Audits & Reviews
Commitment & Culture
Compliance with Standards
Control of Work
Management of Change
MONITORING & IMPROVEMENT
PROCESS SAFETY MANAGEMENT
Food & Drink
Onshore Oil & Gas
Plastics & Polymers
Pulp & Paper
Papua New Guinea
Fluid release to ground
Fluid release to water
Gas/vapour/mist/etc release to air
Rapid phase-transition explosion
Runaway reaction explosion
Solid release to air
Solid release to ground
Solid release to water
Design of Plant
Loss of Process Control
Physical Security Breach
COST (On Site)
ENVIRONMENTAL (On Site)
HUMAN (Offsite At Risk)
HUMAN (Offsite Fatalities)
HUMAN (Offsite Injuries)
HUMAN (On Site At Risk)
HUMAN (On Site Fatalities)
HUMAN (On Site Injuries)
> 100 Fatalities
< 100 Injuries
11 - 100 Fatalities
11 – 100 Fatalities
≥ 100 Injuries
PSV – Pilot Operated
Safety & Control
Shell & Tube
Valves - Safety
Methyl Ethyl Ketone
Oil based solvent
Urea Ammonium Nitrate
Vinyl Chloride Monomer
Live Event Type
Quantitative Risk Assessment
Dust Safety Science
Dutch Safety Board
New Zealand Government
Process Safety Integrity
Step Change in Safety
Corrosion Under Insulation
High Pressure Water
Loss of Utilities
Low Temperature Embrittlement
Normalization of Deviance
Safe Operating Limits
Stress Corrosion Cracking
Permit To Work
Learning from Incidents
Floating Roof Tanks
Minute To Learn
Safety Critical Decisions
202314FebAll DayUerdingen Explosion 1989Bayer Krefeld (DE)Industry:ChemicalsCountry:GermanyLanguage:ENLoC:Overpressure Origin: Marsh Incident:Runaway reaction explosionHazards:ReactiveImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Phthalates
Overheating and explosion of a reactor occurred, likely as a result of a runaway reaction. The cause was suspected to be the addition of the incorrect component. A neighboring building
Overheating and explosion of a reactor occurred, likely as a result of a runaway reaction. The cause was suspected to be the addition of the incorrect component. A neighboring building also was destroyed.
[ Property Damage $63 Million. Estimated Current Value $141 Million ]
Image credit: Currenta
202319FebAll DayConcept Sciences Explosion 1999Concept Sciences Allentown (US-PA)Lessons:Emergency Preparedness,Process Knowledge,Risk Assessment,Stakeholder EngagementIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Overpressure Origin: CSB Incident:Runaway reaction explosionHazards:ReactiveContributory Factors:Loss of Process ControlImpact:HUMAN (Offsite Fatalities)Effects:1-10 FatalitiesMaterial:HydroxylamineTopics:Chemical Reaction,Occupied Buildings
On February 19, 1999, a process vessel containing several hundred pounds of hydroxylamine exploded at the Concept Sciences Inc. production facility near Allentown, Pennsylvania. Employees were distilling an aqueous solution
On February 19, 1999, a process vessel containing several hundred pounds of hydroxylamine exploded at the Concept Sciences Inc. production facility near Allentown, Pennsylvania. Employees were distilling an aqueous solution of hydroxylamine and potassium sulfate, the first commercial batch to be processed at the facility. After the distillation process was shut down, the HA in the process tank and associated piping explosively decomposed, most likely due to high concentration and temperature. Four CSI employees and a manager of an adjacent business were killed. Two CSI employees survived the blast with moderate-to-serious injuries. Four people in nearby buildings were injured. The explosion also caused significant damage to other buildings in the Lehigh Valley Industrial Park and shattered windows in several nearby homes.
• HAZARDS OF PROCESSING HYDROXYLAMINE
• PROCESS HAZARDS EVALUATION
• CHEMICAL FACILITY SITING
1. CSI’s process safety management systems were insufficient to properly address the hazards inherent in its HA manufacturing process and to determine whether these hazards presented substantial risks.
2. Inadequate collection and analysis of process safety information contributed to CSI’s failure to recognize specific explosion hazards.
3. Basic process safety and chemical engineering practices – such as process design reviews, hazard analyses, corrective actions, and reviews by appropriate technical experts – were not adequately implemented.
4. The existing system of siting approval by local authorities allowed a highly hazardous facility to be inappropriately located in a light industrial park.
