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A complex of six platforms located in 30 meters of water in the Gulf of Mexico was subject to a major fire. The fire originated on the lower decks of the production platform and resulted in major damage to that platform, radiation and fire damage to an adjacent compression platform, the loss of bridge links and pipelines, and radiation damage to other bridge links. The root-cause investigation required by the government identified corrosion of a small bore pipeline as the cause of the initial failure.

[ Property Damage $500 Million. Estimated Current Value $650 Million ]

Image credit: PEMEX

On April 2, 2010, the Tesoro Refining and Marketing Company LLC (‘Tesoro’) petroleum refinery in Anacortes, Washington (‘the Tesoro Anacortes Refinery’), experienced a catastrophic rupture of a heat exchanger in the Catalytic Reformer / Naphtha Hydrotreater unit (‘the NHT unit’). The heat exchanger, known as E-6600E (‘the E heat exchanger’), catastrophically ruptured because of High Temperature Hydrogen Attack (HTHA). Highly flammable hydrogen and naphtha at more than 500 degrees Fahrenheit (°F) were released from the ruptured heat exchanger and ignited, causing an explosion and an intense fire that burned for more than three hours. The rupture fatally injured seven Tesoro employees (one shift supervisor and six operators) who were working in the immediate vicinity of the heat exchanger at the time of the incident. To date this is the largest fatal incident at a US petroleum refinery since the BP Texas City accident in March 2005.

The NHT unit at the Tesoro Anacortes Refinery contained two parallel groups, or banks, of three heat exchangers (A/B/C and D/E/F) used to preheat process fluid before it entered a reactor, where impurities were treated for subsequent removal. The E heat exchanger was constructed of carbon steel.

At the time of the release, the Tesoro workers were in the final stages of a startup activity to put the A/B/C bank of heat exchangers back in service following cleaning. The D/E/F heat exchangers remained in service during this operation. Because of the refinery’s long history of frequent leaks and occasional fires during this startup activity, the CSB considers this work to be hazardous and nonroutine. While the operations staff was performing the startup operations, the E heat exchanger in the middle of the operating D/E/F bank catastrophically ruptured. .

KEY ISSUES:
• INHERENTLY SAFER DESIGN
• TESORO PROCESS SAFETY CULTURE
• CONTROL OF NONROUTINE WORK
• MECHANICAL INTEGRITY INDUSTRY STANDARD DEFICIENCIES
• REGULATORY OVERSIGHT OF PETROLEUM REFINERIES

ROOT CAUSES:
1. High Temperature Hydrogen Attack
2. NHT Heat Exchanger Flanges – A History of Leaking
3. Hazardous Nonroutine Work
4. Process Hazard Analyses Failed to Prevent or Reduce the Consequences

Image credit: CSB

A fire broke out in the 188,000 barrels-per-day refinery, caused by flash-floods during heavy rain. The rain overwhelmed the storm drainage system on the refinery, resulting in hydrocarbons being washed out of the drains and around the site. An explosion was reported in the crude distillation unit. There were two fires in the crude distillation unit (CDU), one in the coking plant and two in the topping distillation plant. The government agency said the incident had been caused by hydrocarbons exploding in one of the coke manufacturing furnaces. The furnaces had been shut down, but were still hot enough to ignite the hydrocarbon. It took eight hours to extinguish the fire and 10 hours before the incident was under control. There were no fatalities or injuries.

[ Property Damage $225 Million. Estimated Current Value $243 Million ]

Image credit: YPF

On Tuesday, April 2, 2019, just before 10:46 am, a vapor cloud of isobutylene formed at the KMCO, LLC (‘KMCO’) facility in Crosby, Texas after a three-inch gray iron (a type of cast iron) y-strainer, a piping component, failed.

Shortly after 10:50 am, the vapor cloud found an ignition source and ignited, causing an explosion. The explosion killed one KMCO worker and seriously burned two others. On the day of the incident, more than 200 KMCO employees, contract workers, and visitors were onsite. The incident injured at least 30 workers (seven KMCO employees and 23 contract workers). A shelter-in-place was issued to community members within one mile of the KMCO facility.

KEY ISSUES:
• MECHANICAL INTEGRITY

Image credit: CSB

A fire started inside a depot with 3 million liters of diesel and the flames spread to four neighboring storage tanks. The fire lasted for 9 days.

Fine of around USD $6.4 million (R$ 22.5 million). Environmental impact causing death of thousands of fish

Proximate causes:
• Inadequate management/ supervision
• Inadequate work planning

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Paulo Whitaker / Reuters

At approximately 7:20 a.m. on April 3, 2017, the bottom of a steam condensate (hot water) storage tank catastrophically failed at the Loy-Lange Box Company (LLBC), located at 222 Russell Boulevard in St. Louis, Missouri. The 1952-pound, 30-inch diameter by 17-½-feet long steel tank, called a Semi-Closed Receiver (SCR)4 contained about 510 gallons condensed steam (water at about 330 °F and 100 psig.) Condensate from the vertically-mounted SCR was normally sent to two associated steam generators.

As the pressure in the tank suddenly dropped due to the failure of the tank bottom, a portion of the water in the SCR instantaneously exploded into steam, resulting in an increase in volume of about 75 times the volume of the SCR. A steam explosion of this type is extremely hazardous. The energy released was equivalent to about 350 pounds of TNT. Some of that energy dissipated when the escaping steam condensed to water, but the surveillance video from a nearby custom work truck shop clearly shows the power of the explosion and the effect on the building, as does the damage evident after the event.

The force of the steam explosion exiting the bottom of the SCR destroyed a large portion of the LLBC facility, and launched the storage tank like a rocket through the roof. One LLBC employee was fatally injured, and a second was left in critical condition.

Even after pulling loose from all of the piping and floor attachments, and crashing up through the structure of the building and out through the roof, the 1952-pound SCR was still traveling at about 120 mph. It rose to about 425 feet above street level and traveled laterally across about 520 feet. It remained airborne for over 10 seconds. As it fell, the SCR crashed through the roof of Faultless Healthcare Linen’s property at 2030 S. Broadway, fatally injuring three individuals.

