Lessons Audits & Reviews

Auditing (Management Review and Continuous Improvement) | Audit, Assurance, Management Review and Intervention.

January

202306JanAll 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

202307JanAll 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

202318JanAll 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

202320JanAll DaySURVIVAL INDUSTRIES EXPLOSION 2015Survival Technologies, Ankleshwar (IN)Lessons:Asset integrity,Audits & Reviews,Commitment & Culture,Competency,Compliance with Standards,Contractor Management,Control of Work,Incident Investigation,Management of Change,Operating Procedures,Operational Integrity,Operational Readiness,Performance Indicators,Process Knowledge,Risk Assessment,Workforce InvolvementIndustry:ChemicalsCountry:IndiaLanguage:ENLoC:Operator error Origin: MKOPSC Incident:EXPLOSIONHazards:Harmful/IrritantContributory Factors:Component MalfunctionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:4-hydroxybenzohydrazide

202323JanAll DayDupont (Belle) Toxic Release 2010DuPont Belle (US-WV)Lessons:Asset integrity,Audits & Reviews,Competency,Compliance with Standards,Emergency Preparedness,Incident Investigation,Operating Procedures,Risk AssessmentIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Deterioration Origin: CSB Incident:Gas/vapour/mist/etc release to airHazards:Corrosive,Flammable,ToxicContributory Factors:Containment FailureImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Methyl Chloride,Oleum,Phosgene

202331JanAll 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

February

202306FebAll DayWARSAW CHEMICAL EXPLOSION 2015Warsaw Chemical, Warsaw (US-IN)Lessons:Asset integrity,Audits & Reviews,Commitment & Culture,Control of Work,Emergency Preparedness,Operating Procedures,Risk Assessment,Stakeholder EngagementIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Overpressure Origin: MKOPSC Incident:VCEHazards:Flammable,ToxicImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Methanol

202312FebAll DaySIMAR TOXIC RELEASE 2015Simar, Igualad (ES)Lessons:Audits & Reviews,Competency,Control of Work,Emergency Preparedness,Operating Procedures,Operational Integrity,Process Knowledge,Risk Assessment,Stakeholder Engagement,Workforce InvolvementIndustry:ChemicalsCountry:SpainLanguage:ENLoC:Operator error Origin: MKOPSC Incident:Runaway reaction explosionImpact:HUMAN (Offsite Injuries)Effects:< 100 Injuries

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

March

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

202326MarAll DayAFRICA SUNOIL FIRE 2014Africa Sunoil Refineries, Durban (ZA)Lessons:Audits & Reviews,Competency,Emergency Preparedness,Incident Investigation,Process Knowledge,Risk Assessment,Stakeholder EngagementIndustry:Food & DrinkCountry:South AfricaLanguage:ENLoC:Fire exposure Origin: MKOPSC Incident:VCEHazards:FlammableImpact:HUMAN (On Site At Risk)Effects:EnvironmentalMaterial:Sunflower oil

202329MarAll DayVISAKHAPATNAM FIRECRACKER EXPLOSION 2015Firecrackers, Visakhapatnam (IN)Lessons:Asset integrity,Audits & Reviews,Commitment & Culture,Competency,Compliance with Standards,Contractor Management,Control of Work,Incident Investigation,Management of Change,Operating Procedures,Operational Integrity,Operational Readiness,Performance Indicators,Process Knowledge,Risk Assessment,Workforce InvolvementIndustry:ExplosivesCountry:IndiaLanguage:ENLoC:Confined explosion Origin: MKOPSC Incident:Explosive decompositionHazards:ExplosiveImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Firecrackers/Fireworks

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

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

202313AprAll DayKINDER-MORGAN BORGER EXPLOSION 2015Kinder-Morgan, Borger (US-TX)Lessons:Asset integrity,Audits & Reviews,Commitment & Culture,Competency,Compliance with Standards,Emergency Preparedness,Process Knowledge,Risk AssessmentIndustry:PipelinesCountry:United StatesLanguage:ENLoC:Deterioration Origin: MKOPSC Incident:EXPLOSIONHazards:FlammableImpact:HUMAN (On Site At Risk)Effects:EnvironmentalMaterial:Methane

202321AprAll DayHUACHANG EXPLOSION 2015Huachang Chemical Group, Zhangjiagang, Jiangsu (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:ChemicalsCountry:ChinaLanguage:ENLoC:Fire exposure Origin: MKOPSC Incident:EXPLOSIONHazards:Corrosive,Environmental,ToxicImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Ammonia

202321AprAll DayYANGZI PETROCHEMICAL EXPLOSION 2015Yangzi Petrochemical, Nanjing, Jiangsu (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:PetrochemicalsCountry:ChinaLanguage:ENLoC:UNKNOWN Origin: MKOPSC Incident:VCEHazards:Harmful/IrritantImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Glycol

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