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> 100 Fatalities
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202202OctAll DayXcel Energy Hydroelectric Tunnel Fire 2007Xcel Energy Georgetown (US-CO)Lessons:Contractor Management,Control of Work,Emergency PreparednessIndustry:Renewable PowerCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:FIREHazards:FlammableContributory Factors:Electrostatic AccumulationImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Methyl Ethyl Ketone
On October 2, 2007, a chemical fire inside a permit-required confined space1 at Xcel Energy’s hydroelectric plant in a remote mountain location 45 miles (72 kilometers) west of Denver, Colorado,
On October 2, 2007, a chemical fire inside a permit-required confined space1 at Xcel Energy’s hydroelectric plant in a remote mountain location 45 miles (72 kilometers) west of Denver, Colorado, killed five and injured three workers. Industrial painting contractors were in the initial stages of recoating the 1,530-foot (466-meter) steel portion of a 4,300-foot (1,311-meter) enclosed penstock2 tunnel with an epoxy coating product when a flash fire occurred. Flammable solvent being used to clean the epoxy application equipment in the open penstock atmosphere ignited, likely from a static spark. The initial fire quickly grew as it ignited additional buckets of solvent and substantial amounts of combustible epoxy material, trapping and preventing five of the 11 workers from exiting the single point of egress within the penstock. Fourteen community emergency response teams responded to the incident. The five trapped workers communicated using handheld radios with co-workers and emergency responders for approximately 45 minutes before succumbing to smoke inhalation.
• SAFE LIMITS FOR WORKING IN CONFINED SPACE FLAMMABLE ATMOSPHERES
• PRE-JOB SAFETY PLANNING OF HAZARDOUS MAINTENANCE WORK
• CONTRACTOR SELECTION & OVERSIGHT
• EMERGENCY RESPONSE AND RESCUE
1. Xcel and RPI management did not ensure effective planning and coordination of the Cabin Creek penstock recoating project to control or eliminate the serious confined space hazards that were present.
2. Xcel’s and RPI’s corporate safety policies and permits did not effectively establish safe limits for flammable atmospheres in permit-required confined spaces that would prohibit entry or occupancy when those limits were exceeded.
3. Early in the planning process, Xcel identified the Cabin Creek penstock’s single point of egress in the event of an emergency as a major concern; RPI personnel also raised safety issues about a single exit. However, neither Xcel nor RPI management took remedial action.
4. Xcel management did not provide effective oversight of RPI to ensure the penstock recoating work was safely conducted.
Image credit: CSB
202216OctAll DaySodegaura Refinery Explosion 1992Fuji Oil Co. Sodegaura (JP)Industry:RefiningCountry:JapanLanguage:ENLoC:Maintenance error Origin: Marsh Incident:VCEHazards:FlammableImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Hydrocarbons
An explosion and subsequent fire resulted in significant property damage at this 146,500 bbl per day refinery. The explosion occurred following a heat exchanger failure in the hydrodesulphurization unit for
An explosion and subsequent fire resulted in significant property damage at this 146,500 bbl per day refinery. The explosion occurred following a heat exchanger failure in the hydrodesulphurization unit for light oil. The channel cover and lock ring of this heat exchanger were hurled into an adjacent factory, which was located approximately 650 feet from this plant. The channel cover and lock ring were each five feet in diameter, and weighed 4,000 lb and 2,000 lb, respectively. The hydrodesulphurization unit was being restarted following catalyst exchanging work when plant personnel noticed that hydrocarbon was being released from the heat exchanger. Plant personnel were working to complete the additional tightening work required on the heat exchanger bolts due to thermal expansion when the explosion occurred. The subsequent fire was brought under control in two hours and 45 minutes by firefighters using 15 fire trucks.
[ Property Damage $161 Million. Estimated Current Value $339 Million ]
Image credit: FOC
202217OctAll DayBASF (Ludwigshaven) Explosion 2016BASF Ludwigshaven (DE)Lessons:Contractor Management,Control of WorkIndustry:PetrochemicalsCountry:GermanyLanguage:ENLoC:Maintenance error Origin: ARIA Incident:VCEHazards:FlammableContributory Factors:ErrorImpact:HUMAN (Offsite Fatalities)Effects:1-10 FatalitiesMaterial:Butylene
On Monday, October 17, 2016, there was an explosion and subsequent fires at the North Harbor in Ludwigshafen. “We mourn two colleagues from the fire department and the seaman who
On Monday, October 17, 2016, there was an explosion and subsequent fires at the North Harbor in Ludwigshafen. “We mourn two colleagues from the fire department and the seaman who died in the fire. Our deepest sympathy is with their families and friends. Many people were injured, some of them severely. Our thoughts are with them and their families and friends. We hope that they are on the way to recovery,” said Dr. Kurt Bock, Chairman of the Board of Executive Directors of BASF at a press conference in Ludwigshafen, Germany.
