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HSE
Report No. HSE-PASADENA-1989
1989
Fire Fire Explosion Explosion
Phillips 66 Pasadena 聚乙烯装置反应器沉降腿维修隔离失效导致蒸气云爆炸 VCE（1989，23 死）
Phillips 66 Chemical Complex, Pasadena, Texas, USA (HSE Sragtech Case)
Related equipment → Reactor (reactor)Related equipment → Control valve (control_valve)Related equipment → piping (piping)
23Fatalities
200Injuries
ExplosionMechanism code FTC
⌗Failure Mode · ISO 14224 Mapping
Damage mechanism (recorded in KB)
ExplosionFTC
Internal damage-mechanism code (not ISO 14224)
ISO 14224:2016 functional failure code
OTH · Other
Mapped to ISO OTH — Other.
1What Happened
六台反应器沉降腿清理作业时单隔离球阀实际处于开启状态（气动软管接反，使本应关闭的阀门反而开启），聚乙烯粉料泄漏形成可燃蒸气云，延迟约 2 分钟点火→蒸气云爆炸(VCE)，23 死、130–300 伤
2Root Cause
采用单球阀隔离而非双隔断+盲板；阀门气动软管接反导致本应关闭的阀门实际开启；未断开阀空气软管；无气体检测；未执行 PTW；控制室受损通信中断
3Reliability Lessons (from investigation root cause)
- 采用单球阀隔离而非双隔断
- 盲板；阀门气动软管接反导致本应关闭的阀门实际开启；未断开阀空气软管；无气体检测；未执行 PTW；控制室受损通信中断
4Associated Failure Mechanisms (Keywords)
隔离阀 球阀 误开 氮气置换 动火 蒸气云 VCE 聚乙烯 沉降腿 维修隔离 可燃气体检测
About the Failure-Mode Code (click to expand)
The mechanism code FTC shown on this card is the KB's internal damage-mechanism abbreviation (not an ISO 14224 code); it describes how the equipment failed. The 'ISO 14224 Mapping' block above maps it to the correct ISO functional failure code (which describes what the equipment failed to do) — these are two distinct dimensions in ISO 14224. The mechanism follows the narrative in the card body.
5Evidence Source (transparent)
Authority：Health and Safety Executive (HSE), UK — Sragtech Case Study
Official Report：www.hse.gov.uk ↗
Data Verification：verified_url_hse_2026-08-07
↗Related Failure Modes · Traceability
This accident is not yet linked to a specific FM traceability card.