Event Type 0 11 – 100 Fatalities
Audits & Reviews
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Control of Work
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MONITORING & IMPROVEMENT
PROCESS SAFETY MANAGEMENT
Food & Drink
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Plastics & Polymers
Pulp & Paper
Papua New Guinea
Fluid release to ground
Fluid release to water
Gas/vapour/mist/etc release to air
Rapid phase-transition explosion
Runaway reaction explosion
Solid release to air
Solid release to ground
Solid release to water
Design of Plant
Loss of Process Control
Physical Security Breach
COST (On Site)
ENVIRONMENTAL (On Site)
HUMAN (Offsite At Risk)
HUMAN (Offsite Fatalities)
HUMAN (Offsite Injuries)
HUMAN (On Site At Risk)
HUMAN (On Site Fatalities)
HUMAN (On Site Injuries)
> 100 Fatalities
< 100 Injuries
11 - 100 Fatalities
11 – 100 Fatalities
≥ 100 Injuries
PSV – Pilot Operated
Safety & Control
Shell & Tube
Valves - Safety
Methyl Ethyl Ketone
Oil based solvent
Urea Ammonium Nitrate
Vinyl Chloride Monomer
Live Event Type
Quantitative Risk Assessment
Dust Safety Science
Dutch Safety Board
New Zealand Government
Process Safety Integrity
Step Change in Safety
Corrosion Under Insulation
High Pressure Water
Loss of Utilities
Low Temperature Embrittlement
Normalization of Deviance
Safe Operating Limits
Stress Corrosion Cracking
Permit To Work
Learning from Incidents
Floating Roof Tanks
Minute To Learn
Safety Critical Decisions
202223OctAll DayPhillips 66 Explosion 1989Phillips 66 Pasadena (US-TX)Lessons:Asset integrity,Control of Work,Emergency Preparedness,Operational Integrity,Risk AssessmentIndustry:PetrochemicalsCountry:United StatesLanguage:ENLoC:Maintenance error Origin: HSE Incident:VCEHazards:FlammableImpact:HUMAN (On Site Fatalities)Effects:11 – 100 FatalitiesMaterial:EthyleneTopics:Occupied Buildings
At approximately 1:00 p.m. on the 23rd October 1989 Phillips’ 66 chemical complex at Pasadena, near Houston (USA) experienced a chemical release on the polyethylene plant. A flammable vapour cloud
At approximately 1:00 p.m. on the 23rd October 1989 Phillips’ 66 chemical complex at Pasadena, near Houston (USA) experienced a chemical release on the polyethylene plant. A flammable vapour cloud formed which subsequently ignited resulting in a massive vapour cloud explosion. Following this initial explosion there was a series of further explosions and fires.
The consequences of the explosions resulted in 23 fatalities and between 130 – 300 people were injured. Extensive damage to the plant facilities occurred.
The day before the incident scheduled maintenance work had begun to clear three of the six settling legs on a reactor. A specialist maintenance contractor was employed to carry out the work. A procedure was in place to isolate the leg to be worked on. During the clearing of No.2 settling leg part of the plug remained lodged in the pipework. A member of the team went to the control room to seek assistance. Shortly afterwards the release occurred. Approximately 2 minutes later the vapour cloud ignited.
• MAINTENANCE PROCEDURES
• LEAK / GAS DETECTION
• PLANT LAYOUT
• PERMIT TO WORK SYSTEMS
• ACTIVE / PASSIVE FIRE PROTECTION
• WARNING SISGNS
• EMERGENCY RESPONSE / SPILL CONTROL
Image Credit: Houston Chronicle
202204NovAll DayAppleby-Frodingham Steelworks Explosion 1975Appleby-Frodingham Scunthorpe (GB)Industry:Metal ProcessingCountry:United KingdomLanguage:ENLoC:Deterioration Origin: HSE Incident:Rapid phase-transition explosionHazards:Mechanical/Kinetic/PotentialImpact:HUMAN (On Site Fatalities)Effects:11 – 100 FatalitiesMaterial:Steel
At about 1.25 am on the fourth of November 1975 the foreman at the Queen Victoria Blast Furnace, Appleby-Frodingham Works started a cast that was intended to fill two torpedo
At about 1.25 am on the fourth of November 1975 the foreman at the Queen Victoria Blast Furnace, Appleby-Frodingham Works started a cast that was intended to fill two torpedo ladles. Conditions at the time were normal; the shift manager was in attendance.