The following information is currently known about the accident:
Victims: Two employees of the BASF fire department and an employee of a tanker which was anchored in the harbor died in the accident. Eight people were seriously injured, 22 others were slightly injured. One of the seriously injured has been released from the hospital.
Course of events: The course of events is still being investigated by the public prosecutor’s office of Frankenthal. The incident site is still locked. A few days prior to the accident, a specialized pipeline construction company began to conduct assembly works on a deflated and secured ethylene pipeline route. The aim of the assembly works was to exchange several parts of the pipeline as a preventive maintenance measure. On October 17, a fire started at 11:30 a.m. near the assembly works. Forces of the BASF fire department, emergency service and environment protection arrived a few minutes later at the incident area and immediately started emergency operations. During the initiation of emergency operations an explosion, most likely at the ethylene pipeline, occurred. The explosion led to subsequent fires at various points along the pipeline trench, damaging further product and supply pipelines. Additional emergency forces immediately began rescue measures as well as extinguishing and cooling measures. “The emergency forces operated in an extreme situation. Their effort cannot be expressed in words,” said Margret Suckale, Member of the Board and Site Director of Ludwigshafen.
The fire brigade performed controlled burning of the leaking products in accordance with the fire-fighting concept for compressed gases. The pipelines that burned included those used for ethylene, propylene, a butylene product mix (raffinate), pyrolysis gasoline and ethylhexanol. As of October 17, 9.30 p.m., the emergency forces extinguished the fire.
Environmental impact: Following the start of the fire, comprehensive air measurements were conducted at the site gate and in areas surrounding the site in Ludwigshafen and Mannheim. The measurements showed no elevated levels of hazardous substances, as confirmed by the environmental ministry of Rheinland-Pfalz and the city of Ludwigshafen. Additional measurements conducted by the cities of Speyer, Worms and Frankenthal showed no elevated levels. Elevated levels measured locally were restricted to the immediate area of the incident. BASF has published the results of the air measurements as well as an overview map online. Water samples also showed no elevated levels of hazardous substances. A contamination of the ground at the incident site is likely.
Status of the investigation: On October 26, the District Attorney of Frankenthal/Palatinate and the Police Headquarters of Rheinpfalz announced the following information on the progress of the investigation:
“In the course of intensive investigations directly at the scene of the incident, it has been established that there was a cut made in a pipeline. This was apparently done with a cutting disc. Maintenance work using an angle grinder was in progress on an adjacent pipeline. The cut pipeline was not part of this work. This pipeline contained flammable raffinate.” (Excerpt of the press release from District Attorney of Frankenthal/Palatinate and the Police Headquarters of Rheinpfalz, translated by BASF).
According to the current, preliminary evaluation, this could be the chain of causes: The cut pipeline contained a butylene mixture. BASF assumes that this butylene mixture leaked out and ignited due to the sparks produced by the angle grinder. This could have led to the fire, which caused the described explosion. BASF will continue to support the relevant authorities during the investigation into the cause of the accident.
Source: BASF (https://www.basf.com/global/en/media/news-releases/2016/10/p-16-359.html) | Image Credit: Reuters
202221OctAll DayNew Castle Explosion 1980Amoco New Castle (US-DE)Industry:PetrochemicalsCountry:United StatesLanguage:ENLoC:Maintenance error Origin: Marsh Incident:VCEHazards:FlammableImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Hexane
An explosion occurred while polypropylene polymerization was being carried out in three parallel reaction trains (A,B,C) at this petrochemicals plant. The reactants were carried in a hexane solvent with several
An explosion occurred while polypropylene polymerization was being carried out in three parallel reaction trains (A,B,C) at this petrochemicals plant. The reactants were carried in a hexane solvent with several catalysts and processed onto pellets. As a result of a maintenance error, a 100 millimetre plug valve was blown out of a line in train A, releasing hydrocarbons and polymers. The vapor cloud rose upward, carried by a light wind into the finishing building, where the explosion occurred. Further fires resulted from broken flammable liquid lines in the process area and from the released products in the finishing area. The loss included the three trains, the control building, the compressor building, and part of the finishing building.
