Contributory Factors Process Analysis

February

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

May

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

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