Shortly before 2.00 am some 175 tonnes of metal had been run into the first torpedo and the iron stream diverted to the second ladle. Some 10 to 15 minutes later the blow pipe at the No. 3 tuyere position started to burn down on the side facing on to No. 2 tuyere hearth cooler. The burning developed rapidly with intense flame and sparks despite efforts by the furnace keeper to cool the pipe by spraying it with water.
Whilst the pipe was burning down, a substantial water leak from the furnace or fittings was observed. The source of the leak could not be identified because the face of the furnace was obscured by flame. For the same reason men could not approach the leak to take remedial action. The leak of water was under pressure and fell outwards from the furnace towards the edge of the hob; from the hob the water ran down the slope of the cast house floor joining eventually with the iron runnel Water entered the full torpedo ladle.
Within a few minutes of the blow pipe starting to burn down progressive action was being taken by the furnace crew to bring the furnace off blast so that a new pipe could be fitted.
Shortly before 2.47 am instructions from the shift manager were passed via Traffic Control to a loco driver and shunter to remove the full torpedo ladle from the vicinity of the furnace. Traffic personnel were made aware that water was running into the torpedo. As the loco was coupled to the ladle, water was seen to be coming from the iron runner. An explosion occurred as the ladle was moved. An eye witness identified the throat of the ladle as the seat of the explosion. The incident was timed at 2.47 am.
As a result of the explosion there were four immediate fatalities and 15 hospital admissions. Subsequently a further seven employees died as a result of injuries received.
At the time of the explosion 23 persons were working in the Queen Victoria furnace area. This number included four extra helpers standing by to assist in changing No. 3 blast pipe. Casting to the second torpedo was sti11 proceeding at the time of the explosion.
Image Credit: HSE
202207NovAll DayDSM Beek Explosion 1975DSM Beek (NL)Lessons:Asset integrity,Emergency PreparednessIndustry:RefiningCountry:NetherlandsLanguage:ENLoC:Undertemperature Origin: HSE Incident:VCEHazards:FlammableImpact:HUMAN (On Site Fatalities)Effects:11 – 100 FatalitiesMaterial:Propane
Early on 7 November 1975, start-up of the Naphtha cracker commenced on the ethylene plant at the Dutch State Mines (DSM) works at Beek. At 06:00 hours compressed gas was
Early on 7 November 1975, start-up of the Naphtha cracker commenced on the ethylene plant at the Dutch State Mines (DSM) works at Beek. At 06:00 hours compressed gas was sent to the low temperature system. At 09:48 hours an escape of vapour occurred from the depropaniser which ignited, resulting in a massive vapour cloud explosion. The explosion caused significant damage and started numerous fires around the plant. 14 people were killed and a total of 107 people injured, three of whom were outside of the site.
The investigation was hampered by the destruction of instrument records in the incident but evidence suggested that the release was due to low temperature embrittlement at the depropaniser feed drum. It was thought that the initial fracture had occurred on a 40 mm pipe connecting the feed drum to its relief valve. The normal operating temperature of the drum was 65°C, however, due to a process upset in the de-ethaniser column, the stream feeding into the depropaniser drum was a liquid at about 0°C(or lower) with a high C2 content. This would flash within the drum resulting in a temperature which could be as low as -10°C. The feed drum material could normally be used at temperatures as low as -20°C, however the fracture occurred at a weld, which with ageing may fail at up to 0°C.
The raising of the alarm was also flawed. The first operator to enter the control room to report the gas release was distressed and shocked. A second operator left the room to investigate, leaving orders for the fire alarm to be sounded. This did not occur. Some witnesses stated that the alarm system failed, but the investigation found that the system was in good working order before the explosion, and that none of the button switches had been operated.
