Contributory Factors ORGANIZATIONAL

February

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

202307FebAll DayImperial Sugar Dust Explosion 2008Imperial Sugar Co. Port Wentworth (US-GA)Lessons:Asset integrity,Competency,Compliance with Standards,Incident Investigation,Management of Change,Operational Integrity,Risk AssessmentIndustry:Food & DrinkCountry:United StatesLanguage:ENLoC:Operator error Origin: CSB Incident:Dust explosionHazards:FlammableContributory Factors:HousekeepingImpact:HUMAN (On Site Fatalities)Effects:11 – 100 FatalitiesMaterial:SugarTopics:Combustible Dust

202307FebAll DayTechnic Explosion 2003Technic Inc. Cranston (US-RI)Lessons:Control of Work,Emergency Preparedness,Management of Change,Risk AssessmentIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Confined explosion Origin: CSB Incident:Dust explosionHazards:FlammableContributory Factors:HousekeepingImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:VariousTopics:Chemical Reaction

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

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

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

202312FebAll DayTesoro (Martinez) Toxic Release 2014Tesoro Martinez (US-CA)Lessons:Commitment & Culture,Performance IndicatorsIndustry:RefiningCountry:United StatesLanguage:ENLoC:Deterioration Origin: CSB Incident:Fluid release to groundHazards:CorrosiveContributory Factors:MaintenanceImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Sulfuric Acid

202312FebAll DayPetrobras (Espirito Santos FPSO) Explosion 2015Petrobras, FPSO Cidade de São Mateus, Espírito Santo (BR)Lessons:Asset integrity,Audits & Reviews,Competency,Compliance with Standards,Control of Work,Emergency Preparedness,Incident Investigation,Management of Change,Operating Procedures,Operational Integrity,Process Knowledge,Risk Assessment,Stakeholder Engagement,Workforce InvolvementIndustry:OffshoreCountry:BrazilLanguage:ENLoC:Deterioration Origin: MKOPSC Incident:EXPLOSIONHazards:FlammableContributory Factors:Design of Plant,Management Attitude,Organized Procedures,Process Analysis,SupervisionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Methane

202316FebAll DayCSX (KANAWHA) EXPLOSION 2015CSX Transportation, Kanawha (US-WV)Lessons:Asset integrity,Audits & Reviews,Competency,Compliance with Standards,Contractor Management,Management of Change,Operating Procedures,Performance Indicators,Risk Assessment,Workforce InvolvementIndustry:RailCountry:United StatesLanguage:ENLoC:Transport Origin: MKOPSC Incident:FireballHazards:FlammableContributory Factors:Organized ProceduresImpact:HUMAN (Offsite Injuries)Effects:< 100 InjuriesMaterial:Crude Oil

202318FebAll DayExxonmobil (Torrance) Refinery Explosion 2015ExxonMobil Torrance (US-CA)Lessons:Asset integrity,Operating Procedures,Operational Integrity,Risk AssessmentIndustry:RefiningCountry:United StatesLanguage:ENLoC:Confined explosion Origin: CSB Incident:VCEHazards:FlammableContributory Factors:MaintenanceImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Hydrocarbons

202319FebAll DayHUBEI FUSHENG CHEMICAL EXPLOSION 2015Hubei Fusheng Chemical Co., Yichang, Hubei (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:ChemicalsCountry:ChinaLanguage:ENLoC:Component malfunction Origin: MKOPSC Incident:Explosive decompositionHazards:ExplosiveContributory Factors:Organization Inadequate,Organized Procedures,Training/InstructionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Nitro-based fertilizer,Urea-based fertilizer

202320FebAll DayCTA Acoustics Dust Explosion 2003CTA Acoustics, Inc. Corbin (US-KY)Lessons:Asset integrity,Control of Work,Process Knowledge,Risk AssessmentIndustry:ManufacturingCountry:United StatesLanguage:ENLoC:Operator error Origin: CSB Incident:Dust explosionHazards:FlammableContributory Factors:HousekeepingImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Phenolic resinTopics:Chemical Reaction

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

March

202303MarAll DayTIARUN EXPLOSION 2015Tianrun Chemical Fertilizer Co, Ordos, Inner Mongolia (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:Pressure burstHazards:Corrosive,Environmental,Flammable,ToxicContributory Factors:Organization Inadequate,Organized ProceduresImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Ammonia,Hydrogen

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

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

202318MarAll DayBINZHOU EXPLOSION 2015Binzhou, 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:ChemicalsCountry:ChinaLanguage:ENLoC:Maintenance error Origin: MKOPSC Incident:VCEHazards:Corrosive,OxidisingContributory Factors:Organization Inadequate,Organized ProceduresImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Hydrogen Peroxide

202323MarAll DayBP Texas City Refinery Explosion 2005BP Texas City (US-TX)Lessons:Commitment & Culture,Compliance with Standards,Operating Procedures,Operational Integrity,Performance Indicators,Risk AssessmentIndustry:RefiningCountry:United StatesLanguage:ENLoC:Genuine release Origin: CSB Incident:VCEHazards:FlammableContributory Factors:Organized ProceduresImpact:HUMAN (On Site Fatalities)Effects:11 – 100 FatalitiesMaterial:HydrocarbonsTopics:Occupied Buildings

202327MarAll DayUnion Carbide (Hahnville) Asphyxiation 1998Union Carbide Hahnville (US-LA)Lessons:Control of WorkIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:AsphyxiationHazards:AsphyxiantContributory Factors:Organized ProceduresImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Nitrogen

