Contributory Factors: Process Analysis

Contributory Factors Process Analysis

May

202413MayAll 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

July

202419JulAll DayGEMLIK FERTILIZER EXPLOSION 2015Gemlik Fertilizer, Bursa (TR)Lessons:Asset integrity,Audits & Reviews,Competency,Control of Work,Operating Procedures,Operational Integrity,Process Knowledge,Risk Assessment,Stakeholder Engagement,Workforce InvolvementIndustry:ChemicalsCountry:TurkeyLanguage:ENLoC:Confined explosion Origin: MKOPSC Incident:EXPLOSIONContributory Factors:Design of Plant,Organized Procedures,Process AnalysisImpact:HUMAN (On Site Fatalities)Effects:1-10 Fatalities

August

202404AugAll DayNORANDA ALUMINUM EXPLOSION 2015Noranda, Marston (US-MO)Lessons:Commitment & Culture,Competency,Compliance with Standards,Incident Investigation,Risk AssessmentIndustry:Metal ProcessingCountry:United StatesLanguage:ENLoC:Overpressure Origin: MKOPSC Incident:Rapid phase-transition explosionHazards:FlammableContributory Factors:Organized Procedures,Process AnalysisImpact:HUMAN (Offsite Injuries)Effects:< 100 InjuriesMaterial:Aluminium

202413AugAll DayPACIFIC STEEL TOXIC RELEASE 2015Pacific Steel Recycling. Spokane (US-WA)Lessons:Audits & Reviews,Commitment & Culture,Competency,Compliance with Standards,Control of Work,Incident Investigation,Operating Procedures,Operational Integrity,Process Knowledge,Risk Assessment,Stakeholder Engagement,Workforce InvolvementIndustry:Waste TreatmentCountry:United StatesLanguage:ENLoC:Operator error Origin: MKOPSC Incident:Gas/vapour/mist/etc release to airHazards:Environmental,Oxidising,ToxicContributory Factors:Organized Procedures,Process Analysis,Training/InstructionImpact:HUMAN (Offsite Injuries)Effects:< 100 InjuriesMaterial:Chlorine

202425AugAll DayStanwell Toxic Release 2015Stanwell, Queensland (AU-QLD)Lessons:Asset integrity,Compliance with Standards,Emergency Preparedness,Operational Integrity,Process Knowledge,Risk Assessment,Stakeholder EngagementIndustry:RoadCountry:AustraliaLanguage:ENLoC:Deterioration Origin: MKOPSC Incident:Gas/vapour/mist/etc release to airHazards:Corrosive,Environmental,ToxicContributory Factors:Organized Procedures,Process AnalysisImpact:HUMAN (Offsite At Risk)Effects:EnvironmentalMaterial:Ammonia

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