KEY ISSUES:
• CORROSION
• MECHANICAL INTEGRITY & INSPECTION

ROOT CAUSES:
1. Steam generator repairs.

Image credit: CSB

On 5 April 1975 at 11.lO hrs there was an explosion at the factory of Laporte Industries Ltd, Uphall Road , llford, Essex. It occurred in the process plant called a Lurgi Electrolytor and as a result of uncontrolled release of the caustic electrolyte used in the plant one man subsequently died from his injuries. The plant itself was extensively damaged by the explosion and there was some local damage to the building on the site.

The purpose of the electrolytor is to produce hydrogen by the electrolysis of potassium hydroxide solution. The process also produces oxygen which is discharged as a waste product.

On Saturday 5 April the operator on duty was R Church. He had come on duty at 06.30 hrs. At about 11.10 hrs there was an explosion in the oxygen separator drum which ruptured. This liberated a large quantity of caustic solution which splashed over the operator and covered most of his body. He was alone in the room at the time in accordance with normal practice. He was heard shouting for help by the shift supervisor (FW Howe) who was nearby and had hurried to the building after hearing a loud noise. Mr Howe found Mr Church kneeling on the floor of the building and led him outside. The factory rescue team took him to the washroom and put him in the shower. Shortly afterwards he was taken to hospital and died later as a result of caustic burns. Mr Howe and RJ McCool who assisted Mr Church both received burns as a result of contact with the caustic solution on his clothing, and RS Boxall, a lorry driver who was passing the building at the time was also splashed with caustic on the head and arms. He was detained in hospital for a few days, but all three men were able to resume their work in a short time.

Report: https://www.icheme.org/media/13690/the-explosion-at-laporte-industries-ilford.pdf

Image Credit: HSE

Fire in a chemical plant fueled by unidentified chemicals. Two explosions were reported, one of them was a cylinder. Smoke and debris

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Norman Price

A blast occurred in a pumping station, after leaking oil caught fire. 177 fire engines and more than 800 firefighters were rushed to the blaze, and more than 14,000 residents in the surrounding area were evacuated.

Proximate causes:
• Improper use of protective methods (Improper welding of conveying pipe)

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Getty

On April 7, 2003, at about 8:55 p.m., central daylight time, an 80,000-barrel storage tank at ConocoPhillips Company’s Glenpool South tank farm in Glenpool, Oklahoma, exploded and burned as it was being filled with diesel. The tank, designated tank 11, had previously contained gasoline, which had been removed from the tank earlier in the day. The tank contained between 7,397 and 7,600 barrels of diesel at the time of the explosion.

The resulting fire burned for about 21 hours and damaged two other storage tanks in the area. The cost of the accident, including emergency response, environmental remediation, evacuation, lost product, property damage, and claims, was $2,357,483. There were no injuries or fatalities. Nearby residents were evacuated, and schools were closed for 2 days.

Image Credit: NTSB

On April 8, 2011, at approximately 8:50 am, an explosion and fire occurred at a magazine known as ‘A-21’ located at Waikele Self Storage in Waipahu, Hawaii. Five Donaldson Enterprises, Inc. (DEI) employees were fatally injured and a sixth sustained minor injuries.

DEI, a small unexploded ordnance (UXO) clearance company based on the island of Oahu, was using the magazine to store seized contraband fireworks and prepare them for disposal. On the morning of the incident, five DEI personnel were disassembling one-inch contraband firework tubes on a cement loading dock located directly in front of the magazine entrance, while a sixth remained inside the magazine cleaning and organizing . To accomplish the disassembly work, DEI personnel cut into the individual firework tubes by hand using a PVC pipe cutter or knife and separated the individual explosive components contained within each tube, the aerial shells and the black powder (which functions as a lift charge) into cardboard boxes.

According to witness statements, around 8:30 am it began to rain heavily, and the DEI workers quickly moved materials involved in the disassembly process – including tools, chairs, and boxes containing aerial shells, black powder, and partially disassembled firework tubes – to just inside the magazine entrance. While five of the workers remained inside, the project supervisor went outside to the front left corner of the loading dock to make a phone call. While he was on the phone, an explosion occurred inside the magazine, and a fire ensued.

The five individuals located inside the magazine at the time of the incident did not survive. Three DEI employees sustained fatal burn injuries while two succumbed to carbon monoxide poisoning. The project supervisor sustained minor injuries.

KEY ISSUES:
• HAZARDS OF FIREWORKS DISPOSAL & THE ACCUMULATION OF EXPLOSIVE FIREWORKS COMPONENTS
• LACK OF REGULATIONS & INDUSTRY STANDARDS ADDRESSING FIREWORKS DISPOSAL
• INSUFFICIENT CONTRACTOR SELECTION & OVERSIGHT REQUIREMENTS FOR HAZARDOUS ACTIVITIES

ROOT CAUSES:
1. DEI’s hazard analysis of its fireworks disposal process was insufficient. The company failed to identify key hazards of handling, disassembling, and storing contraband commercial display fireworks, and did not adequately control the identified and evaluated hazards.
2. DEI personnel disposing of the fireworks lacked the training, experience, and knowledge of procedural safeguards for the safe conduct of the fireworks disposal.
3. DEI’s modifications to the fireworks disposal process accumulated substantially large quantities of explosive material in boxes, greatly increasing the potential explosion hazard. This change to the disposal process was not adequately reviewed for safety implications.

Image & AcciMap Credit: CSB

Image credit: CSB

On April 8, 2004, four workers were seriously injured when highly flammable gasoline components were released and ignited at the Giant Industries Ciniza refinery, east of Gallup, New Mexico. The release occurred as maintenance workers were removing a malfunctioning pump from the refinery’s hydrofluoric acid (HF) alkylation unit. Unknown to personnel, a shut-off valve connecting the pump to a distillation column was apparently in the open position, leading to the release and subsequent explosions.