[ Property Damage $45 Million. Estimated Current Value $147 Million ]
Image credit: Leo S. Matkins
202223OctAll DayPhillips 66 Explosion 1989Phillips 66 Pasadena (US-TX)Lessons:Asset integrity,Control of Work,Emergency Preparedness,Operational Integrity,Risk AssessmentIndustry:PetrochemicalsCountry:United StatesLanguage:ENLoC:Maintenance error Origin: HSE Incident:VCEHazards:FlammableImpact:HUMAN (On Site Fatalities)Effects:11 – 100 FatalitiesMaterial:EthyleneTopics:Occupied Buildings
At approximately 1:00 p.m. on the 23rd October 1989 Phillips’ 66 chemical complex at Pasadena, near Houston (USA) experienced a chemical release on the polyethylene plant. A flammable vapour cloud
At approximately 1:00 p.m. on the 23rd October 1989 Phillips’ 66 chemical complex at Pasadena, near Houston (USA) experienced a chemical release on the polyethylene plant. A flammable vapour cloud formed which subsequently ignited resulting in a massive vapour cloud explosion. Following this initial explosion there was a series of further explosions and fires.
The consequences of the explosions resulted in 23 fatalities and between 130 – 300 people were injured. Extensive damage to the plant facilities occurred.
The day before the incident scheduled maintenance work had begun to clear three of the six settling legs on a reactor. A specialist maintenance contractor was employed to carry out the work. A procedure was in place to isolate the leg to be worked on. During the clearing of No.2 settling leg part of the plug remained lodged in the pipework. A member of the team went to the control room to seek assistance. Shortly afterwards the release occurred. Approximately 2 minutes later the vapour cloud ignited.
• MAINTENANCE PROCEDURES
• LEAK / GAS DETECTION
• PLANT LAYOUT
• PERMIT TO WORK SYSTEMS
• ACTIVE / PASSIVE FIRE PROTECTION
• WARNING SISGNS
• EMERGENCY RESPONSE / SPILL CONTROL
Image Credit: Houston Chronicle
202225OctAll DayPULAU MERLIMAU FIRE 1988Singapore Refinery Co. Pulau Merlimau (SG)Industry:RefiningCountry:SingaporeLanguage:ENLoC:Maintenance errorIncident:FIREHazards:FlammableImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Naptha
A fire broke out at the SRC at around 1.30 pm on 25 October 1988. It was the refinery’s second major fire; the first occurred on 16 August 1984. Even
A fire broke out at the SRC at around 1.30 pm on 25 October 1988. It was the refinery’s second major fire; the first occurred on 16 August 1984. Even though the 1988 fire did not claim any lives, it injured 25 people, mostly firefighters, including five who were seriously hurt.
The fire lasted about five days before it was completely extinguished at about 7 am on 30 October. Damages, loss of profit, loss of raw materials (especially naphtha) and construction costs of new tanks were initially estimated by insurers to be between S$15 and S$20 million. In November 1988, then Director of the Singapore Fire Service Arthur Lim estimated damages to be around S$30 million. The fire and temporary closure of SRC caused the price of naphtha to rise by US$15 per tonne in the Far East.
Image Credit: SCDF
202205NovAll DayValero (Delaware) Refinery Asphyxiation 2005Valero Delaware City (US-DE)Lessons:Competency,Control of WorkIndustry:RefiningCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:AsphyxiationHazards:AsphyxiantContributory Factors:ViolationImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Nitrogen
The Valero Delaware City refinery asphyxiation death of two contractor employees who were preparing to reassemble a pipe on a pressure vessel while it was being purged with nitrogen. The
The Valero Delaware City refinery asphyxiation death of two contractor employees who were preparing to reassemble a pipe on a pressure vessel while it was being purged with nitrogen. The first worker, in an attempt to retrieve a roll of tape from inside the vessel, was overcome by nitrogen, collapsed in the vessel, and died. His co-worker, the crew foreman, was asphyxiated while attempting to rescue him.
