Accident Lesson Card · Real investigation (tap external link for official report)
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HSE Report No. HSE-TEXACO-1994 1994 Fire Fire Explosion Explosion
Texaco Milford Haven 炼油厂 控制阀误关(指示开)致 20 吨烃释放爆炸
Texaco Refinery, Milford Haven, Wales, UK (HSE Sragtech Case)
Related equipment → Control valve (control_valve)
0Fatalities
0Injuries
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

FCCU 火炬分液罐出口管控制阀实际关闭而控制系统指示开→20 吨烃溢流释放并爆炸(另有多起次生火)

2Root Cause

控制阀实际关闭而控制系统的指示为开;仪表/设备维护不足;改造未做后果评估;控制室人机界面缺陷

3Reliability Lessons (from investigation root cause)
  • The 'Root Cause' above is the core lesson of this accident; not split further.
4Associated Failure Mechanisms (Keywords)
控制阀 阀门 误关 指示错误 维护不足 释放 爆炸 火炬
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_2026-07-24
Report No. HSE-TEXACO-1994 · Data from HSE public investigation conclusions, compiled by Reliability AI, for reliability demonstration purposes only. This case is derived from public incident investigation reports for learning purposes only. AIM does not endorse or guarantee its accuracy.