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April
Summary
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
Summary
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
Summary
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
Summary
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

Summary
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
Summary
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
Summary
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
Summary
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

Summary
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
Summary
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
Summary
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
Summary
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

Summary
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
Summary
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
Summary
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
Summary
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
Summary
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
Summary
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
Summary
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
Summary
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
Summary
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,
Summary
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

Related Events
Summary
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
Summary
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

Summary
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 (
Summary
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
Summary
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
Summary
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

Summary
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
Summary
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

Related Events
Summary
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
Summary
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
Summary
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
Summary
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)

Summary
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
Summary
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
Summary
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
Summary
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)

Summary
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
Summary
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

Summary
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
Summary
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
Summary
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
Summary
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

Related Events
Summary
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
Summary
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
Summary
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
Summary
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
Related Events
Summary
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
Summary
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
Related Events
Summary
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
Summary
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
Summary
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
Summary
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

Summary
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
Summary
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

Related Events
Summary
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
Summary
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)

Summary
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
Summary
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
Summary
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
Summary
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
Summary
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
Summary
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

Related Events
Summary
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
Summary
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
Summary
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
Summary
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

Summary
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
Summary
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
Summary
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
Summary
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

Summary
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
Summary
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
Summary
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.
Summary
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
Related Events
Summary
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
Summary
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
Summary
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
Summary
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
May
Summary
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,
Summary
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
Summary
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
Summary
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

Summary
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
Summary
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

Summary
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
Summary
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
Summary
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.
Summary
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
References
Summary
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
Summary
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

Summary
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
Summary
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
Summary
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
Summary
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
Summary
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
Summary
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
Summary
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
Summary
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
Summary
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
Summary
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
Summary
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
Summary
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)

Summary
A 30-inch diameter crude oil pipeline failed and destroyed three spheroids, pumping units, and other equipment. Ignition was caused by motor vehicles.
Summary
A 30-inch diameter crude oil pipeline failed and destroyed three spheroids, pumping units, and other equipment. Ignition was caused by motor vehicles.
Summary
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
Summary
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.
The blaze spread to at least one other vessel docked beside the oil tanker while the force of the explosion caused minor damage to nearby homes, Dayan added.
Image Credit: AFP
Summary
On Tuesday 11 May 2004, at about noon, an explosion occurred at Grovepark Mills, Maryhill, Glasgow which caused the substantial collapse of the former Mill building. As a result, 9
Summary
On Tuesday 11 May 2004, at about noon, an explosion occurred at Grovepark Mills, Maryhill, Glasgow which caused the substantial collapse of the former Mill building. As a result, 9 people lost their lives and 45 people were seriously injured or exposed to the risk of death or injury.
The immediate cause of the explosion was the escape of LPG from the substantially corroded underground pipework at the cracked right-angled bend close to the southern wall of the building, the tracking of the escaped gas into the basement of the building at the west end, the accumulation of the gas in the basement to a point where it constituted an explosive mixture in air, and the ignition of that mixture.
Image Credit: HSE
Topics
11th May 2004
Summary
An explosion and fire razed a chemical factory in the Bandar Kinrara Industrial Park Fire & Rescue Department deployed eight fire trucks and 54 fire fighters. It was reported that
Summary
An explosion and fire razed a chemical factory in the Bandar Kinrara Industrial Park Fire & Rescue Department deployed eight fire trucks and 54 fire fighters. It was reported that the spark from the factory’s production floor ignited the highly flammable Hexane
Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: The Star
Summary
An electrical discharge in Acton Technologies company caused a fire in a warehouse were acetone was stored. School evacuation Proximate causes: • Hazardous work exposure Source: A web-based collection and analysis
Summary
An electrical discharge in Acton Technologies company caused a fire in a warehouse were acetone was stored. School evacuation
Proximate causes:
• Hazardous work exposure
Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Times Leader
Summary
A natural gas drilling rig sank in the Caribbean Sea, but all 95 workers were evacuated safely and there was no reported leakage. The sinking was caused by a sudden
Summary
A natural gas drilling rig sank in the Caribbean Sea, but all 95 workers were evacuated safely and there was no reported leakage. The sinking was caused by a sudden surge of water entering one of the submarine rafts that the platform legs floated on. Automatic subsea safety valves meant the well was secure and no leakage of oil occurred.
[ Property Damage $235 Million. Estimated Current Value $270 Million ]
Image credit: AFP
Summary
Ammonia release at recycling center workers was evacuated. Shelter in place was issued in nearby areas. Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285) Image
Summary
Ammonia release at recycling center workers was evacuated. Shelter in place was issued in nearby areas.
Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: BBC
Summary
On 15 May, an explosion at a chemicals plant in an industrial zone in Venice, Italy seriously burned two workers and sent clouds of smoke and flames into the sky,
Summary
On 15 May, an explosion at a chemicals plant in an industrial zone in Venice, Italy seriously burned two workers and sent clouds of smoke and flames into the sky, reports Reuters.
Citing local media, Reuters states that the explosion “hit” 3V Sigma, a specialty chemicals company. Reportedly, the blast prompted local authorities to order residents to stay indoors and close windows.
The scene was attended by ambulances and fire services, as well as officials from environmental agency ARPAV.
According to the news agency, an official from the civil protection department, Gianpaolo Bottacin, said that the area was blocked off to prevent the fire from extending beyond the 3V Sigma site. He added that he doubted it would be put out any time soon. The report does not note if or when the fire was extinguished.
Image Credit: Vigili del Fuoco via AP
Summary
A leakage of Carbon disulfide cooling pipe occurred in Ruixing company. 8 killed and 6 injured in the following rescue process. Proximate causes: • Inadequate tools, equipment & vehicles (pipe leaking) Source:
Summary
A leakage of Carbon disulfide cooling pipe occurred in Ruixing company. 8 killed and 6 injured in the following rescue process.
Proximate causes:
• Inadequate tools, equipment & vehicles (pipe leaking)
Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)

