, especially when
assessing the rules and regulations for LPG installation in various countries. The TN0 report
and analysis (1984) constitutes an excellent
source of information about the San Juanico
disaster in this respect (Pietersen and Huerta.
1984).
1. Prevention
The status of an LPC distribution plant is completely dependent on the allocation of sufficient
resources for maintenance and daily inspection.
Advanced training of personnel is also necessary.
in order to provide the greatest degree of security. In order to discover a gas leak at an early
stage there are now gas alarms, which should be
placed in sufficient numbers inside and around
the installation. They go off before the quantity
of gas approaches the explosion limit.
An emergency plan. including a check-list for
emergency measures. names and telephone numbers, must be formulated. The plan presupposes
that good preventive protection has been implemcntcd and that regular drills are held both
with personnel and management from the company and from the fire department and other
agcncics providing emergency help. If this is
carried out at least once a year, an updating is
ohtaincd of the plants measures to limit gas
Icakagc or prevent a flame from becoming a
holocaust.
2. Safe distance
Requirements regarding the safe distance between a major plant and local buildings involve
more than just the risk of fires spreading if gas
begins to burn or if BLEVEs occur. It also
includes the risk of damage by flying tanks or
other fragments of plant equipment. Other environmental factors, such as noise and odour.
also make the existence of a free zone around the
plant a priority.
The free area around the Pemex plant had
shrunk bit by bit: at the time of the accident only
l3Om separated the closest tanks from the local
populations houses. The distance should have
been at least 4tW)m. In that case there would have
been no danger of heat from the fireball or of
LPG droplets falling on clothing. The distance
would, however, not have been sufficient to pre-

101

vent damage from flying tanks or parts thereof.


In San Juanico a tank weighing about 30 tons
landed 12OOm away from the plant. This is a new
record. The previous distance considered to be
entirely safe was 800m. It is difficult to set a
definite limit. therefore total safety cannot be
achieved. In connection with transport of LPG.
for example, there are risks that must be eliminated in ways other than by setting distances
(Arturson. 1981).
3. The disaster could have been even worse
Of special interest from the technical point of
view are the very large number of BLEVEs that
occurred in the plant, the manner in which the
droplets spread and the consequences they had.
When the first explosion was under way, there
was no possibility of preventing others, yet the
two largest spheres, each with a volume of
2400 m, burned out without any BLEVE. There
are different theories as to why this happened.
However, if a BLEVE had occurred there during
the late morning, a large number of those 3OUO
people who were engaged in rescue and guarding
would have been killed or severely injured. Firemen tried to cool off the burning spheres with
water. Photographic documentation shows how
the water vaporized immediately (Fig. 9). No one
knows how close these spheres were to a
BLEVE. Eyewitnesses reported that an explosion took place in a cylindrical tank while firemen
were trying to cool it.
4. Disaster medicine
The most positive lessons are learned from the
rescue and medical field. After the understandable confusion caused by the chaos during the
first hours the different rescue efforts functioned
well, working through various organizations,
physicians and other health specialists, police and
military teams. There is no firebrigade in the
world trained to control such a situation from the
beginning. The work done in the first few hours
was particularly risky, considering the large number of BEEVES that rocked the area. Traffic
chaos and other obstacles initially prevented
effective rescue. Taking all this into account,
injured people who could be saved probably
received all possible help within the shortest
possible time-span.
There are several important reasons for the
fact that the disaster, in spite of its enormous
dimensions, could be mastered in a satisfactory
way. A disaster plan operated by the army and
used mainly as an earthquake plan was put into
action. From that time on large and complex

Burns (1987) Vol. 1YNo. 2

102

multidisciplinary rescue teams were functioning,


headed by a very competent chief commander. It
is interesting to notice that the total number of
personnel in these rescue teams was about the
same as the number of injured. It must have been
hard work to structure the rescue and restoration
measures. The prerequisites for a disastermedicine success were there, however, namely
enough resources in trained personnel and equipment, an enormous transport capacity and sufficient hospital beds in special bum units within
short distances.

Acknowledgements
The author acknowledges with thanks the help

Corrmpondcncr

given by Dr J. A. D. Settle in
English language in this article.

improving the

REFERENCES
Artur~~n G. (1981) The Los Alfaques Disaster: a
boiling-liquid expanding-vapour explosion. Burns 7,
233.
OEDC. Compendium, (1985).
Pietetsen C. M. and Huerta S. C. (1984) Analysis off/w
LPG Incident in San Juan Ixhuatepec, Mexico City.
19 November 1984. The Hague: TNO.

Paper accepted 14 November 1986.

should br oddrcssrd fo: Dr G. Arturson. Burn Ccnlrc. University Hospital. Uppsda. Swcdcn.

INHALATION INJURIES IN MAJOR BURNS


Saturday 3 October 1987, Leuven, Belgium

The aim of this international interdisciplinary symposium is to


gather worldwide experience on this very difficult subject in order
to improve knowledge of treatment of inhalation injuries and
other pulmonary complications in major burns.
Speakers include: J. W. L. Davies (Glasgow), T. H. Prien
(Miinster), D. Traber (Galveston), C. H. Clark (Glasgow),
B. Vanacker (Leuven), W. Boeckx (Leuven), R. E. Spijker and
D. T. Mackie (Beverwijk), D. Herndon (Galveston), H. Klasen
(Groningen), C. H. Puchstein (Miinster) and W. L. Manson
(Groningen).
For further information contact: Department of Anaesthesia,
Katholieke Universiteit Leuven, Gasthuisberg, Herestraat 49,
B-3000 Leuven, Belgium.

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