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January
Summary
On January 7, 1998, two explosions in rapid succession destroyed the Sierra Chemical Company Kean Canyon plant near Mustang, Nevada, killing four workers and injuring six others. The Kean Canyon plant
Summary
On January 7, 1998, two explosions in rapid succession destroyed the Sierra Chemical Company Kean Canyon plant near Mustang, Nevada, killing four workers and injuring six others.
The Kean Canyon plant manufactured explosive boosters for the mining industry. When initiated by a blasting cap or detonation cord, boosters provide the added energy necessary to detonate less sensitive blasting agents or other high explosives. The boosters manufactured at the Kean Canyon plant consisted of a base mix and a second explosive mix, called Pentolite, both of which were poured into cardboard cylinders. The primary explosives used in the base mix were TNT (2,4,6-trinitrotoluene), PETN (pentaerythritol tetranitrate), and Comp-B, a mixture of TNT and RDX (hexahydro-1,3,5-trinitro-1,3,5-triazine). The Pentolite is a mix of TNT and PETN.
KEY ISSUES:
• PROCESS SAFETY MANAGEMENT
• WORKER TRAINING
• PROCESS HAZARD ANALYSIS
• LANGUAGE BARRIERS
ROOT CAUSES:
1. Process hazard analysis (PHA) conducted by the facility was inadequate.
2. Training programs for facility personnel were inadequate.
3. Written operating procedures were inadequate or not available to workers.
4. The facility was built with insufficient separation distances between different operations and the design and construction of buildings was inadequate.
5. There was no systematic safety inspection or auditing program.
6. The employee participation program was inadequate.
Image Credit: CSB
Summary
An explosion occurred at one of Petrobras’ refineries. The blast occurred at a hydrogen conduit in an enclosed space, causing a flare and a displacement of air that threw the
Summary
An explosion occurred at one of Petrobras’ refineries. The blast occurred at a hydrogen conduit in an enclosed space, causing a flare and a displacement of air that threw the contract workers against the refinery’s metal structure.
Proximate causes:
• Inadequate maintenance
• Failure following procedures
• Lack of work rules/policies/ standards/procedures
• Physical condition (the accident may have been the result of maintenance work being carried out under tight deadlines and long shifts imposed on refinery workers)
• Mental stress
• Mental state
Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Daily Motion
April
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