Summary
An explosion occurred in a chemical container Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Summary
An explosion occurred in a chemical container
Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)

Summary
A faulty temperature probe on a 600,000-metric-ton-per-year ethylene plant initiated an isolation of the hydrogenation reactor located within the cold section. While the operators were attempting to regain normal control,
Summary
A faulty temperature probe on a 600,000-metric-ton-per-year ethylene plant initiated an isolation of the hydrogenation reactor located within the cold section. While the operators were attempting to regain normal control, the pressure relief system operated. About the same time, fire was noted near grade level at the base of the de-ethanizer column. The source of fuel was believed to have been a flange at the de-ethanizer column reboiler or in the relief system pipe work. Leaking hydrocarbon, mostly propylene at 375 psig, was possibly ignited by hot steam piping. The intense fire rapidly engulfed the adjoining ethylene and propylene distillation columns and spread 180 feet to the storage area. Eventually, one vertical pressurized propane storage tank exploded, its top section traveling 1,500 feet and missing a gas holder by 30 feet. Two other propylene tanks toppled; one onto a pipe rack, and the other against an ethylene tank. All were protected by deluge waterspray systems, which apparently were ineffective under the intense fire exposure. Five of the eight ethylene and propylene tanks collapsed or exploded. The fire also spread to the API separator and to three floating roof tanks. Pipe racks, motor control centers, and pumps were severely damaged or destroyed. A few minutes after the fire brigade responded, the ethylene column released its 9,300 US gallon inventory, destroying one of the plant’s two foam trucks. Assisted by outside fire fighting agencies, the plant fire brigade brought the fire under control over 40 hours and finally extinguished it four days after the initial ignition.
[ Property Damage $74 Million. Estimated Current Value $185 Million ]
Image credit: No credit
Summary
An explosion at Kuraray America on May 19, 2018, injured 21 workers at the EVAL facility in Pasadena, Texas. The facility manufactures ethylene vinyl-alcohol copolymers, sold as EVAL. Kuraray America
Summary
An explosion at Kuraray America on May 19, 2018, injured 21 workers at the EVAL facility in Pasadena, Texas. The facility manufactures ethylene vinyl-alcohol copolymers, sold as EVAL. Kuraray America is a Tokyo-based specialty chemical manufacturer.
During pre-startup pressure-testing activities of a chemical reactor, an abnormal high-pressure condition occurred and over 2,000 pounds of ethylene were released to the atmosphere from a pressure relief valve. The ethylene vapors ignited, resulting in worker injuries. Twenty-one injured workers were transported to off-site medical facilities for treatment.
KEY ISSUES:
• HOT WORK
Image credit: CSB

