Journal of Loss Prevention in the Process Industries 16 (2003) 297–303 www.elsevier.com/locate/jlp Fire incident at a refinery in West Malaysia: the causes and lessons learned Ibrahim M. Shaluf a,* , Fakhrul-Razi Ahmadun a , Aini Mat Said b a Department of Chemical and Environmental Engineering, University Putra Malaysia, 43400 Serdang, Selangor, Malaysia b Department of Resource Management and Consumer Studies, University Putra Malaysia, 43400 Serdang, Selangor, Malaysia Abstract Refineries are major hazard installations (MHI) which possess large quantities of hazardous substances. Refineries are charac- terized by high complexity and tight-coupled organization. Due to the high complexity and level of interaction among subsystems, designers and operators are unable to predict failures at the refinery units. The world has seen many incidents in refineries through leakage, fire and explosions. The consequences of the accidents sometimes extend beyond the boundary of the property and reach the neighboring residents. This paper reviews refinery incidents worldwide and also outlines the causes of a fire incident at a refinery in West Malaysia and the lessons learned.  2003 Elsevier Science Ltd. All rights reserved. Keywords: Major hazard installation; Refinery; Fire; Accident; Causes; Lessons learned 1. Introduction Nowadays, almost every country in the world operates a refinery(ies) to provide its industrial, transportation, commercial, housing, and other sectors with the required fuel. Refineries possess a large inventory of hazardous material, which exceed the threshold quantities and, therefore, are classified as major hazard installations. Major hazard installation is defined by CIMAH (1996) as an industrial activity which produces, processes, handles, uses, disposes of or stores, whether permanently or temporarily, one or more hazardous substances or a category or categories of hazardous substances in a quantity or quantities which is or are equal to or exceed the threshold quantity. Refineries are highly complex and tight-coupled organizations. The characteristics of high complexity and tight-coupled organizations are summarized by Turner and Pedgeon (1997). Perrow (cited in Turner and Pedgeon, 1997) has suggested that some contemporary technical installations are so complex and so closely meshed that accidents are inherent in their design: such * Corresponding author. Fax: 60-3-8657099. E-mail addresses: imshaluf@yahoo.co.uk (I.M. Shaluf); fakhrul @eng.upm.edu.my (F.-R. Ahmadun); ainimatsaid@hotmail.com (A.M. Said). 0950-4230/03/$ - see front matter  2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0950-4230(03)00021-4 systems generate what he calls “normal accidents”. Sys- tems of this kind display both a high degree of com- plexity and a very tight degree of coupling. It was pointed out that (Shrivistava, 1992) the acci- dents in complex, tightly coupled, interactive technologi- cal systems are caused by multiple failures in design, equipment, supplies, and procedures. Typically, system accidents occur because of unanticipated interactions among multiple failures. One component’s failure trig- gers failures in other components or subsystems. Due to the high complexity and level of interaction among subsystems, designers and operators are unable to predict failures or their mutual interactions. In addition, tight coupling between subsystems reduces the operator’s ability to control damages and recover from accidents once they are set in motion. The world has seen many incidents in refineries due to fire and explosions and leakage. For example, on 3 December 1999, an explosion occurred at the Thailand Oil Refinery at Si Raeha. The incident resulted in seven fatalities, 12 injuries, and US$ 25 million in damages and shutdown of the refinery. The fire continued for 42 hours, and forced thousands of people to flee their homes (Kong, 2000). On 24 October 1995, lightning struck a floating roof storage tank containing naphtha, at the Cila- cap Refinery. The fire spread into storage tanks resulting in a US$ 34.7 million loss (Kong, 2000). On 9 Nov-