Contributory Factors Component Malfunction

Component/machinery failure/malfunction

March

202310MarAll DayCHANGZHOU FIRE 2015Changzhou, Jiangsu (CN)Lessons:Asset integrity,Audits & Reviews,Commitment & Culture,Competency,Control of Work,Emergency Preparedness,Incident Investigation,Operating Procedures,Operational Integrity,Operational Readiness,Process Knowledge,Risk AssessmentIndustry:WarehouseCountry:ChinaLanguage:ENLoC:Fire exposure Origin: MKOPSC Incident:ConflagrationContributory Factors:Component Malfunction,Organized ProceduresImpact:HUMAN (On Site At Risk)Effects:Environmental

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

April

202302AprAll DayKMCO Explosion 2019KMCO Crosby (US-TX)Lessons:Asset integrityIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Deterioration Origin: CSB Incident:VCEHazards:FlammableContributory Factors:Component MalfunctionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Isobutylene

202309AprAll DayWEIFANG FATALITIES 2015Weifang, Shandong (CN)Lessons:Audits & Reviews,Commitment & Culture,Competency,Compliance with Standards,Control of Work,Emergency Preparedness,Management of Change,Operating Procedures,Operational Integrity,Operational Readiness,Performance Indicators,Process Knowledge,Risk Assessment,Workforce InvolvementIndustry:Water TreatmentCountry:ChinaLanguage:ENLoC:Operator error Origin: MKOPSC Incident:AsphyxiationHazards:Environmental,Flammable,ToxicContributory Factors:Component MalfunctionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Hydrogen Sulfide

202310AprAll DayDALIAN FIRE 2015Dalian, Liaoning (CN)Lessons:Audits & Reviews,Competency,Risk AssessmentIndustry:PipelinesCountry:ChinaLanguage:ENLoC:Deterioration Origin: MKOPSC Incident:FireballHazards:FlammableContributory Factors:Component MalfunctionImpact:HUMAN (On Site At Risk)Effects:EnvironmentalMaterial:Crude Oil,Methane

May

202316MayAll DayLIAONING RUIXING TOXIC RELEASE 2015Liaoning Ruixing, Jincheng, Shanxi (CN)Lessons:Audits & Reviews,Commitment & Culture,Competency,Compliance with Standards,Control of Work,Emergency Preparedness,Operating Procedures,Operational Integrity,Operational Readiness,Process Knowledge,Risk Assessment,Workforce InvolvementIndustry:ChemicalsCountry:ChinaLanguage:ENLoC:Deterioration Origin: MKOPSC Incident:Fluid release to groundHazards:FlammableContributory Factors:Component MalfunctionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Carbon disulfide

202325MayAll DayLAOZHOU FIRE 2015Laozhou, Jiangxi (CN)Lessons:Audits & Reviews,Commitment & Culture,Competency,Compliance with Standards,Control of Work,Operational Integrity,Risk Assessment,Workforce InvolvementIndustry:PetrochemicalsCountry:ChinaLanguage:ENLoC:Overtemperature Origin: MKOPSC Incident:ConflagrationContributory Factors:Component MalfunctionImpact:HUMAN (On Site At Risk)Effects:EnvironmentalMaterial:Terpene

June

202308JunAll DayMILLER CHEMICAL EXPLOSION 2015Miller Chemical & Fertilizer, Conewago (US-PA)Lessons:Asset integrity,Audits & Reviews,Commitment & Culture,Competency,Emergency Preparedness,Risk AssessmentIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:UNKNOWN Origin: MKOPSC Incident:Explosive decompositionHazards:ExplosiveContributory Factors:Component MalfunctionImpact:HUMAN (On Site At Risk)Effects:EnvironmentalMaterial:Fertilizer

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