Summary
Two people were injured by an oil tank explosion in Galveston, Texas on May 19. Local officials said workers had been conducting welding near or on the crude oil storage
Summary
Two people were injured by an oil tank explosion in Galveston, Texas on May 19. Local officials said workers had been conducting welding near or on the crude oil storage tank before the explosion happened at the storage terminal on the coast of Texas, southeast of Houston.
The blast happened at the Pelican Island Storage Terminal where tanks can hold up to 2 million gallons of crude oil. A fire was caused by the explosion, but firefighters were able to put the blaze out by using foam cannons before it could spread.
The nearby Texas A&M University issued a shelter-in-place order for those on the campus. The condition of the two injured workers is unknown.
The oil storage terminal is leased by Enjet, LLC. According to its website, Enjet specialises in the worldwide marketing, blending and storage of carbon black feedstock oils, fuel oils and feedstocks.
Image Credit: KPRC
Summary
On Wednesday 23 May 1984, a group of 44 people was assembled in a valve house set into a hillside at the outfall end of the Lune/Wyre Transfer Scheme at
Summary
On Wednesday 23 May 1984, a group of 44 people was assembled in a valve house set into a hillside at the outfall end of the Lune/Wyre Transfer Scheme at Abbeystead. The visitors were attending a presentation to allay anxieties on the effects of the installation on the winter flooding of the lower Wyre Valley.
As part of this presentation, water was to be pumped over the weir regulating the flow of water into the Wyre. Shortly after pumping commenced there was an intense flash, followed immediately by an explosion causing severe damage to the valve house.
Sixteen people were killed; no one escaped without injury from the valve house.
The explosion was caused by the ignition of a mixture of methane and air, which had accumulated in the valve house. The methane had been displaced from a void, which had formed in the end of the Wyresdale Tunnel during a period of 17 days before the explosion when no water was pumped through the system.
No source of ignition for the explosion has been positively identified. Thorough examination and testing of the electrical equipment has not revealed any faults likely to have caused ignition and there is insufficient evidence to confirm any of the other explanations which have been considered. Smoking in the Valve House was not prohibited because the likelihood of a flammable atmosphere arising there had not been envisaged.
KEY ISSUES:
• DESIGN CODES – PLANT
• LEAK / GAS DETECTION
• OPERATING PROCEDURES
• TRAINING
Report: https://www.icheme.org/media/13697/the-abbeystead-explosion.pdf
Image Credit: HSE
Related Events
Summary
On May 24, 2017, an explosion occurred at the Midland Resource Recovery (MRR) facility in Philippi, West Virginia, killing two workers and severely injuring another worker. The founder and president
Summary
On May 24, 2017, an explosion occurred at the Midland Resource Recovery (MRR) facility in Philippi, West Virginia, killing two workers and severely injuring another worker. The founder and president of MRR was one of the victims. The CSB initiated an investigation of the incident and deployed an investigative team on May 28, 2017. While the CSB was investigating this incident, the MRR facility experienced a second explosion, on June 20, 2017. This explosion fatally injured a contractor employed by Specialized Professional Services, Inc. (SPSI). MRR had hired SPSI to perform investigation and mitigation work at its Philippi facility following the May 24, 2017, explosion.
The CSB determined that the probable cause of these incidents was reactive, unstable chemicals that exploded when workers tried to drain the uncharacterized, chemically treated liquid from natural gas odorizer equipment. The CSB investigation found that MRR lacked an effective safety management system to identify and control hazards from reactive chemicals. Among other things, MRR had no formal hazard identification process in place to analyze or characterize what chemicals were inside the odorizer vessels (and in what quantity) before decommissioning and chemically treating this equipment with sodium hypochlorite. The company also lacked effective safeguards to prevent unexpected or uncontrolled chemical reactions.
Following these catastrophic incidents, MRR asserts that it has stopped using reactive chemicals, including sodium hypochlorite, and the company now uses a proprietary process to remove the mercaptan smell from decommissioned odorization equipment.
KEY ISSUES:
• INEFFECTIVE MANAGEMENT OF REACTIVE CHEMICAL HAZARDS
• LACK OF A PROCESS SAFETY MANAGEMENT SYSTEM
• PERSISTING GAPS IN FEDERAL SAFETY REGULATIONS FOR REACTIVE CHEMICAL HAZARDS
ROOT CAUSES:
1. The company did not conduct a formal evaluation of the reactive chemistry, perform a hazard analysis, and ensure that sufficient safeguards are in place to prevent reactive chemical incidents.
2. The company did have a thorough and complete understanding of their reactive chemistry under design conditions and under all foreseeable abnormal conditions.
Image credit: CSB