April

202302AprAll DayULTRACARGO FIRE 2015Ultracargo, Santos (BR)Lessons:Audits & Reviews,Competency,Emergency Preparedness,Operating Procedures,Operational Integrity,Process Knowledge,Risk Assessment,Stakeholder EngagementIndustry:StorageCountry:BrazilLanguage:ENLoC:Fire exposure Origin: MKOPSC Incident:Pool fireHazards:FlammableContributory Factors:Maintenance,Management Attitude,SupervisionImpact:HUMAN (On Site At Risk)Effects:EnvironmentalMaterial:Diesel fuel

202306AprAll DayDRAGON AROMATICS EXPLOSION 2015Dragon Aromatics, Zhangzhou City, Fujian (CN)Lessons:Audits & Reviews,Commitment & Culture,Competency,Compliance with Standards,Control of Work,Emergency Preparedness,Incident Investigation,Management of Change,Operating Procedures,Operational Integrity,Operational Readiness,Process Knowledge,Risk Assessment,Stakeholder Engagement,Workforce InvolvementIndustry:PipelinesCountry:ChinaLanguage:ENLoC:UNKNOWN Origin: MKOPSC Incident:VCEHazards:FlammableContributory Factors:Manufacture/ConstructionImpact:HUMAN (Offsite Injuries)Effects:< 100 InjuriesMaterial:Paraxylene

202308AprAll DayGiant Industries Refinery Fire Explosion 2004Giant Industries Ciniza (US-NM)Lessons:Asset integrity,Management of Change,Operational IntegrityIndustry:RefiningCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:FIREHazards:FlammableContributory Factors:MaintenanceImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Alkylate

202308AprAll DayDonaldson Enterprises Explosion 2011Donaldson Enterprises Waipahu (US-HI)Lessons:Compliance with Standards,Contractor Management,Process KnowledgeIndustry:ExplosivesCountry:United StatesLanguage:ENLoC:Confined explosion Origin: CSB Incident:Explosive decompositionHazards:ExplosiveContributory Factors:Training/InstructionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Explosives

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

202326AprAll DayHusky Energy Refinery Explosion 2018Husky Superior (US-WI)Lessons:Process KnowledgeIndustry:RefiningCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:VCEHazards:FlammableContributory Factors:MaintenanceImpact:HUMAN (Offsite Injuries)Effects:< 100 InjuriesMaterial:Hydrocarbons

May

202301MayAll DayThird Coast Industries Fire 2002Third Coast Industries Brazoria County (US-TX)Lessons:Asset integrity,Compliance with StandardsIndustry:ManufacturingCountry:United StatesLanguage:ENLoC:Fire exposure Origin: CSB Incident:FIREHazards:FlammableContributory Factors:HousekeepingImpact:HUMAN (Offsite At Risk)Effects:EnvironmentalMaterial:Petroleum productsTopics:Pressure Systems

202313MayAll DayACTON TECHNOLOGIES FIRE 2015Acton Technologies Inc, Jenkins (US-PA)Lessons:Asset integrity,Audits & Reviews,Commitment & Culture,Competency,Compliance with Standards,Emergency Preparedness,Management of Change,Operational Integrity,Process Knowledge,Risk Assessment,Stakeholder Engagement,Workforce InvolvementIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:UNKNOWN Origin: MKOPSC Incident:Pool fireHazards:FlammableContributory Factors:Organized Procedures,Process AnalysisImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Acetone

202319MayAll DayKuraray America Explosion 2018Kuraray America Pasadena (US-TX)Lessons:Control of WorkIndustry:PetrochemicalsCountry:United StatesLanguage:ENLoC:Genuine release Origin: CSB Incident:VCEHazards:FlammableContributory Factors:TestingImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Ethylene

202331MayAll DayDidion Milling Explosion 2017Didion Milling Cambria (US-WI)Lessons:Operational Integrity,Process KnowledgeIndustry:Food & DrinkCountry:United StatesLanguage:ENLoC:Confined explosion Origin: CSB Incident:Dust explosionHazards:FlammableContributory Factors:HousekeepingImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Corn

June

202305JunAll DayPartridge Raleigh Oilfield Explosion 2006Partridge-Raleigh oilfield Raleigh (US-MS)Lessons:Control of WorkIndustry:Onshore Oil & GasCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:VCEHazards:FlammableContributory Factors:MaintenanceImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Hydrocarbons

202309JunAll DayConAgra Explosion 2009ConAgra Garner (US-NC)Lessons:Competency,Compliance with Standards,Control of Work,Incident Investigation,Operating ProceduresIndustry:Food & DrinkCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:EXPLOSIONHazards:FlammableContributory Factors:MaintenanceImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Methane

202311JunAll DayGoodyear Heat Exchanger Rupture 2008Goodyear Houston (US-TX)Lessons:Asset integrity,Control of Work,Emergency PreparednessIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Overpressure Origin: CSB Incident:Pressure burstHazards:Corrosive,Environmental,ToxicContributory Factors:MaintenanceImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:AmmoniaTopics:Pressure Systems

202313JunAll DayWilliams Olefins Explosion 2013Williams Olefins Geismar (US-LA)Lessons:Asset integrity,Management of Change,Operating Procedures,Operational IntegrityIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Overpressure Origin: CSB Incident:BLEVEHazards:FlammableContributory Factors:MaintenanceImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:PropaneTopics:Pressure Systems

202318JunAll DayHAOLIANGHE TOXIC RELEASE 2015Haolianghe, Heilongjiang (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:ChemicalsCountry:ChinaLanguage:ENLoC:Operator error Origin: MKOPSC Incident:Gas/vapour/mist/etc release to airHazards:Corrosive,Environmental,ToxicContributory Factors:Organized ProceduresImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Ammonia

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