Contributory Factors Loss of Process Control
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
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
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
202311AprAll DayD.D. Williamson Catastrophic Vessel Failure 2003D.D. Williamson Louisville (US-KY)Lessons:Asset integrity,Competency,Operating Procedures,Risk AssessmentIndustry:Food & DrinkCountry:United StatesLanguage:ENLoC:Overpressure Origin: CSB Incident:Pressure burstHazards:Corrosive,Environmental,ToxicContributory Factors:Loss of Process ControlImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:AmmoniaTopics:Pressure Systems
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
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. .
• OVERPRESSURE PROTECTION
• HAZARD EVALUATION SYSTEMS
• LAYERS OF PROTECTION
• OPERATING PROCEDURES & TRAINING
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
202312AprAll DayMFG Chemical (Dalton) Toxic Release 2004MFG Chemical, Inc. Callahan Rd. Dalton (US-GA)Lessons:Emergency Preparedness,Process Knowledge,Stakeholder EngagementIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Genuine release Origin: CSB Incident:Runaway reaction explosionHazards:FlammableContributory Factors:Loss of Process ControlImpact:HUMAN (Offsite Injuries)Effects:≥ 100 InjuriesMaterial:Allyl alcohol,Allyl chlorideTopics:Chemical Reaction
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
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.
• REACTIVE CHEMICALS PROCESS DESIGN
• PROCESS SCALE-UP
• EMERGENCY PLANNING & RESPONSE
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
202304MayAll DayVeolia Environmental Services Explosion 2009Veolia West Carrollton (US-OH)Lessons:Asset integrity,Emergency Preparedness,Risk AssessmentIndustry:Waste TreatmentCountry:United StatesLanguage:ENLoC:Component malfunction Origin: CSB Incident:VCEHazards:FlammableContributory Factors:Loss of Process ControlImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:HydrocarbonsTopics:Occupied Buildings
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 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.
• UNSAFE BUILDING SITING
• ATMOSPHERIC RELIEF SYSTEMS
• PLANT EMERGENCY PROCEDURES
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
202314JunAll DayUniversal Form Clamp Explosion 2006Universal Form Clamp Co. Bellwood (US-IL)Lessons:Asset integrity,Compliance with Standards,Emergency PreparednessIndustry:ManufacturingCountry:United StatesLanguage:ENLoC:Genuine release Origin: CSB Incident:VCEHazards:FlammableContributory Factors:Loss of Process ControlImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Heptane
On the morning of June 14, 2006, an operator was mixing and heating a flammable mixture of heptane and mineral spirits in a 2,200-gallon open top tank equipped with steam
On the morning of June 14, 2006, an operator was mixing and heating a flammable mixture of heptane and mineral spirits in a 2,200-gallon open top tank equipped with steam coils. The finished product, ‘Super Clean and Tilt’ is a proprietary mixture, which is applied to cured concrete surfaces to prevent bonding with wet concrete.
As the operator was adding an ingredient to the batch, he observed a ‘dense fog’ accumulating on the floor below the tank. He immediately notified a senior operator who helped him shut down the operation. They both exited the building and advised workers in adjoining areas to leave.
As the vapor cloud spread throughout the mixing area and surrounding workspaces, other employees exited the building.
Within about 10 minutes after the operator first observed the vapor cloud, most employees who were working in the area had evacuated. A contracted delivery driver passed some of these employees as he walked into the building and into the spreading vapor cloud. The cloud ignited within seconds of him entering. The driver died several days later from the burns he received.
The pressure created by the ignition blew the doors open to an adjacent area, injuring a temporary employee. This employee suffered second-degree burns and was hospitalized for three days. .
• FLAMMABLE LIQUID PROCESS DESIGN
• ENGINEERING CONTROLS
• PLAN REVIEW & CODE ENFORCEMENT
• EMERGENCY PREPAREDNESS
1. The process was not designed and constructed in accordance with fire safety codes and OSHA regulations.
2. The Fire Department did not require UFC to comply with critical safety requirements (local exhaust and floor level ventilation)
3. The facility was unprepared for an emergency release of this magnitude.
Image credit: CSB