Summary
A fire occurred in the terpene resin production line reactor overheating, and it damaged an area of 800-900 square meters Proximate causes: • Inadequate tools, equipment & vehicles (overheat from reactor
Summary
A fire occurred in the terpene resin production line reactor overheating, and it damaged an area of 800-900 square meters
Proximate causes:
• Inadequate tools, equipment & vehicles (overheat from reactor of Terpene dilute resin leads the final pipeline explosion)
Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)

Summary
An abnormal chemical reaction occurred during the batch production of a thermoplastic rubber product, resulting in an explosion at this plant. As a result of the explosion the reactor, process
Summary
An abnormal chemical reaction occurred during the batch production of a thermoplastic rubber product, resulting in an explosion at this plant. As a result of the explosion the reactor, process controls, accessories, control room, and building for this production unit were completely destroyed.
The fire then spread to involve part of the tank farm, resulting in the destruction of five atmospheric storage tanks. At approximately 12:30, the first of four one million US gallon and a 500,000 US gallon styrene storage tanks exploded. A fire fighting attack using cooling water and foam hose streams was used to prevent the fire from involving other nearby storage tanks, two of which contained butadiene. The fire was extinguished after approximately nine hours.
[ Property Damage $182 Million. Estimated Current Value $363 Million ]
Image credit: Mike Cottrell
Related Events
Summary
Six people were killed and five others injured after a suspected explosion hit a hydropower plant in southwest China’s Yunnan Province on Friday. The emergency management department of Yunnan said the
Summary
Six people were killed and five others injured after a suspected explosion hit a hydropower plant in southwest China’s Yunnan Province on Friday.
The emergency management department of Yunnan said the accident happened at 11:10 a.m. at the Sinanjiang Hydropower Station in Mojiang County. It happened as workers were dredging the dam’s ventilation tunnel.
Authorities said the rescue operation had been completed and the injured were not in a life-threatening condition. An investigation has been launched into the cause of the accident
Image Credit: TN
Summary
On 29th May 2000 at 18:07 p.m. all power was lost to No. 1, 5 & 10 electrical substations that supply electrical power to the North Side of the Complex
Summary
On 29th May 2000 at 18:07 p.m. all power was lost to No. 1, 5 & 10 electrical substations that supply electrical power to the North Side of the Complex which contains the Oil Refinery, various chemical plants, utility plants and logistics facilities.
As a result, emergency shutdown of the Oil Refinery and the chemical plants on the North Side occurred and the utility plants were also affected due to a loss of power to the main cooling water pump systems. (There was some smoky flaring visible as a result of the emergency shutdown.)
In addition because of the duration of the power failure, a controlled shutdown of some other facilities elsewhere on-site (some chemical plants on the South Side and the Kinneil operations) was also necessary because the supply of steam for the correct operation of the flare system could not be maintained.
The HSE concluded that the power loss which occurred on the 29th May 2000 was caused by an earth fault on a 33kV underground power cable between No.1 and No.5 sub-station and the failure of the 33kV circuit breaker in No.1 sub-station to trip and clear the fault.
The source of the earth failure was not immediately apparent. The cable which failed was situated in the bottom part of the excavated trench, almost in the side wall of the trench and only protruded from its protective cable tile over a short length.
The fault was ultimately cleared by two 33kV circuit breakers in No.2 electrical sub-station resulting in power loss to No.1, No.5 and No.10 electrical sub-stations.