Image Credit: CSB
202313MarAll DayBP Amoco Thermal Decomposition 2001BP Amoco Augusta (US-GA)Lessons:Incident Investigation,Operational Integrity,Risk AssessmentIndustry:Plastics & PolymersCountry:United StatesLanguage:ENLoC:Operator error Origin: CSB Incident:Runaway reaction explosionHazards:ReactiveContributory Factors:MaintenanceImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:PolymersTopics:Chemical Reaction
On March 13, 2001, three people were killed as they opened a process vessel containing hot plastic at the BP Amoco Polymers plant in Augusta, Georgia. They were unaware that
On March 13, 2001, three people were killed as they opened a process vessel containing hot plastic at the BP Amoco Polymers plant in Augusta, Georgia. They were unaware that the vessel was pressurized. The workers were killed when the partially unbolted cover blew off the vessel, expelling hot plastic. The force of the release caused some nearby tubing to break. Hot fluid from the tubing ignited, resulting in a fire.
• RECOGNITION OF REACTIVE HAZARDS
• LEARNING FROM NEAR-MISS INCIDENTS
• OPENING OF PROCESS EQUIPMENT
1. Amoco, the developer of the Amodel process, did not adequately review the conceptual process design to identify chemical reaction hazards.
2. The Augusta facility did not have an adequate review process for correcting design deficiencies.
3. The Augusta site system for investigating incidents and nearmiss incidents did not adequately identify causes or related hazards. This information was needed to correct the design and operating deficiencies that led to the recurrence of incidents.
Image Credit: CSB
202321MarAll DayCarbide Industries Fire 2011Carbide Industries Louisville (US-KY)Lessons:Compliance with Standards,Operational Integrity,Risk Assessment,Workforce InvolvementIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Overpressure Origin: CSB Incident:Rapid phase-transition explosionHazards:ReactiveContributory Factors:Component MalfunctionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Calcium CarbideTopics:Occupied Buildings
On March 21, 2011, during calcium carbide production at the Carbide Industries plant in Louisville, KY, an electric arc furnace exploded, ejecting solid and powdered debris, flammable gases, and molten
On March 21, 2011, during calcium carbide production at the Carbide Industries plant in Louisville, KY, an electric arc furnace exploded, ejecting solid and powdered debris, flammable gases, and molten calcium carbide at temperatures near 3800°F (2100°C). Two workers died and two others were injured.
• FACILITY SITING
• NORMALIZATION OF DEVIANCE
• CONSENSUS STANDARDS
1. Despite past incidents, neither the previous owners nor Carbide Industries identified that the control room should be relocated and cameras installed to better protect workers while they remotely monitored the furnace.
2. Carbide Industries issued 26 work orders for leak repair for water leaks on the furnace cover in the five months prior to the March 2011 incident, but continued operating the furnace despite the hazard from ongoing water leaks.
3. The company did not adequately address past explosive incidents, which normalized blows as routine events.
4. The company did not have a process safety management program in place that required the elimination of overpressure incidents in the furnace.
Image credit: CSB
202308AprAll DayMorton International Runaway Chemical Reaction 1998Morton International Inc. Paterson (US-NJ)Lessons:Commitment & Culture,Risk Assessment,Workforce InvolvementIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Overpressure Origin: CSB Incident:Runaway reaction explosionHazards:Reactive,ToxicContributory Factors:Loss of Process ControlImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Ortho-NitrochlorobenzeneTopics:Chemical Reaction
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
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.
• INTERNAL HAZARD COMMUNICATION & PROCESS SAFETY INFORMATION
• REACTIVE HAZARD MANAGEMENT
• PROCESS SAFETY MANAGEMENT
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
202325AprAll DayKaltech Explosion 2002Kaltech Industries New York City (US-NY)Lessons:Compliance with Standards,Contractor Management,Control of WorkIndustry:ManufacturingCountry:United StatesLanguage:ENLoC:Confined explosion Origin: CSB Incident:Runaway reaction explosionHazards:Corrosive,ReactiveContributory Factors:HousekeepingImpact:HUMAN (Offsite Injuries)Effects:< 100 InjuriesMaterial:Nitric acid
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
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.
• HAZARD COMMUNICATION
• HAZARDOUS WASTE HANDLING
• MUNICIPAL OVERSIGHT
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
202328AprAll DayCorden Pharmachem Runaway Reaction 2008Corden Pharmachem, Little Island, Cork (IE)Lessons:Risk AssessmentIndustry:Life SciencesCountry:IrelandLanguage:ENLoC:Overpressure Origin: IChemE Incident:Runaway reaction explosionHazards:ReactiveImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesTopics:Chemical Reaction
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.
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
202301MayAll DaySterlington Explosion 1991Angus Chemical Co Sterlington (US-LA)Industry:PetrochemicalsCountry:United StatesLanguage:ENLoC:Fire exposure Origin: Marsh Incident:VCEHazards:Flammable,Reactive,ToxicImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Nitromethane
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,
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