• OXYGEN-DEFICIENT ATMOSPHERE HAZARDS OUTSIDE CONFINED SPACE OPENINGS
• NITROGEN HAZARD AWARENESS
• UNPLANNED CONFINED SPACE RESCUE
1. Workers suddenly involved in emergency activities allow emotions to override safe work procedures and training.
Image credit: CSB
202209NovAll DayE. I. Dupont De Nemours Explosion 2010E.I. duPont de Nemours and Co. Buffalo (US-NY)Lessons:Control of Work,Operational IntegrityIndustry:Plastics & PolymersCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:VCEHazards:Flammable,ToxicContributory Factors:MaintenanceImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Vinyl Fluoride
November 9, 2010 explosion at an E.I. duPont de Nemours and Co. Inc., Yerkes chemical plant in Buffalo, New York when a contract welder and foreman were repairing the agitator
November 9, 2010 explosion at an E.I. duPont de Nemours and Co. Inc., Yerkes chemical plant in Buffalo, New York when a contract welder and foreman were repairing the agitator support atop an atmospheric storage tank containing flammable vinyl fluoride. The welder died instantly from blunt force trauma, and the foreman received first-degree burns and minor injuries. The explosion blew most of the top off the tank. The top and agitator assembly hung over the side of the tank supported only by a 2-foot section of the top (cover photo). The explosion caused minor overpressure damage in the tank farm area and the adjacent production building.
• FLAMMABLE GAS MONITORING
• TANK ISOLATION
• HOT WORK PERMITS, PROCEDURES & SIGN-OFFS
1. All potential explosion hazards associated with hot work activities not identified and mitigated
2. All relevant forms required for permits not completed in accordance with corporate policies and industry standards (including NFPA 326 and NFPA 51B)
3. Appropriate DuPont personnel did not officially approve hot work permits, by signature or equivalent, consistent with DuPont policies
Image credit: CSB
202222NovAll DayExxonmobil (Baton Rouge) Fire 2016ExxonMobil Baton Rouge (US-LA)Lessons:Asset integrity,Competency,Operating ProceduresIndustry:RefiningCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:FIREHazards:FlammableContributory Factors:MaintenanceImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Isobutane
On November 22, 2016, an isobutane release and fire seriously injured four workers in the sulfuric acid alkylation unit at the ExxonMobil Refinery in Baton Rouge, Louisiana (‘Baton Rouge refinery’).
On November 22, 2016, an isobutane release and fire seriously injured four workers in the sulfuric acid alkylation unit at the ExxonMobil Refinery in Baton Rouge, Louisiana (‘Baton Rouge refinery’). During removal of an inoperable gearbox on a plug valve, the operator performing this activity removed critical bolts securing the pressure-retaining component of the valve known as the top-cap. When the operator then attempted to open the plug valve with a pipe wrench, the valve came apart and released isobutane into the unit, forming a flammable vapor cloud. The isobutane reached an ignition source within 30 seconds of the release, causing a fire and severely burning four workers who were unable to exit the vapor cloud before it ignited.
• HUMAN FACTORS
• EQUIPMENT DESIGN
• HIERARCHY OF CONTROLS
• OPERATING PROCEDURES & TRAINING
1. Human factors associated with operational difficulties that exist in machinery and other equipment.
2. Deficient procedures for workers performing potentially hazardous work.
3. Inadequate training to ensure workers can perform all anticipated job tasks safely.
Image credit: CSB
202311JanAll DayBethune Point Explosion 2006City of Daytona Beach Bethune Point (US-FL)Lessons:Asset integrity,Control of Work,Process Knowledge,Workforce InvolvementIndustry:Water TreatmentCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:VCEHazards:Flammable,ToxicContributory Factors:MaintenanceImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Methanol
On Wednesday, January 11, 2006, three workers continued the roof removal. About 11:15 a.m., the lead mechanic and the third worker were cutting the metal roof directly above the methanol
On Wednesday, January 11, 2006, three workers continued the roof removal. About 11:15 a.m., the lead mechanic and the third worker were cutting the metal roof directly above the methanol tank vent. Sparks, showering down from the cutting torch, ignited methanol vapors coming from the vent, creating a fireball on top of the tank. The fire flashed through a flame arrester on the vent, igniting methanol vapors and air inside the tank, causing a explosion inside the steel tank.