The immediate cause of the power distribution failure was a combination of two direct causes:
The Earth Fault
Forensic evidence indicated that the earth fault was caused by physical damage to the cable from an air powered tool known as a clayspade.The
clayspade equipment was operated by a number of different personnel during the construction of the trench and the cable was protected over the majority of its length, except in the location where the damage occurred, by the protective cable tile system. All personnel were aware of the responsibility to report any problems during the construction of the trench but none were reported. As a result of the damage the integrity of the lead sheath on the cable was breached, allowing water ingress, weakening of the cable’s insulation and the resultant earth fault.
Circuit Breaker Failure
The cable fault described above should have caused the 33kV circuit breaker in No.1 electrical sub-station to operate and clear the fault. However it failed to operate because its earth protection relay had been disabled by two small sections of plastic (cable ties with the ends cut-off) inserted in the connections between the relay and its current transformer. This meant that the earth fault protection relay was disabled and would not operate.
The power distribution failure had the potential to cause fatal injury and environmental impact, although no serious injury occurred, and there was only short term impact on the environment.
KEY ISSUES:
• Systems of work;
• The clarity and adequacy of instructions;
• The adequacy of supervision;
• Operatives behaviour;
• BP planning processes;
• Risk assessments carried out by the contractors;
• Details in the method statements;
• Inconsistent and different methods of application of the permit-to-work (PTW) system;
• Procedures, systems of work and test equipment for the testing of the 33kV circuit breaker;
• Implementation of maintenance policies.
Image Credit: HSE
Summary
A failure led to the release of light hydrocarbons that dispersed and found an ignition source. An intense fire followed in the tank farm. After less than five minutes, a
Summary
A failure led to the release of light hydrocarbons that dispersed and found an ignition source. An intense fire followed in the tank farm. After less than five minutes, a 5,000-bbl storage sphere failed, resulting in a large fireball and rocketed pieces of the sphere throughout the plant. Within the next 20 minutes, five 1,000-bbl horizontal vessels, four 1,000 bbl vertical vessels, and one additional 5,000 bbl sphere failed, either as a result of missile damage or due to a boiling liquid expanding vapor explosion (BLEVE). Pieces of the tanks travelled in all directions, falling into operating units and tank farms, starting more fires. Fragments also hit the firewater storage tank and electric fire pumps, leaving only the two diesel fire pumps operational.
[ Property Damage $55 Million. Estimated Current Value $211 Million ]
Image credit: Valero
Summary
At approximately 11:00 PM on May 31, 2017, explosion(s) at the Didion Milling (Didion) facility in Cambria, Wisconsin, resulted in 5 worker deaths and an additional 14 workers injured. Because
Summary
At approximately 11:00 PM on May 31, 2017, explosion(s) at the Didion Milling (Didion) facility in Cambria, Wisconsin, resulted in 5 worker deaths and an additional 14 workers injured. Because the event occurred at night, only 19 employees were working within the facility at the time of the incident.
Shortly before the explosion(s) at Didion, workers saw or smelled smoke on the first floor of one of the mill buildings. In trying to find its source, workers focused on a piece of equipment called a gap mill. While inspecting the equipment, workers witnessed a filter connected to an air intake line for the mill blow off, resulting in corn dust filling the air, and flames shooting from the air intake line, followed by one or more explosions..
KEY ISSUES:
• DUST HAZARD AWARENESS
• DUST LEVEL PERCEPTION
Image credit: CSB