KEY ISSUES:
• MECHANICAL INTEGRITY
• CORROSION & SCALE FORMATION
• VALVE DESIGN
• HUMAN FACTORS CONSIDERATION
• MANAGEMENT OF CHANGE
• LOCKOUT/TAGOUT & ISOLATION

ROOT CAUSES:
1. An MOC hazard analysis was not conducted.
2. the facility lacked procedures to verify that the pump had been isolated, depressurized and drained.
3. Instead of determining the cause of frequent pump malfunctions and then implementing a program that would prevent problems before they occurred, Giant used breakdown maintenance by making repeated repairs to the pump seals after failure.

Image Credit: CSB

A chemical drum which is speculated to have contained an old chemical exploded at Echotech fiber manufacturing factory workshop.

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Unidentified

On April 8, 1998, an explosion and fire occurred during the production of Automate Yellow 96 Dye at the Morton International Inc. plant in Paterson, New Jersey. The explosion and fire were the consequence of a runaway reaction, which overpressurized a 2000-gallon chemical vessel and released flammable material that ignited. Nine employees were injured.

KEY ISSUES:
• INTERNAL HAZARD COMMUNICATION & PROCESS SAFETY INFORMATION
• REACTIVE HAZARD MANAGEMENT
• PROCESS SAFETY MANAGEMENT

ROOT CAUSES:
1. Neither the preliminary hazard assessment conducted by Morton in Paterson during the design phase in 1990 nor the process hazard analysis conducted in 1995 addressed the reactive hazards of the Yellow 96 process.
2. Process safety information provided to plant operations personnel and the process hazard analysis team did not warn them of the potential for a dangerous runaway chemical reaction.

Image Credit: CSB

On April 9, 1998, an 18,000-gallon propane tank exploded at the Herrig Brothers farm in Albert City, Iowa. The explosion killed two volunteer firefighters and injured seven other emergency response personnel. Several buildings were also damaged by the blast.

KEY ISSUES:
• DESIGN & INSTALLATION DEFICIENCIES
• REGULATORY OVERSIGHT
• BLEVE HAZARD & EMERGENCY RESPONSE

ROOT CAUSES:
1. Protection for aboveground piping was inadequate.
2. The diameter of the pipe downstream from an excess flow valve was too narrow, which prevented the valve from functioning properly.
3. Fire fighter training for responding to BLEVEs was inadequate.

Image Credit: CSB

An oil spill occurred due to a failure of a block valve to seat properly during maintenance on a pump strainer in the visbreaker unit. The oil auto-ignited and the ensuing fire spread and destroyed the visbreaker and damaged adjacent equipment. Subsequent explosions, heat restricted fire fighting access, inadequately trained fire brigade personnel, and damage to the firewater distribution system further hindered extinguishing the fire in a timely manner. The fire was spread by the firewater application, and was finally extinguished with the help of the local fire department.

[ Property Damage $159 Million. Estimated Current Value $271 Million ]

Image credit: Citgo

Two employees accidently fell in an aerobic tank sewage treatment station. Two more employees fell into the aerobic tank in the subsequent rescue.

Proximate causes:
• Inadequate tools, equipment & vehicles (Aerobic tank no special ventilation equipment)

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)

A two-inch-diameter line carrying hydrogen gas at 3,000 psi failed at a weld, resulting in a high pressure hydrogen fire. The fire resulted in flame impingement on the calcium silicate insulation of the skirt for a 100-feet-high reactor in a hydrocracker unit. The steel skirt for this reactor, which was between 10 and 12 feet in diameter and had a wall thickness of seven inches, subsequently failed. The falling reactor damaged air coolers and other process equipment, greatly increasing the size of the loss. At the time of the incident, the hydrocracker unit was being shut down for maintenance and the reactor was in a hydrogen purge cycle. The initial hydrogen leak is believed to have resulted from the failure of an elbow to reducer weld in the two-inch-diameter hydrogen preheat exchanger by-pass line.

[ Property Damage $90 Million. Estimated Current Value $202 Million ]

Image credit: San Francisco Chronicle

A crack occurred in a pipeline (diameter 200 mm) conveying oil and gas, and the following fire damaged three pumps and some instrumentation

Proximate causes:
• Inadequate tools, equipment & vehicles (Equipment failure: sealing failure and pipe leak)

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)

An April 11, 2003, vessel explosion at the D.D. Williamson & Co., Inc. (DDW), plant in Louisville, Kentucky, killed one operator. The explosion damaged the western end of the facility and released 26,000 pounds of aqua ammonia (29.4 percent ammonia solution in water), forcing the evacuation of as many as 26 residents and requiring 1,500 people to shelter-in-place.

DDW used the vessel in the manufacture of food-grade caramel coloring. It functioned as a feed tank for a spray dryer that produced powdered colorants. The feed tank, which was heated with steam and pressurized with air, was operated manually. To ensure that the filling, heating, and material transfer processes stayed within operating limits, operators relied on their experience and on readouts from local temperature and pressure indicators.

The feed tank most likely failed as a result of overheating the caramel color liquid, which generated excessive pressure. .

KEY ISSUES:
• OVERPRESSURE PROTECTION
• HAZARD EVALUATION SYSTEMS
• LAYERS OF PROTECTION
• OPERATING PROCEDURES & TRAINING

ROOT CAUSES:
1. D.D. Williamson did not have effective programs in place to determine if equipment and processes met basic process and plant engineering requirements.
2. D.D. Williamson did not have adequate hazard analysis systems to identify feed tank hazards, nor did it effectively use contractors and consultants to evaluate and respond to associated risks.
3. D.D. Williamson did not have adequate operating procedures or adequate training programs to ensure that operators were aware of the risks of allowing the spray dryer feed tanks to overheat and knew how to respond appropriately.

Image Credit: CSB

A total of 638 workers were evacuated from this flotel after it began to lean to one side when water entered a pontoon. The flotel was located about 80 kilometres offshore Campeche, Mexico. There were no injuries reported as a result of the sudden inclination. It was reported that a total loss of the flotel resulted.