The explosion inside the methanol storage tank
• rounded the tank’s flat bottom, permanently deforming the tank and raising the side wall about onefoot;
• ripped the nuts from six bolts used to anchor the tank to a concrete foundation;
• blew the flame arrester off the tank vent pipe;
• blew a level sensor off a 4-inch flange on the tank top;
• separated two 1-inch pipes, valves, and an attached level switch from flanges on the side of the tank;
• separated a 4-inch tank outlet pipe from the tank outlet valve; and
• separated a 4-inch tank fill pipe near the top the tank.
Methanol discharged from the separated pipes ignited and burned, spreading the fire. Methanol also flowed into the containment around the tank and through a drain to the WWTP where it was diluted and harmlessly processed. The lead mechanic and the third worker were in the man-lift basket over the methanol tank when the ignition occurred. They were likely burned from the initial fireball and burning methanol vapors discharging from the tank vent under pressure from the explosion. The lead mechanic, fully engulfed in fire, likely jumped or fell from the man-lift. Emergency responders found his body within the concrete containment next to the tank.
The third worker stated that he had been partially out of the man-lift basket leaning over the roof when the fire ignited. On fire, he climbed onto the roof to escape. Co-workers, unable to reach him with a ladder, told him to jump to an adjacent lower roof and then to the ground. He sustained second and third degree burns over most of his body, and was hospitalized for 4 months before being released to a medical rehabilitation facility. Methanol sprayed from separated pipes onto the crane, burning the crane cab with the mechanic inside. On fire, he exited the cab and was assisted by co-workers. He died in the hospital the following day.
• HAZARD COMMUNICATION
• HOT WORK CONTROL
• PLASTIC PIPE IN FLAMMABLE SERVICE
• FLAME ARRESTER MAINTENANCE
• FLORIDA PUBLIC EMPLOYEE SAFETY PROGRAMS
1. The City of Daytona Beach did not implement adequate controls for hot work at the Bethune Point WWTP.
2. The City of Daytona Beach had a hazard communication program that did not effectively communicate the hazards associated with methanol at the Bethune Point WWTP.
Image credit: CSB
202311JanAll DayRuwais Refinery Fire 2017ADNOC Ruwais (AE)Industry:RefiningCountry:Abu DhabiLanguage:ENLoC:Maintenance error Origin: Marsh Incident:FIREHazards:FlammableImpact:HUMAN (On Site At Risk)Effects:EnvironmentalMaterial:Crude Oil
A release of hot light hydrocarbon during the completion of a maintenance activity resulted in a major fire. The fire occurred on a residual fluid catalytic cracking (RFCC) unit that
A release of hot light hydrocarbon during the completion of a maintenance activity resulted in a major fire. The fire occurred on a residual fluid catalytic cracking (RFCC) unit that had recently been commissioned as part of a major expansion, doubling the overall refinery capacity. The fire resulted in the closure of the expanded area of the refinery while extensive rebuilding activity was delivered. The value of the property damage loss is currently estimated to be in excess of US$1 billion.
[ Property Damage $1000 Million. Estimated Current Value $1000 Million ]
Image credit: ADNOC
202330JanAll DayLittle General Store Explosion 2007Little General Store Ghent (US-WV)Lessons:Emergency Preparedness,Process Knowledge,Stakeholder EngagementIndustry:MiscellaneousCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:VCEHazards:FlammableContributory Factors:SupervisionImpact:HUMAN (Offsite Fatalities)Effects:1-10 FatalitiesMaterial:Propane
On January 30, 2007, a propane explosion at the Little General Store in Ghent, West Virginia, killed two emergency responders and two propane service technicians, and injured six others. The
On January 30, 2007, a propane explosion at the Little General Store in Ghent, West Virginia, killed two emergency responders and two propane service technicians, and injured six others. The explosion leveled the store, destroyed a responding ambulance, and damaged other nearby vehicles.
On the day of the incident, a junior propane service technician employed by Appalachian Heating was preparing to transfer liquid propane from an existing tank, owned by Ferrellgas, to a newly installed replacement tank. The existing tank was installed in 1994 directly next to the store’s exterior back wall in violation of West Virginia and U.S. Occupational Safety and Health Administration regulations.