Summary
A fire and subsequent explosion near the distillation unit on the refinery resulted in the whole site’s shutdown, which is expected to last up to 12 months.
Summary
A fire and subsequent explosion near the distillation unit on the refinery resulted in the whole site’s shutdown, which is expected to last up to 12 months.
June
Summary
At about 16:53 hours on Saturday 1 June 1974 the Nypro (UK) site at Flixborough was severely damaged by a large explosion. Twenty-eight workers were killed and a further 36
Summary
At about 16:53 hours on Saturday 1 June 1974 the Nypro (UK) site at Flixborough was severely damaged by a large explosion. Twenty-eight workers were killed and a further 36 suffered injuries. It is recognised that the number of casualties would have been more if the incident had occurred on a weekday, as the main office block was not occupied. Offsite consequences resulted in fifty-three reported injuries. Property in the surrounding area was damaged to a varying degree.
Prior to the explosion, on 27 March 1974, it was discovered that a vertical crack in reactor No.5 was leaking cyclohexane. The plant was subsequently shutdown for an investigation. The investigation that followed identified a serious problem with the reactor and the decision was taken to remove it and install a bypass assembly to connect reactors No.4 and No.6 so that the plant could continue production.
During the late afternoon on 1 June 1974 a 20 inch bypass system ruptured, which may have been caused by a fire on a nearby 8 inch pipe. This resulted in the escape of a large quantity of cyclohexane. The cyclohexane formed a flammable mixture and subsequently found a source of ignition. At about 16:53 hours there was a massive vapour cloud explosion which caused extensive damage and started numerous fires on the site.
Eighteen fatalities occurred in the control room as a result of the windows shattering and the collapse of the roof. No one escaped from the control room. The fires burned for several days and after ten days those that still raged were hampering the rescue work.
KEY ISSUES:
• PLANT MODIFICATION / CHANGE PROCEDURES
• DESIGN CODES – PIPEWORK
• MAINTENANCE PROCEDURES
• PLANT LAYOUT
• CONTROL ROOM DESIGN
• OPERATING PROCEDURES
• INERTING
Image Credit: Scunthorpe Telegraph (George Schofield)
Topics
Summary
Shortly after 6pm, on 2 June 2011, an atmospheric storage tank within the amine regeneration unit at the Chevron Pembroke Refinery exploded. A fireball split the tank open and killed
Summary
Shortly after 6pm, on 2 June 2011, an atmospheric storage tank within the amine regeneration unit at the Chevron Pembroke Refinery exploded. A fireball split the tank open and killed four workers: Robert Broome, Julie Jones, Dennis Riley and Andrew Jenkins. The sole survivor, Andrew Phillips, sustained severe burns and suffered life-changing injuries.
The force of the explosion ejected the five-tonne steel tank roof over 55 metres through the air. After narrowly missing a multi-fuel pipe track, the roof crashed onto a pressurised storage sphere containing extremely flammable butane. Good fortune prevented the airborne roof from puncturing the butane storage vessel, which would have led to an uncontrolled release of liquified petroleum gas (LPG).
The explosion was caused by the unintended ignition of a flammable atmosphere within the tank (17T302), during what should have been a routine cleaning operation conducted in preparation for maintenance.
KEY ISSUES:
• OPERATING PROCEDURES
• PERMIT SYSTEM
• CONTROL OF CONTRACTORS
• RISK ASSESSMENT
• COMPETENCE
Image Credit: HSE
Summary
A gas release from a corroded pipeline resulted in an explosion at a gas plant. This resulted in a 30% reduction in the Australian state’s domestic gas supply and a
Summary
A gas release from a corroded pipeline resulted in an explosion at a gas plant. This resulted in a 30% reduction in the Australian state’s domestic gas supply and a 45% reduction in the supply of gas to mines and other industries. Workers were evacuated from the island as a precaution. It took six months before the plant was returned to full capacity operation.
[ Property Damage $120 Million. Estimated Current Value $143 Million ]
Image credit: WA News
Summary
10 workers have now died following an explosion on 3 June, at a chemicals factory in India, reports news agency The Indian Express. Reportedly, more than 70 others were injured. The
Summary
10 workers have now died following an explosion on 3 June, at a chemicals factory in India, reports news agency The Indian Express. Reportedly, more than 70 others were injured.
The blast occurred at a facility owned by specialty chemicals and intermediates company Yashashvi Rasayan, in an industrial area located in Dahej, in the Bharuch district of Gujarat, India. New Delhi Television (NDTV) reports that the ensuing fire engulfed the entire factory.
The Indian Express reports that at the time of the blast nearly 150 employees were inside the factory. Of the 77 injured workers admitted to hospitals for treatment, 33 have now been discharged. Two workers are in critical condition, according to M D Modia of the General Administration Department of the Gujarat Government.