[ Property Damage $160 Million. Estimated Current Value $177 Million ]

Image credit: PEMEX

On the night of April 12, 2004, during an attempt to make the first production batch of triallyl cyanurate (TAC) at MFG Chemical, Inc. (MFG) in Dalton, Georgia, a runaway chemical reaction released highly toxic and flammable allyl alcohol and toxic allyl chloride into the nearby community. The fire department ordered an evacuation of residents and businesses within a halfmile of the facility. The release forced more than 200 families from their homes. One MFG employee sustained minor chemical burns and 154 people received decontamination and treatment at the local hospital for chemical exposure, including 15 police and ambulance personnel assisting with the evacuation. Five residents required overnight hospitalization for breathing difficulties. The reactor continued venting toxic vapor for nearly eight hours and the evacuation order lasted more than nine hours.

KEY ISSUES:
• REACTIVE CHEMICALS PROCESS DESIGN
• PROCESS SCALE-UP
• EMERGENCY PLANNING & RESPONSE

ROOT CAUSES:
1. MFG did not understand or anticipate the reactive chemistry hazards. They did not make use of readily available literature on the hazards of reactive chemistry, or conduct a comprehensive literature search of the reactive chemistry specifically involved in manufacturing the product, which would have alerted them to the hazards involved in manufacturing TAC.
2. MFG did not perform a comprehensive process design and hazard review of the laboratory scale-up to full production before attempting the first production run.
3. MFG did not prepare and implement an adequate emergency response plan. They did not train or equip employees to conduct emergency mitigation actions.
4. MFG did not implement the EPA Risk Management Program or the OSHA Process Safety Management program prior to receiving the allyl alcohol. The regulations require comprehensive engineering analyses of the process, emergency planning, a pre-startup safety review, and coordination with the local community before receiving the covered chemical at the site and introducing the covered chemical into the process.

Image Credit: CSB

A natural gas pipeline that was situated within a plowed field exploded and caused a fire. The location of the explosion helped crews keep it contained. One home was voluntarily evacuated

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: News Channel 10 Amarillo

The incident took place on Easter Monday the 16th April 2001. During the morning the SGP was operating normally and the Central Control Room (CCR) reported a quiet shift, with no alarms showing for the SGP. In the early afternoon there were only 185 people on site, rather than a normal weekday figure of about 800. Most of the staff were inside buildings preparing for the shift handover, which was due to occur at 3pm. A number of people were working in the open air.

At approximately 14.20 hrs a catastrophic failure of a section of pipework on the SGP plant occurred at an elbow just downstream of a water-into-gas injection point. The six inch diameter pipe P4363, (the overhead line carrying flammable gas under high pressure),ruptured releasing a huge cloud containing around 90% ethane/propane/butane. About 20-30 seconds later the gas cloud ignited. As a result a massive explosion and fire followed.

KEY LESSONS:

Management of Pipework Inspection
• Effective pipework inspection systems are a vital major accident prevention measure for high hazard pipework.
• Such systems should at least meet current industry good practice standard.
• Decisions on inspection intervals should be informed by suitable and sufficient information on process conditions and previous inspection findings.

Management of Change
• Effective management of change systems, which consider both plant and process modifications, are essential to prevent major accidents.
• Particular care is needed to ensure that ‘quick fix’ modifications, during the commissioning and early operation phases of new plant, are covered.

Management of Corrosion
• Systematic and thorough arrangements are necessary for the effective management of corrosion on major hazard installations.
• Such arrangements should ensure that any available information on relevant corrosion degradation mechanisms is identified and acted on.
• Adequate resource, including relevant expertise, should be applied to ensure that adequate standards are achieved and maintained.

Communication
• Effective communication is an important element of any safety management system. In the context of major hazard establishments the accurate recording and effective sharing of information and data relevant to plant corrosion is essential for major accident prevention.
• Communication systems should aim to actively involve the workforce in the prevention of major accidents as part of an adequately resourced process safety management system.

Image Credit: HSE

The Texas City disaster was an industrial accident that occurred April 16, 1947, in the Port of Texas City, Texas, at Galveston Bay. It was the deadliest industrial accident in U.S. history, and one of history’s largest non-nuclear explosions.

A mid-morning fire started on board the French-registered vessel SS Grandcamp (docked in the port), and detonated her cargo of approximately 2,200 tons (approximately 2,100 metric tons) of ammonium nitrate. This started a chain reaction of additional fires and explosions in other ships and nearby oil-storage facilities. The events killed a total of at least 581 people, including all but one member of the Texas City fire department.

The disaster triggered the first-ever class action lawsuit against the United States government, under the recently enacted Federal Tort Claims Act (FTCA), on behalf of 8,485 victims.

Image Credit: Carl E Linde / AP

During the transfer of acetal from one vessel to another a fire and explosion occurred due a chemical reaction, which caused the rupture of one of the vessels.

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Unidentified

On April 17, 2013, a fire and explosion occurred at the West Fertilizer Company (WFC), a fertilizer blending, retail, and distribution facility in West, Texas. The violent detonation fatally injured 12 emergency responders and three members of the public. Local hospitals treated more than 260 injured victims, many of whom required hospital admission. The blast completely destroyed the WFC facility and caused widespread damage to more than 150 offsite buildings. The WFC explosion is one of the most destructive incidents ever investigated by the U.S. Chemical Safety and Hazard Investigation Board (CSB) as measured by the loss of life among emergency responders and civilians; the many injuries sustained by people both inside and outside the facility fenceline; and the extensive damage to residences, schools, and other structures. Following the explosion, WFC filed for bankruptcy.

The explosion happened at about 7:51 pm central daylight time (CDT), approximately 20 minutes after the first signs of a fire were reported to the local 911 emergency response dispatch center. Several local volunteer fire departments responded to the facility, which had a stockpile of between 40 and 60 tons (80,000 to 120,000 pounds) fertilizer grade ammonium nitrate (FGAN), not counting additional FGAN not yet offloaded from a railcar.