• DESIGN CODES – PLANT
• EMERGENCY RESPONSE / SPILL CONTROL
Image Credit: Nationaal Archief
202219NovAll DayPike River Mine Explosion 2010Pike River Coal Pike River (NZ)Lessons:Audits & Reviews,Contractor Management,Emergency Preparedness,Operational ReadinessIndustry:MiningCountry:New ZealandLanguage:ENLoC:Deterioration Origin: New Zealand Government Incident:EXPLOSIONHazards:FlammableImpact:HUMAN (On Site Fatalities)Effects:11 – 100 FatalitiesMaterial:Methane
On Friday 19 November 2010 at 3:45pm there was an underground explosion at the Pike River coal mine. Twenty-nine men lost their lives, and their bodies have not been recovered. Two
On Friday 19 November 2010 at 3:45pm there was an underground explosion at the Pike River coal mine. Twenty-nine men lost their lives, and their bodies have not been recovered.
Two men survived the explosion. They were in the stone access tunnel (drift), a distance from the pit bottom area where the main workplaces were located. Although initially overcome, Daniel Rockhouse rescued himself and his colleague Russell Smith.
The New Zealand Police led the emergency response that involved emergency services, and mines rescue crews from New Zealand, New South Wales and Queensland. Despite strenuous efforts by everyone involved, a lack of information concerning the conditions underground prevented a rescue attempt.
A second explosion on Wednesday 24 November extinguished any hope of the mens survival. The emergency focus changed to recovery of the bodies.
Image Credit: AFP
202304JanAll DayFeyzin LPG Explosion 1966Total Feyzin (FR)Lessons:Asset integrity,Emergency Preparedness,Operating ProceduresIndustry:LPGCountry:FranceLanguage:ENLoC:Operator error Origin: HSE Incident:VCEHazards:FlammableImpact:HUMAN (On Site Fatalities)Effects:11 – 100 FatalitiesMaterial:Propane
On 4th January 1966, an operation to drain off an aqueous layer from a propane storage sphere was attempted. Two valves were opened in series on the bottom of the
On 4th January 1966, an operation to drain off an aqueous layer from a propane storage sphere was attempted. Two valves were opened in series on the bottom of the sphere. When the operation was nearly complete, the upper valve was closed and then cracked open again. No flow came out of the cracked valve, so it was opened further. The blockage, assumed to be ice or hydrate, cleared and propane gushed out. The operator was unable to close the upper valve and by the time he attempted to close the lower valve this was also frozen open. The alarm was raised and traffic on the nearby motorway was stopped. The resulting vapour cloud is thought to have found its source of ignition from a car about 160 m away. The storage sphere was enveloped in a fierce fire and upon lifting of the relief valve a stream of escaping vapour was ignited.
The LPG tank farm where the sphere was located consisted of four 1200 m3 propane and four 2000 m3 butane spheres. The fire brigade arrived on site, but were not experienced in dealing in refinery fires, and it appears they did not attempt to cool the burning sphere. They concentrated their hoses on cooling the remaining spheres. About 90 minutes after the initial leakage, the sphere ruptured, killing the men nearby. A wave of liquid propane flowed over the compound wall and fragments of the ruptured sphere cut through the legs of the next sphere which toppled over. The relief valve on this tank began to emit liquid.
The fire killed 18 people and injured 81 others. Five of the storage spheres were destroyed.
• DESIGN CODES – PIPEWORK
• SECONDARY CONTAINMENT
• OPERATING PROCEDURES
• EMERGENCY RESPONSE / SPILL CONTROL
• DESIGN CODES – PLANT
Image Credit: Fonds Georges Vermard
202308JanAll DayBantry Bay Terminal Explosion 1979Betelgeuse Whiddy Island (IE)Industry:ShippingCountry:IrelandLanguage:ENLoC:Fire exposure Origin: Marsh Incident:VCEHazards:FlammableImpact:HUMAN (On Site Fatalities)Effects:11 – 100 FatalitiesMaterial:Crude Oil
An 11-year-old, 121,000-deadweight-ton tanker had completed unloading its first parcel of Arabian heavy crude when a small fire was noticed on deck. About 10 minutes later, fire spread to both
An 11-year-old, 121,000-deadweight-ton tanker had completed unloading its first parcel of Arabian heavy crude when a small fire was noticed on deck. About 10 minutes later, fire spread to both sides of the ship. Later, a massive explosion occurred. The initiating event of the disaster was likely the buckling of the ship’s structure at deck level. Explosions in the ballast tanks and the breaking of the ship’s back followed. These events were produced by the conjunction of two separate factors: a seriously weakened hull due to inadequate maintenance and an excessive stress due to incorrect ballasting at the time of the disaster. In addition to the total loss of the ship, 1,130 feet of the concrete and steel jetty were damaged or destroyed.