Following the explosion – reportedly heard from 3 km away – around 4,800 people were evacuated from the nearby villages of Lahki and Luvara, says another report from The Indian Express. According to Times Now, Modia said this was due to the presence of poisonous chemicals. The Indian Express reports that it was as a precautionary measure. It is not noted whether residents have yet returned to their homes.
According to The Indian Express, the Gujarat Government issued a closure notice to Yashashvi Rasayan for the site where the incident took place, and additionally ordered an audit of all the factories in Dahej. The report added that according to an official release from Vipul Mittra of the Gujarat Government, “[t]he unit will not be allowed to resume operations, until adequate safety measures are in place”.
N D Vaghela, Assistant Director in the Office for Industrial Safety & Health, reportedly said that the blast occurred in a chemical tank and damaged others. Reportedly, officials are unable to enter the storage area for now.
The Indian Express reports that the cause of the blast is currently unknown, according to Vaghela. A previous report from The Indian Express said the explosion was caused by an unknown reaction between two containers, and reports from other outlets have referred to the explosion as a boiler blast.
Image Credit: Times of India
Summary
A well-intervention vessel lost power and collided with an unmanned platform forming part of this 230,000 bbl per day complex. Heavy damage was caused to the vessel and the platform,
Summary
A well-intervention vessel lost power and collided with an unmanned platform forming part of this 230,000 bbl per day complex. Heavy damage was caused to the vessel and the platform, including damage to the platform structure, linking access bridge, and well equipment. Some 23,000 bbl per day of oil production was reportedly affected. The force of the collision caused the bow of the vessel to compress by about two meters, with the platform pushed partly out of position, loosening several support legs from the main load-bearing structure. One of the water injection risers on the platform was bent extensively and several wellheads were moved, with a catalog of further damage from the collision also identified.
[ Property Damage $750 Million. Estimated Current Value $909 Million ]
Image credit: No credit
Summary
Around 21,000 t of diesel has leaked into a Russian river near Norilsk, which is inside the Arctic circle, after a storage tank collapsed. It is believed that posts supporting
Summary
Around 21,000 t of diesel has leaked into a Russian river near Norilsk, which is inside the Arctic circle, after a storage tank collapsed. It is believed that posts supporting the tank sank due to melting permafrost following unusually warm weather.
The spill occurred at a heat and power plant operated by Norilsk-Taymyr Energy Company (NTEC), a subsidiary of Norilsk Nickel, on 29 May. According to Norilsk Nickel, around 21,000 t of diesel leaked into the Ambarnaya river. The company said that supporting posts at the base of a storage tank suddenly sank. Sergey Dyachenko, First Vice President and Chief Operating Officer of Norilsk Nickel, said: “We can assume that abnormally mild temperatures could have caused permafrost thawing resulting in partial subsidence of the tank’s supports.”
NTEC teams are currently assessing the risk of sinking soil under hazardous objects installed in permafrost. Dyachenko said that the tanks are inspected every second year so that negligence was not the cause of the collapse.
A fire also occurred on the site after a car came into contact with the leaked fuel, causing a fire around 300 m2 in area. The fire was contained and extinguished and the driver did not sustain any injuries.
Image Credit: Getty
Summary
An explosion at the Partridge-Raleigh oilfield in Raleigh, Mississippi. The incident occurred at about 8:30 a.m. on June 5, 2006, when Stringer’s Oilfield Services contract workers were installing pipe from
Summary
An explosion at the Partridge-Raleigh oilfield in Raleigh, Mississippi. The incident occurred at about 8:30 a.m. on June 5, 2006, when Stringer’s Oilfield Services contract workers were installing pipe from two production tanks to a third. Welding sparks ignited flammable vapor escaping from an open-ended pipe about four feet from the contractors’ welding activity on tank 4. The explosion killed three workers who were standing on top of tanks 3 and 4. A fourth worker was seriously injured.
KEY ISSUES:
• HOT WORK CONTROL
• SAFE WORK PRACTICES AT OIL & GAS PRODUCTION WELLS
ROOT CAUSES:
1. A gas detector was not used to test for flammable vapor.
2. ‘Flashing’ tanks containing hydrocarbons with a lit oxy-acetylene torch to determine the presence of flammable vapor is unsafe and extremely dangerous.
3. The open pipe on the adjacent tank was not capped or otherwise isolated.
4. A makeshift work platform – a ladder placed between the tanks – was used.
5. All tanks were interconnected and some of the tanks contained flammable residue and crude oil.
Image credit: CSB