More than half of the structures damaged during the explosion were demolished to make way for reconstruction. The demolished buildings include an intermediate school (552 feet southwest of the facility), a high school (1,263 feet southeast), a two-story apartment complex with 22 units (450 feet west) where two members of the public were fatally injured, and a 145-bed nursing home (500 feet west) where many of the seriously injured civilians resided. A middle school (2,000 feet southwest) also sustained serious but reparable damage. Section 3 describes the incident and its consequences in detail.

KEY ISSUES:
• REGULATORY OVERSIGHT
• HAZARD AWARENESS
• EMERGENCY PLANNING & RESPONSE
• FERTILIZER GRADE AMMONIUM NITRATE STORAGE PRACTICES
• LAND USE PLANNING & ZONING

ROOT CAUSES:
1. The presence of combustible materials used for construction of the facility and the fertilizer grade ammonium nitrate (FGAN) storage bins, in addition to the West Fertilizer Company (WFC) practice of storing combustibles near the FGAN pile, contributed to the progression and intensity of the fire and likely resulted in the detonation.
2. The WFC facility did not have a fire detection system to alert emergency responders or an automatic sprinkler system to extinguish the fire at an earlier stage of the incident.
3. Regulatory, Insurance, Emergency Response, Emergency & Land Use Planning deficiencies.

Image credit: CSB

On April 20, 2010, a multiple-fatality incident occurred at the Macondo oil well approximately 50 miles off the coast of Louisiana in the Gulf of Mexico during temporary well-abandonment activities on the Deepwater Horizon (DWH) drilling rig. Control of the well was lost, resulting in a blowout—the uncontrolled release of oil and gas (hydrocarbons) from the well. On the rig, the hydrocarbons found an ignition source and ignited. The resulting explosions and fire led to the deaths of 11 individuals, serious physical injuries to 17 others, the evacuation of 115 individuals from the rig, the sinking of the Deepwater Horizon, and massive marine and coastal damage from a reported 4 million barrels of released hydrocarbons.

BP was the main operator/lease holder responsible for the well design, and Transocean was the drilling contractor that owned and operated the DWH. On the day of the incident, the crew was completing temporary abandonment of the well so that it could be left in a safe condition until a production facility could return later to extract oil and gas from it.

Abandonment activities would essentially plug the well. Earlier, a critical cement barrier intended to keep the hydrocarbons below the seafloor had not been effectively installed at the bottom of the well. BP and Transocean personnel misinterpreted a test to assess cement barrier integrity, leading them to erroneously believe that the hydrocarbon bearing zone at the bottom of the well had been sealed. When the crew removed drilling mud from the well in preparation to install an additional cement barrier, the open blowout preventer (BOP) was the only physical barrier that could have potentially prevented hydrocarbons from reaching the rig and surrounding environment. The ability of the BOP to act as this barrier was contingent primarily upon human detection of the kick and timely activation and closure of the BOP.

Removing drilling mud after the test allowed hydrocarbons to flow past the failed cement barrier toward the DWH. The hydrocarbons continued to flow from the reservoir for almost an hour without human detection or the activation of the automated controls to close the BOP. Eventually, oil and gas passed above the BOP and forcefully released onto the rig. In response, the well operations crew manually closed the BOP. Oil and gas that had already flowed past the BOP continued to gush onto the rig, igniting and exploding. The explosion likely activated an automatic emergency response system designed to shear drillpipe passing through the BOP and seal the well, but it was unsuccessful.

KEY ISSUES:
• BOP TECHNICAL FAILURE ANALYSIS
• BARRIER MANAGEMENT AT MACONDO
• SAFETY CRITICAL ELEMENTS
• HUMAN FACTORS
• ORGANIZATIONAL LEARNING
• SAFETY PERFORMANCE INDICATORS
• RISK MANAGEMENT PRACTICES
• CORPORATE GOVERNANCE
• SAFETY CULTURE

ROOT CAUSES:
1. Technical Factors
2. Human and Organizational Factors
3. Regulatory Factors

Image Credit: CSB

A fire occurred in a company producing ammonia, and other chemical products. The facility was severely damaged in the catastrophic fire.

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)

An explosion occurred in a glycol unit refining tower of a petrochemical plant

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: CCTV

A piping leak resulted in a fire in this refinery coker unit. Smoke rose to over 3,000 feet, and the coker was shut down for approximately two months.

[ Property Damage $120 Million. Estimated Current Value $204 Million ]

Image credit: Tosco

On April 23, 2004, an explosion and fire killed five and seriously injured three workers at the Formosa Plastics Corporation, IL (Formosa-IL) PVC manufacturing facility in Illiopolis, Illinois. The explosion occurred after a large quantity of highly flammable vinyl chloride monomer (VCM) was inadvertently released from a reactor and ignited. The explosion and fire that followed destroyed much of the facility and burned for two days. Local authorities ordered residents within one mile of the facility to evacuate.

KEY ISSUES:
• HUMAN FACTORS
• HAZARD EVALUATION
• INCIDENT INVESTIGATION
• EMERGENCY RESPONSE

ROOT CAUSES:
1. Borden Chemical did not adequately address the potential for human error.
2. Formosa-IL did not adequately address the potential for human error.
3. Formosa-IL relied on a written procedure to control a hazard with potentially catastrophic consequences.

Image Credit: CSB

During the conversion of one of the platform wells from oil to gas production, a high-pressure gas pocket was encountered that forced the drill pipe out of the well. The business operations platform (BOP) failed to shut in the well, and sparks, caused by the drill pipe that was ejected from the well hitting one of the platform legs, ignited the escaping gas. The fire lasted for 31 days. The majority of the topside structure was destroyed and the facility was later declared a total loss. Redesign of the production module was completed in 45 days in an effort to shorten the loss of production as much as possible. Full production was restored 18 months after the loss.

[ Property Damage $330 Million. Estimated Current Value $762 Million ]

Image credit: Petrobras

On April 25, 2002, a chemical waste-mixing incident occurred at Kaltech Industries Group, Inc., a sign manufacturer located in the Chelsea district of New York City. At least 36 people were injured, including members of the public and six firefighters. Kaltech employees were consolidating hazardous waste from smaller containers into two larger drums when the explosion and fire occurred.

