Contributory Factors PLANT/EQUIPMENT

February

202316FebAll DayValero (Sunray) Refinery Fire 2007Valero Sunray (US-TX)Lessons:Compliance with Standards,Management of Change,Risk AssessmentIndustry:RefiningCountry:United StatesLanguage:ENLoC:Undertemperature Origin: CSB Incident:FIREHazards:FlammableContributory Factors:Containment FailureImpact:HUMAN (On Site At Risk)Effects:< 100 InjuriesMaterial:PropaneTopics:Natural Hazards

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

March

202304MarAll DaySonat Exploration Vessel Overpressurization 1998Sonat Exploration Co. Pitkin (US-LA)Lessons:Asset integrity,Operating Procedures,Risk AssessmentIndustry:Onshore Oil & GasCountry:United StatesLanguage:ENLoC:Overpressure Origin: CSB Incident:FIREHazards:FlammableContributory Factors:Containment FailureImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:HydrocarbonsTopics:Pressure Systems

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

202317MarAll DayITC Tank Fire 2019ITC Deer Park (US-TX)Lessons:Emergency Preparedness,Operational Integrity,Stakeholder EngagementIndustry:StorageCountry:United StatesLanguage:ENLoC:Deterioration Origin: CSB Incident:FIREHazards:FlammableContributory Factors:Containment FailureImpact:HUMAN (Offsite At Risk)Effects:EnvironmentalMaterial:Naptha

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 DayTesoro (Anacortes) Refinery Explosion 2010Tesoro Anacortes (US-WA)Lessons:Asset integrity,Commitment & Culture,Compliance with Standards,Control of WorkIndustry:RefiningCountry:United StatesLanguage:ENLoC:Deterioration Origin: CSB Incident:VCEHazards:FlammableContributory Factors:Containment FailureImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Naptha

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

202303AprAll DayLoy Lange Box Co. Pressure Vessel Explosion 2017Loy-Lange Box Company St. Louis (US-MO)Lessons:Asset integrityIndustry:ManufacturingCountry:United StatesLanguage:ENLoC:Overpressure Origin: CSB Incident:Rapid phase-transition explosionHazards:Mechanical/Kinetic/PotentialContributory Factors:Corrosion/Erosion/FatigueImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Steam

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

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

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

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

202317AprAll DayWest Fertilizer Explosion 2013West Fertilizer Co. West (US-TX)Lessons:Commitment & Culture,Compliance with Standards,Emergency Preparedness,Process Knowledge,Risk Assessment,Stakeholder Engagement,Workforce InvolvementIndustry:AgricultureCountry:United StatesLanguage:ENLoC:Fire exposure Origin: CSB Incident:Dust explosionHazards:ExplosiveContributory Factors:Runaway ReactionImpact:HUMAN (Offsite Fatalities)Effects:11 – 100 FatalitiesMaterial:Ammonium NitrateTopics:Occupied Buildings

202320AprAll DayDeepwater Horizon Blowout & Explosion 2010BP Macondo (US-GM)Lessons:Asset integrity,Commitment & Culture,Compliance with Standards,Contractor Management,Incident Investigation,Management of Change,Operating Procedures,Operational IntegrityIndustry:OffshoreCountry:United StatesLanguage:ENLoC:Overpressure Origin: CSB Incident:VCEHazards:FlammableContributory Factors:Containment FailureImpact:HUMAN (On Site Fatalities)Effects:11 – 100 FatalitiesMaterial:Crude Oil

May

202303MayAll DayAB Specialty Silicones Explosion 2019AB Specialty Silicones Waukegan (US-IL)Lessons:Asset integrity,Operational IntegrityIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Component malfunction Origin: CSB Incident:VCEHazards:FlammableContributory Factors:Runaway ReactionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Silicon Hydride

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

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

202324MayAll DayMidland Resource Recovery Explosion 2017Midland Resource Recovery Philippi (US-WV)Lessons:Commitment & Culture,Compliance with Standards,Risk AssessmentIndustry:StorageCountry:United StatesLanguage:ENLoC:Operator error Origin: CSB Incident:Runaway reaction explosionHazards:Corrosive,OxidisingContributory Factors:Runaway ReactionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Sodium HypochloriteTopics:Chemical Reaction

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

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

202321JunAll DayPhiladelphia Energy Solutions Refinery Explosion 2019Philadelphia Energy Solutions Philadelphia (US-PA)Lessons:Asset integrityIndustry:RefiningCountry:United StatesLanguage:ENLoC:UNKNOWN Origin: CSB Incident:VCEHazards:FlammableContributory Factors:Corrosion/Erosion/FatigueImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Hydrocarbons

202327JunAll DayEnterprise Pascagoula Explosion 2016Enterprise Pascagoula Moss Point (US-MS)Lessons:Asset integrity,Emergency Preparedness,Operational Integrity,Workforce InvolvementIndustry:Gas ProcessingCountry:United StatesLanguage:ENLoC:Deterioration Origin: CSB Incident:VCEHazards:FlammableContributory Factors:Corrosion/Erosion/FatigueImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Hydrocarbons

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