Summary
An 18″ medium pressure (MP) steam main located near to the A904 Boness road ruptured at 23:18 p.m. on 7th June 2000 resulting in a significant loss of MP steam
Summary
An 18″ medium pressure (MP) steam main located near to the A904 Boness road ruptured at 23:18 p.m. on 7th June 2000 resulting in a significant loss of MP steam directly into the atmosphere. The steam leak damaged fencing immediately adjacent to the ruptured pipework. Debris and steam was blown across the road until the leak was isolated. The leak also caused significant noise (similar to a jet engine) being heard in the Grangemouth area. A member of the public walking the dog 300 metres away sustained rib injuries from tripping over the dog.
There was significant disruption to the steam supply system for the Complex for approximately one hour until the steam leak could be isolated and as a result of the incident the A904 Boness road was closed for public access until 22nd June whilst repairs were carried out.
The medium pressure (MP) steam main rupture had the potential to cause fatal injury and environmental impact, although no serious injury occurred, and there was only short term impact on the environment.
The critical factors that led to the incident were created a week earlier. Significant levels of condensate built up in the steam line following isolation of a steam trap to gain access for inspection of the tunnel, after the culvert was flooded following the power distribution failure.
The immediate cause of the catastrophic failure of an MP steam distribution pipeline was “condensation induced water hammer” which caused gross overpressure.
KEY ISSUES:
• Management of change (change control procedures);
• Failure to adequately investigate significant plant upsets and to carry out risk assessments;
• Operating regimes and lack of certain site standards;
• Inspection and maintenance of equipment;
• Management structure and organisation;
• Failure to learn lessons from previous incidents/events on-site.
Image Credit: HSE
Summary
A contractor died after entering a confined space at Dow Chemical’s plant in Oyster Creek. Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285) Image Credit:
Summary
A contractor died after entering a confined space at Dow Chemical’s plant in Oyster Creek.
Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Unidentified
Summary
On June 7, 2010, at 2:40 p.m., a truck-mounted power auger (auger truck) operated by C&H Power Line Construction (C&H) struck and punctured a 36-inch-diameter natural gas transmission pipeline
Summary
On June 7, 2010, at 2:40 p.m., a truck-mounted power auger (auger truck) operated by C&H Power Line Construction (C&H) struck and punctured a 36-inch-diameter natural gas transmission pipeline operated by Enterprise Products Operating, LLC (Enterprise). C&H, a contractor working for Brazos Electric (Brazos), was using the auger truck to dig holes for the installation of new electric service utility poles.
The accident occurred about 45 miles southwest of Fort Worth, Texas, near the town of Cleburne. The natural gas ignited and killed the auger operator and burned six workers, who were transported to a nearby hospital for treatment. The pipeline had a maximum allowable operating pressure (MAOP) of 1,051 pounds per square inch, gauge (psig) and was operating at 950 psig at the time of the accident. Total property damage and clean-up costs were estimated to be $1,029,000.
Summary
An explosion and fire occurred at one of manufacturing plant’s process units at Eastman Chemical Resins in Jefferson Hills. The fire was extinguished about 2 h after it began.
Summary
An explosion and fire occurred at one of manufacturing plant’s process units at Eastman Chemical Resins in Jefferson Hills. The fire was extinguished about 2 h after it began. Shelter-in-place order was issued
Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Unidentified
Summary
Fire and explosions occurred at the Miller Chemical and Fertilizer Complex, which blended raw materials to manufacture agricultural products Damage to the facility: $20 million dollars/Shelter-inplace within a mile radius of
Summary
Fire and explosions occurred at the Miller Chemical and Fertilizer Complex, which blended raw materials to manufacture agricultural products
Damage to the facility: $20 million dollars/Shelter-inplace within a mile radius of the warehouse
Proximate causes:
• Defective equipment
Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: 911 Photography
Summary
There was a chemical leak in a cracking unit at Dow Chemical’s Oyster Creek Plant. In this incident the release did not result in a fire. Nearby residents and employees
Summary
There was a chemical leak in a cracking unit at Dow Chemical’s Oyster Creek Plant. In this incident the release did not result in a fire. Nearby residents and employees were asked to stay indoors
Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Dow