The Kaltech facility was located in a mixed-occupancy building in a densely populated urban area. Because the highly confined workspace in the basement offered limited pathways for the explosion to vent, there was extensive damage to the 10-story building. Street traffic was restricted for several days, and building tenants faced significant business interruptions.

KEY ISSUES:
• HAZARD COMMUNICATION
• HAZARDOUS WASTE HANDLING
• MUNICIPAL OVERSIGHT

ROOT CAUSES:
1. Kaltech did not develop or maintain a chemical hazard communication program in accordance with established OSHA standards.
2. Kaltech did not manage its hazardous waste in accordance with established EPA regulations.

Image Credit: CSB

On April 26, 1986, the Number Four RBMK reactor at the nuclear power plant at Chernobyl, Ukraine, went out of control during a test at low-power, leading to an explosion and fire that demolished the reactor building and released large amounts of radiation into the atmosphere. Safety measures were ignored, the uranium fuel in the reactor overheated and melted through the protective barriers. RBMK reactors do not have what is known as a containment structure, a concrete and steel dome over the reactor itself designed to keep radiation inside the plant in the event of such an accident. Consequently, radioactive elements including plutonium, iodine, strontium and caesium were scattered over a wide area. In addition, the graphite blocks used as a moderating material in the RBMK caught fire at high temperature as air entered the reactor core, which contributed to emission of radioactive materials into the environment.

Image Credit: Getty

On April 26, 2018, an explosion and subsequent fire occurred at the Superior Refinery Company LLC refinery in Superior, Wisconsin (‘Husky Superior Refinery’). The incident occurred in the refinery’s Fluid Catalytic Cracking Unit (FCCU). In preparation for the shutdown, the refinery brought in hundreds of contractors and increased operations staffing. The contractors were performing many tasks such as electrical work, preparing for chemical cleaning, building scaffolding, and welding. As a result of the explosion, thirty-six people sought medical attention, including eleven refinery and contract workers who suffered OSHA recordable injuries. In addition, a large portion of Superior, Wisconsin was evacuated. The refinery was shutting down in preparation for a five-week turnaround when an explosion occurred, sending several people to area hospitals with injuries.

KEY ISSUES:
• PYROPHORIC IRON SULFIDE

Image credit: CSB

Bulk Terminals was a storage tank farm with 78 tanks ranging in size up to 4900 m3. At about 12:30 hours on Friday 26 April 1974 a dull thud was heard and fumes were seen rising from the bund surrounding a 3300 m3 tank of silicon tetrachloride. It was discovered that a pressure relief valve on a 6-inch line leading to the tank had been inadvertently closed. The pressure in the system was sufficient to burst a flexible coupling in the line, shifting the piping system and cracking a 3-inch line on the tank wall. Liquid silicon tetrachloride escaped forming an irritant cloud containing hydrogen chloride gas.

The terminal management waited for the owners of the chemical to take emergency action and the fire service did not respond, as there was no fire. The EPA sent lime trucks to neutralise the chemical, but these were refused entry to the site. By 15:00 hours the cloud was 400 m wide, 300-450 m high and 1600 m long.

At 04:10 hours on Saturday 27 April, foam was added to blanket the liquid in the bund but this failed. At 09:00 hours fuel oil was added along with eight truck loads of lime. The vaporisation reduced dramatically and operations began to transfer the liquid from the damaged tank. At 08:00 hours on Sunday 28th April, it began to rain. Power lines were corroded by the hydrochloric acid in the rain, and four pumps became inoperable due to corrosion before a general power failure stopped all pumping.

The materials added into it had reduced the capacity of the bund, and a further pit had to be dug to take the overflow in the event of a full tank failure. It was attempted to seal the leak on the tank using quick drying cement. The first attempt failed and it wasn’t until 23:30 hours on Monday 29 April that the leak was sealed. It took until 3 May to empty the tank and until 15 May before emissions had reduced to tolerable levels. One person was killed, 160 hospitalised and 16,000 people were evacuated during this incident.

KEY ISSUES:
• RELIEF SYSTEMS / VENT SYSTEMS
• DESIGN CODES – PIPEWORK
• EMERGENCY RESPONSE / SPILL CONTROL
• SECONDARY CONTAINMENT

Image Credit: Chicago Fire Dept

A runaway chemical reaction occurred at Corden Pharma Ltd in Cork on Monday 28th April 2008. The incident resulted in the death of one operator and serious injury to another. The investigation carried out jointly between the Health and Safety Authority and Chilworth showed that the immediate cause of the incident was due to omission of acetone in reactor K6003 prior to Diethylcarbamoyl chloride (DECC) addition during synthesis of the acyloxypyridinium salt precursor to 2-cyano-3-methylpyridine. This resulted in a higher than expected adiabatic temperature rise leading to a two-stage decomposition, firstly of the acyloxypyridinium salt and then of the Picoline-Noxide starting material. The energy of the event was significant and resulted in considerable distortion of the reactor and release of contents at high temperature and pressure. The pressure wave resulted in significant building damage and ejection of debris. The exact reason why acetone was omitted has never been established although, with such a potentially severe consequence, the investigation concluded that more should have been done to eliminate the possibility of human error for this process step. The investigation also highlighted deficiencies in the sites execution of its process safety management systems, particular its HAZOP / risk assessment for this process.

Image credit: Independent.ie

A shelter-in-place was ordered when a fire broke out following an explosion in the propylene refrigeration section of an ethylene unit. The fire, which burned for three days, forced the shutdown of the facility for approximately six months, but caused no deaths or serious injuries.

[ Property Damage $200 Million. Estimated Current Value $268 Million ]

Image credit: Mark M. Hancock

Two firefighters were injured tackling a blaze at a refinery. The incident occurred when crude oil leaked from a pipe supplying the refinery from bulk storage tanks.

