Contributory Factors ORGANIZATIONAL

December

202311DecAll DayEnvironmental Enterprises Toxic Release 2002Environmental Enterprises Cincinnati (US-OH)Lessons:Asset integrity,Commitment & Culture,Operating Procedures,Workforce InvolvementIndustry:Waste TreatmentCountry:United StatesLanguage:ENLoC:Material incompatibility Origin: CSB Incident:Gas/vapour/mist/etc release to airHazards:Flammable,ToxicContributory Factors:Organized ProceduresImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Hydrogen Sulfide

January

202406JanAll DayMFG CHEMICAL (DALTON) TOXIC RELEASE 2015MFG Chemical, Inc. Dalton (US-GA)Lessons:Asset integrity,Audits & Reviews,Commitment & Culture,Competency,Compliance with Standards,Control of Work,Emergency Preparedness,Incident Investigation,Management of Change,Operating Procedures,Operational Integrity,Performance Indicators,Process Knowledge,Risk Assessment,Stakeholder Engagement,Workforce InvolvementIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Overpressure Origin: MKOPSC Incident:Runaway reaction explosionContributory Factors:Management Attitude,SupervisionImpact:HUMAN (On Site Fatalities)Effects:1-10 Fatalities

202407JanAll DayTexas Tech University Explosion 2010Texas Tech University Lubbock (US-TX)Lessons:Audits & Reviews,Commitment & Culture,Operating Procedures,Risk AssessmentIndustry:LaboratoryCountry:United StatesLanguage:ENLoC:Operator error Origin: CSB Incident:Runaway reaction explosionHazards:ReactiveContributory Factors:Organized ProceduresImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:NHP

202411JanAll DayBethune Point Explosion 2006City of Daytona Beach Bethune Point (US-FL)Lessons:Asset integrity,Control of Work,Process Knowledge,Workforce InvolvementIndustry:Water TreatmentCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:VCEHazards:Flammable,ToxicContributory Factors:MaintenanceImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Methanol

202413JanAll DayBLSR Operating Fire 2003BLSR Rosharon (US-TX)Lessons:Compliance with Standards,Contractor Management,Operating Procedures,Process KnowledgeIndustry:Waste TreatmentCountry:United StatesLanguage:ENLoC:Operator error Origin: CSB Incident:VCEHazards:FlammableContributory Factors:Training/InstructionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:BS&W

202416JanAll DayGeorgia-Pacific Toxic Release 2002Georgia-Pacific Pennington (US-AL)Lessons:Emergency Preparedness,Management of Change,Operating Procedures,Risk AssessmentIndustry:Pulp & PaperCountry:United StatesLanguage:ENLoC:Material incompatibility Origin: CSB Incident:Gas/vapour/mist/etc release to airHazards:Flammable,ToxicContributory Factors:Organized ProceduresImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Hydrogen SulfideTopics:Chemical Reaction

202418JanAll DayPETROBRAS (RLAM) EXPLOSION 2015Petrobras, Landulpho Alves Refinery, Salvador (BR)Lessons:Asset integrity,Audits & Reviews,Competency,Compliance with Standards,Control of Work,Emergency Preparedness,Incident Investigation,Management of Change,Operating Procedures,Operational Integrity,Operational Readiness,Performance Indicators,Process Knowledge,Risk Assessment,Stakeholder Engagement,Workforce InvolvementIndustry:RefiningCountry:BrazilLanguage:ENLoC:Deterioration Origin: MKOPSC Incident:EXPLOSIONHazards:FlammableContributory Factors:Corrosion/Erosion/Fatigue,Health,Maintenance,Organized ProceduresEffects:< 100 InjuriesMaterial:Hydrogen

202429JanAll DayWest Pharmaceutical Services Dust Explosion 2003West Pharmaceutical Services Kinston (US-NC)Lessons:Compliance with Standards,Process KnowledgeIndustry:Plastics & PolymersCountry:United StatesLanguage:ENLoC:Operator error Origin: CSB Incident:Dust explosionHazards:FlammableContributory Factors:HousekeepingImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:PolyethyleneTopics:Combustible Dust

202430JanAll DayLittle General Store Explosion 2007Little General Store Ghent (US-WV)Lessons:Emergency Preparedness,Process Knowledge,Stakeholder EngagementIndustry:MiscellaneousCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:VCEHazards:FlammableContributory Factors:SupervisionImpact:HUMAN (Offsite Fatalities)Effects:1-10 FatalitiesMaterial:Propane

202431JanAll DaySynthron Explosion 2006Synthron Morganton (US-NC)Lessons:Audits & Reviews,Emergency Preparedness,Operational Integrity,Risk AssessmentIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Overpressure Origin: CSB Incident:VCEHazards:FlammableContributory Factors:Equipment IsolationImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Acrylic monomersTopics:Chemical Reaction

202431JanAll DayLINYI EXPLOSION 2015Linyi Huasheng Group, 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:Metal ProcessingCountry:ChinaLanguage:ENLoC:Deterioration Origin: MKOPSC Incident:EXPLOSIONHazards:FlammableContributory Factors:Organization Inadequate,Organized Procedures,Training/InstructionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Coke

202431JanAll DayHoeganaes Fires 2010Hoeganaes Gallatin (US-TN)Lessons:Compliance with Standards,Incident Investigation,Process KnowledgeIndustry:Metal ProcessingCountry:United StatesLanguage:ENLoC:Operator error Origin: CSB Incident:Dust explosionHazards:FlammableContributory Factors:MaintenanceImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:IronTopics:Combustible Dust

February

202402FebAll 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

202407FebAll 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

202407FebAll 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

202407FebAll 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

202408FebAll 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

202408FebAll 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

202412FebAll 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

202412FebAll 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

202416FebAll 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

202418FebAll 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

202419FebAll 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

202420FebAll 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

202423FebAll 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

202403MarAll 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

202410MarAll 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

202413MarAll 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

202418MarAll 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

202423MarAll 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

202427MarAll 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

202402AprAll 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

202406AprAll 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

202408AprAll 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

202408AprAll 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

202425AprAll 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

202426AprAll 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

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