[ Property Damage $70 Million. Estimated Current Value $248 Million ]
Image credit: Irish Times
202319JanAll DaySkikda Explosion 2004Sonatrach Skikda (DZ)Industry:LNGCountry:AlgeriaLanguage:ENLoC:Deterioration Origin: Marsh Incident:VCEHazards:FlammableImpact:HUMAN (On Site Fatalities)Effects:11 – 100 FatalitiesMaterial:LNG
An explosion at a liquefied natural gas (LNG) plant resulted in 27 people killed, 72 injured, and seven reported missing. The explosion destroyed three out of six liquefaction trains, damaged
An explosion at a liquefied natural gas (LNG) plant resulted in 27 people killed, 72 injured, and seven reported missing. The explosion destroyed three out of six liquefaction trains, damaged a nearby power plant, and led to the shutdown of a 335,000 bbl per day refinery. There was also some damage to the neighboring industrial facilities. A faulty boiler was initially blamed for the incident. Investigations, however, indicated that a large release of hydrocarbon from a cold-box exchanger was ignited upon ingestion into the boiler. Train six of the LNG complex re-started in May 2004 and trains five and 10 in September 2004. Trains 20, 30, and 40 were destroyed in the incident, representing 50% of the capacity of the LNG complex.
[ Property Damage $470 Million. Estimated Current Value $689 Million ]
Image credit: Sonatrach
202307FebAll DayImperial Sugar Dust Explosion 2008Imperial Sugar Co. Port Wentworth (US-GA)Lessons:Asset integrity,Competency,Compliance with Standards,Incident Investigation,Management of Change,Operational Integrity,Risk AssessmentIndustry:Food & DrinkCountry:United StatesLanguage:ENLoC:Operator error Origin: CSB Incident:Dust explosionHazards:FlammableContributory Factors:HousekeepingImpact:HUMAN (On Site Fatalities)Effects:11 – 100 FatalitiesMaterial:SugarTopics:Combustible Dust
On February 7, 2008, at about 7:15 p.m., a series of sugar dust explosions at the Imperial Sugar manufacturing facility in Port Wentworth, Georgia, resulted in 14 worker fatalities. Eight
On February 7, 2008, at about 7:15 p.m., a series of sugar dust explosions at the Imperial Sugar manufacturing facility in Port Wentworth, Georgia, resulted in 14 worker fatalities. Eight workers died at the scene and six others eventually succumbed to their injuries at the Joseph M. Still Burn Center in Augusta, Georgia. Thirty six workers were treated for serious burns and injuries – some caused permanent, life altering conditions. The explosions and subsequent fires destroyed the sugar packing buildings, palletizer room, and silos, and severely damaged the bulk train car loading area and parts of the sugar refining process areas.
• COMBUSTIBLE DUST HAZARD RECOGNITION
• MINIMIZING COMBUSTIBLE DUST ACCUMULATION IN THE WORKPLACE
• EQUIPMENT DESIGN & MAINTENANCE
1. Sugar and cornstarch conveying equipment was not designed or maintained to minimize the release of sugar and sugar dust into the work area.
2. Inadequate housekeeping practices resulted in significant accumulations of combustible sugar and sugar dust on the floors and elevated surfaces throughout the packing buildings.
3. Imperial Sugar emergency evacuation plans were inadequate. Emergency evacuation drills were not conducted, and prompt worker notification to evacuate in the event of an emergency was inadequate.
Image credit: CSB