[ Property Damage $110 Million. Estimated Current Value $147 Million ]

Image credit: ISAB

Workers were preparing to check a compressor in the nitroparaffin unit when they noticed a small fire and sounded the plant fire alarm. About 30 seconds later, an explosion occurred, which was followed by a series of smaller explosions. The effects of the initial explosion were reported as far away as eight miles from the plant. Additionally, the initial explosion completely damaged an area of the plant approximately the size of a city block. Subsequent fires were reported to have burned for more than seven hours. Although the incident did not damage the two ammonia units on site, the entire plant was temporarily shut down for precautionary measures.

[ Property Damage $120 Million. Estimated Current Value $257 Million ]

Image credit: No credit

In the early morning hours of May 1, 2002, a fire erupted at the Third Coast Industries Friendswood facility, located in an unincorporated area of Brazoria County, Texas. The facility (which blended and packaged motor oils, hydraulic oils, and engine and other lubricants) was inadequately designed and protected to prevent the spread of fire.

Firefighters arrived at the scene within minutes, but had insufficient means to fight the fire, which burned for more than 24 hours. The fire consumed 1.2 million gallons of combustible and flammable liquids and destroyed the site. One hundred nearby residents were evacuated, a local school was closed, and significant environmental cleanup was necessary due to fumes and runoff. No employees or firefighters were injured during the incident..

KEY ISSUES:
• FIRE CONTROL
• CONSENSUS STANDARDS
• FIRE CODES

ROOT CAUSES:
1. Third Coast did not conduct an adequate fire protection analysis to ensure implementation of fire protection measures.
2. The Third Coast facility fire suppression system was inadequate for detecting and warning of fire or smoke or for stopping fire spread.
3. The Third Coast facility lacked adequate control measures to limit the spread of the initial fire.

Image Credit: CSB

On May 3, 2019, a silicone manufacturing process generated a flammable gas inside an enclosed production building at the AB Specialty Silicones (‘AB Specialty’) facility in Waukegan, Illinois. At approximately 9:30 p.m., the flammable vapor cloud found an ignition source and ignited, causing an explosion and fire. The flammable vapor originated from the area where AB Specialty was making a silicon hydride emulsion.

The explosion fatally injured four AB Specialty employees and caused serious injury to another AB Specialty employee. At the time of the incident there were nine AB Specialty employees onsite. The explosion heavily damaged the AB Specialty’s production building. Additionally, the force from the explosion was felt up to 20 miles away in the surrounding communities, and some nearby businesses sustained damage from the blast. Post-incident, AB Specialty has resumed some of its operations at another location.

KEY ISSUES:
• FLAMMABLE GAS DETECTION
• FLAMMABLE GAS VENTILATION

Image credit: CSB

Enbridge responded to an explosion on Line 10 of its Texas Eastern Transmission Co. (Tetco) system in Fleming County, Kentucky, and said Tuesday that it has shut-in a section of the pipeline and secured the area. No injuries were reported.

The incident has reportedly impacted more than 1 billion cubic feet of daily north-to-south capacity on the system, sending natural gas futures higher after gaining Monday on falling production and higher anticipated demand due to predicted cold weather.

Line 10 is a 30-inch pipeline that is part of Enbridge’s Texas Eastern Natural Gas system.

Toronto-based Enbridge releases a brief statement in response to the blast.

“Enbridge is continuing to respond to the incident that occurred at approximately 5:00 p.m. ET, Monday, May 4, 2020, on its Line 10 natural gas pipeline in Fleming County, Kentucky. There were no injuries,” the company said.

“Our crews are on site and have secured the area. The impacted section of pipe was shut-in following the incident and remains isolated.”

Enbridge said it has notified county, state and federal agencies and officials and reportedly notified customers of a force majeure event resulting in an unplanned outage.

Genscape analyst Josh Garcia said in a note to clients early Tuesday morning that the blast occurred north of its Owingsville Compressor and “just upstream” of where an Enbridge pipeline explosion occurred in 2019.

Image Credit: Lex18

An explosion at a plant that manufactured ammonium perchlorate (AP) for rocket fuel flattened the local industrial park, left a crater 125 meters across, and cracked walls 15 miles away. Two people were killed. The cause was thought to be a fire in a batch dryer. The initial explosion was at 11:53 and was equivalent to 108 tons of TNT, with a second explosion four minutes later equivalent to 235 t of TNT. Approximately 50% of the buildings in the nearby town of Henderson, Nevada were destroyed, at cost of US$70 million. A natural gas pipeline that ran under the plant was ruptured in the event and burned for one week.

[ Property Damage $300 Million. Estimated Current Value $693 Million ]

Image credit: Las Vegas Review-Journal

At about 12:07 a.m. on May 4, 2009, highly flammable vapor, released from a waste recycling process, ignited and violently exploded, severely injuring two employees and slightly injuring two others at Veolia ES Technical Solutions, LLC. Multiple explosions afterward significantly damaged every structure on the site. Residences and businesses in the surrounding community also sustained considerable damage. The fire was declared under control by 10:38 a.m. that day.

KEY ISSUES:
• UNSAFE BUILDING SITING
• ATMOSPHERIC RELIEF SYSTEMS
• PLANT EMERGENCY PROCEDURES

ROOT CAUSES:
1. The vent devices were not designed to contain or control hazardous and/or toxic vapor.
2. No record existed of a process hazard analysis (PHA) to evaluate the siting of the lab/operations building so close to the operating units.