When the technician removed a plug from the existing tank’s liquid withdrawal valve, liquid propane unexpectedly released. For guidance, he called his supervisor, a lead technician, who was offsite delivering propane. During this time propane continued releasing, forming a vapor cloud behind the store. The tank’s placement next to the exterior wall and beneath the open roof overhang provided a direct path for the propane to enter the store.
About 15 minutes after the release began, the junior technician called 911. A captain from the Ghent Volunteer Fire Department subsequently arrived and ordered the business to close. Little General employees closed the store but remained inside. Additional emergency responders and the lead technician also arrived at the scene. Witnesses reported seeing two responders and the two technicians in the area of the tank, likely inside the propane vapor cloud, minutes before the explosion.
Minutes after the emergency responders and lead technician arrived, the propane inside the building ignited. The resulting explosion killed the propane service technicians and two emergency responders who were near the tank. The blast also injured four store employees inside the building as well as two other emergency responders outside the store.
• EMERGENCY EVACUATION
• HAZARDOUS MATERIALS INCIDENT TRAINING FOR FIREFIGHTERS
• 911 CALL CENTER RESOURCES
• PROPANE COMPANY PROCEDURES
• PROPANE SERVICE TECHNICIAN TRAINING
1. The Ferrellgas inspection and audit program did not identify the tank location as a hazard. Consequently, the tank remained against the building for more than 10 years.
2. Appalachian Heating did not formally train the junior technician, and on the day of incident he was working alone.
3. Emergency responders were not trained to recognize the need for immediate evacuation during liquid propane releases.
Image credit: CSB
202302FebAll DayBethlehem Steel Fire 2001Bethlehem Steel Corp. Chesterton (US-IN)Lessons:Control of Work,Operational Integrity,Operational ReadinessIndustry:Metal ProcessingCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:FIREHazards:FlammableContributory Factors:MaintenanceImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Coke gas
On February 2, 2001, a fire occurred at Bethlehem Steel Corporation’s Burns Harbor mill in Chesterton, Indiana. One Bethlehem Steel millwright and one contractor supervisor died. Four Bethlehem Steel millwrights
On February 2, 2001, a fire occurred at Bethlehem Steel Corporation’s Burns Harbor mill in Chesterton, Indiana. One Bethlehem Steel millwright and one contractor supervisor died. Four Bethlehem Steel millwrights were injured, one seriously. Workers were attempting to remove a slip blind and a cracked valve from a coke oven gas line leading to a decommissioned furnace. During removal of the valve, flammable liquid was released and ignited.
• MAINTENANCE JOB PLANNING
• FACILITY WINTERIZATION & DEADLEGS
• LINE & EQUIPMENT OPENING
• DECOMMISSIONING & DEMOLITION
1. Management systems for the supervision, planning, and execution of maintenance work were inadequate.
2. The Burns Harbor facility did not have a system for monitoring and controlling hazards that could be caused by changes in COG condensate flammability or accumulation rates.
Image Credit: CSB
202307FebAll DayKleen Energy Explosion 2010Kleen Energy Middletown (US-CT)Lessons:Competency,Compliance with Standards,Control of Work,Incident InvestigationIndustry:Fossil PowerCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:EXPLOSIONHazards:FlammableContributory Factors:MaintenanceImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Methane
Six workers were fatally injured during a planned work activity to clean debris from natural gas pipes at Kleen Energy in Middletown, CT. To remove the debris, workers used natural
Six workers were fatally injured during a planned work activity to clean debris from natural gas pipes at Kleen Energy in Middletown, CT. To remove the debris, workers used natural gas at a high pressure of approximately 650 pounds per square inch. The high velocity of the natural gas flow was intended to remove any debris in the new piping. During this process, the natural gas found an ignition source and exploded.
• SIMILAR NATURAL GAS BLOW INCIDENTS
• INDUSTRY PRACTICES AND SAFER ALTERNATIVE METHODOLOGIES
• HAZARDS OF RELEASING NATURAL GAS NEAR WORK AREAS
• CODES AND STANDARDS
1. Natural gas blows are common
2. Workers remained in building during gas blow
Image credit: CSB
202308FebAll DayLIAOCHENG EXPLOSION 2015Liaocheng, Shandong (CN)Lessons:Commitment & Culture,Competency,Compliance with Standards,Control of Work,Operating Procedures,Operational Integrity,Operational Readiness,Performance Indicators,Process Knowledge,Risk Assessment,Workforce InvolvementIndustry:PetrochemicalsCountry:ChinaLanguage:ENLoC:Maintenance error Origin: MKOPSC Incident:VCEHazards:FlammableContributory Factors:Organization Inadequate,Organized Procedures,Training/InstructionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Ethanol
An explosion occurred when 8 personnel were working on the repair of a catalyst tower. Proximate causes: • Inadequate training/knowledge transfer (Lack of understanding the process) • Lack of work rules/policies/
An explosion occurred when 8 personnel were working on the repair of a catalyst tower.