Image credit: CSB

At 3:37 a.m. on May 5, 1988, an explosion occurred in the catalytic cracking unit (CCU) of an oil and gas refinery. The explosion apparently was the result of corrosion of an 8-inch (200 mm) vapor line. This vapor line, under 270 pounds per square inch (1,900 kPa) pressure, ran from a 10-inch (250 mm) header that originated as the main overhead vapor line from the depropanizer column. The apparent instantaneous line failure released approximately 17,000 pounds (7,700 kg) of hydrocarbon vapor for approximately 30 seconds. A possible ignition source could have been the unit’s superheater furnace. The damage pattern indicated that the explosion was probably an aerial explosion with an epicenter located in the area between the depropanizer and the CCU control room. Employees #1, #2, #4, #5, and #7 were found fatally injured inside the CCU control room as a direct result of the blast. Employee #3 was found fatally injured approximately 30 feet (9.1 m) outside the west side of the CCU control room as a direct result of the blast. Employee #6 was fatally injured while he was exiting the GO-1 South control room. Damage from the explosion radiated one mile (1.6 km) from the center of the explosion and debris could be found as far as five miles (8.0 km) from the center of the explosion. The blast could be heard approximately 25 miles (40 km) away in New Orleans. There were reports that the blast set off burglar alarms in New Orleans. The explosion caused a fire to burn for eight hours at the oil refinery before it was brought under control. Chemicals that escaped during the explosion resulted in cars and homes being covered by a black film. The governor declared a state of emergency in Norco and St. Charles Parish. Seven shell workers were killed during the explosion and 48 residents and Shell workers were injured in the explosion. The explosion released 159 million pounds (72 kt) of toxic chemicals into the air, which led to widespread damage and the evacuating on 4,500 people.

[ Property Damage $288 Million. Estimated Current Value $665 Million ]

Image credit: Fort Myers Fire Academy

A devastating explosion Tuesday afternoon at an automotive plastics plant in Ottaviano, Italy, killed one worker and injured two, states the Facebook page for the country’s chief firefighting agency.

Video posted by Vigili del Fuoco shows a shattered industrial complex complete with wrecked cars, collapsed fencing and roofs stripped to the structural steel. Likewise, video posted to YouTube by nearby residents shows extensive damage to nearby homes.

Adler Plastics, based in Ottaviano, is a multi-national corporation with 58 plants in 19 countries. The company specializes in plastics used for acoustic and thermal comfort in high value automobiles

Authorities identified the single fatality as Vincenzo Lanza, 55, from Ottaviano. The injured workers were taken to hospitals in Nola and Cardarelli.

What one newspaper described as a ‘crazy roar’ heard more than 10 kilometers away preceded the 4 p.m. blast. That same publication, Il Riformista, said the blast originated in a portion of the facility occupied by ovens used to heat the plastics.

Air quality monitoring of the black smoke rising from the wreckage is in progress, officials said

Image Credit: iNews24.it

At least 12 people were killed and 129 injured in an explosion and fire at a petrochemicals plant that manufactured polybutadiene. In addition, thousands of people were evacuated from adjacent factories and communities within a three-kilometre-radius of the site. The explosion and subsequent fire sent thick black smoke into the air above the site. The deaths and injuries were as a result of blast injuries, burns, and inhalation of toxic fumes. It was reported that the explosion and fire occurred while workers were cleaning the polymer production line to change between batches, using toluene as a cleaning solvent.

[ Property Damage $143 Million. Estimated Current Value $156 Million ]

Image credit: Rigzone

Five people have serious injuries after an explosion at Grosvenor coal mine at Moranbah in central Queensland’s Bowen Basin.

Key points:
– Five workers have suffered serious injuries after an explosion at the coal mine
– The injured have significant burns to their torsos and airways
– Mining company Anglo American says the mine has been evacuated and all other personnel are accounted for

The patients suffered burns to their upper bodies and airways and were taken to Moranbah Hospital in a serious condition.

Ambulance crews were called to the scene just after 3:00pm and multiple rescue helicopters were called in.

A spokesperson for Queensland Mines Minister Anthony Lynham said the explosion took place at Grosvenor coal mine, which is operated by Anglo American.

In a statement, mining company Anglo American said it was in the process of evacuating the mine and the emergency response was underway.

“Five people have been injured and transported to hospital. All of the injured people’s families have been contacted,” it read.

Image Credit: ABC News

A gas leak at an Indian chemical factory has killed at least 11 people and hospitalised hundreds. The styrene tanks had been left unattended due to India’s coronavirus lockdown.

The LG Chemical plant, located in Visakhapatnam on India’s east coast, had been offline due to India’s coronavirus lockdown which began on 24 March. Relaxing of lockdown restrictions led to the plant restarting operations, which is when the leak occurred. Maintenance personnel were on-site at the time of the leak.

Two 5,000 t tanks of styrene leaked due a fault in the refrigeration unit, according to The Hindu, which created a styrene vapour cloud that spread around 3 km from the plant and affected five villages. It occurred around 03:00 local time on 7 May and at least 11 people were killed, including two children.

According to The Guardian, the gas caused people to collapse in the streets as they tried to evacuate. Dead cattle were also lying in the streets. Reports suggest 300–1,000 people have been hospitalised, with hospitals already under strain due to the Covid-19 pandemic. Victims suffer from a burning sensation in their eyes as well as breathing difficulties, with some needing ventilators. The BBC reported that according to officials, most should recover.

The gas leak is now under control, according to The New York Times.

The accident echoes the Bhopal tragedy in India in 1984, when a gas leak from a pesticide plant killed thousands and caused chronic illnesses for at least 100,000 people in the area.

Image Credit: AFP

An explosion, caused by sodium metal reacting with water, occurred in a chemical plant in Mohekou Bengbu City Industrial Park. The fire was put off in 1 h.

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)

A 30-inch diameter crude oil pipeline failed and destroyed three spheroids, pumping units, and other equipment. Ignition was caused by motor vehicles.

At least 22 people were injured when a crude oil tanker burst into flames at one of Indonesia’s busiest ports on Monday (May 11) with rescuers scrambling to reach dozens trapped on board, an official said.

Two explosions were heard shortly before the blaze erupted on the 250m long Jag Leela, belching huge clouds of thick black smoke into the air.

Firefighters on board another boat battled to put out the inferno on the Indonesia flagged vessel that was docked for repairs at North Sumatra’s Belawan port.

Emergency personnel rushed 22 injured sailors to hospital with dozens more still trapped on the tanker, said local police chief Dayan, who goes by one name.

The cause of the explosion and fire had yet to be determined, he said.