• Inadequate training/knowledge transfer (Lack of understanding the process)
• Lack of work rules/policies/ standards/procedures (wrong procedures for inspections);
• Inadequate work rules plan (lack of the pre-start safety review before inspection).
Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
202308FebAll DayPCA (Deridder) Explosion 2017PCA DeRidder (US-LA)Lessons:Asset integrity,Commitment & Culture,Control of Work,Risk AssessmentIndustry:Pulp & PaperCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:VCEHazards:FlammableContributory Factors:MaintenanceImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Hydrocarbons
On Wednesday, February 8, 2017, at approximately 11:05 am, a foul condensate tank, part of a non-condensable gas system, exploded at the Packaging Corporation of America (PCA) containerboard mill in
On Wednesday, February 8, 2017, at approximately 11:05 am, a foul condensate tank, part of a non-condensable gas system, exploded at the Packaging Corporation of America (PCA) containerboard mill in DeRidder, Louisiana. The explosion killed three people and injured seven others. All 10 people were working at the mill as contractors. The explosion also heavily damaged the surrounding process. The foul condensate tank travelled approximately 375 feet and over a six-story building before landing on process equipment.
At the time of the incident, the mill was undergoing its annual planned maintenance outage, also referred to as a shutdown. The foul condensate tank likely contained water, a layer of flammable liquid turpentine on top of the water, and an explosive vapor space containing air and flammable turpentine vapor.
• PROCESS SAFETY MANAGEMENT SYSTEM
• INHERENTLY SAFER DESIGN
• PROCESS HAZARD ANALYSIS
• INEFFECTIVE SAFEGUARDS
• HOT WORK SAFETY MANAGEMENT
1. PCA did not evaluate the majority of the non-condensable gas system, including the foul condensate tank, for certain hazards. The DeRidder mill never conducted a process hazard analysis to identify, evaluate, and control process hazards for the non-condensable gas system.
2. PCA did not expand the boundaries of its process safety management program beyond the units covered by safety regulations.
3. PCA did not effectively apply the hierarchy of controls to the selection and implementation of safeguards that the company used to prevent a potential non-condensable gas explosion.
4. PCA did not evaluate inherently safer design options that could have eliminated the possibility of air entering the non-condensable gas system, including the foul condensate tank.
5. PCA did not establish which mill operations group held ownership of, and responsibility for, the foul condensate tank.
6. PCA did not apply important aspects of industry safety guidance and standards.
Image credit: CSB
202323FebAll DayTosco Avon (Crude Unit) Fire 1999Tosco Avon Martinez (US-CA)Lessons:Asset integrity,Commitment & Culture,Control of Work,Management of ChangeIndustry:RefiningCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:FIREHazards:FlammableContributory Factors:MaintenanceImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Naptha
On February 23, 1999, a fire occurred in the crude unit at Tosco Corporation. Avon oil refinery in Martinez, California. Workers were attempting to replace piping attached to a 150-foot-tall
On February 23, 1999, a fire occurred in the crude unit at Tosco Corporation. Avon oil refinery in Martinez, California. Workers were attempting to replace piping attached to a 150-foot-tall fractionator tower while the process unit was in operation. During removal of the piping, naphtha was released onto the hot fractionator and ignited. The flames engulfed five workers located at different heights on the tower. Four men were killed, and one sustained serious injuries.
• CONTROL OF HAZARDOUS NONROUTINE MAINTENANCE
• MANAGEMENT OVERSIGHT & ACCOUNTABILITY
• MANAGEMENT OF CHANGE
• CORROSION CONTROL
1. Tosco Avon refinery’s maintenance management system did not recognize or control serious hazards posed by performing nonroutine repair work while the crude processing unit remained in operation.
2. Tosco’s safety management oversight system did not detect or correct serious deficiencies in the execution of maintenance and review of process changes at its Avon refinery.
Image Credit: CSB