Lessons Management of Change

Control of Modifications and Project Management

December

202203DecAll DayBhopal Toxic Release 1984Union Carbide Bhopal Madhya Pradesh (IN)Lessons:Asset integrity,Control of Work,Emergency Preparedness,Management of Change,Risk Assessment,Stakeholder EngagementIndustry:ChemicalsCountry:IndiaLanguage:ENLoC:Genuine release Origin: HSE Incident:Gas/vapour/mist/etc release to airHazards:Corrosive,Flammable,ToxicImpact:HUMAN (Offsite Fatalities)Effects:> 100 FatalitiesMaterial:Methyl IsocyanateTopics:Chemical Reaction

202211DecAll DayBuncefield Explosion 2005Hertfordshire Oil Storage Ltd (GB)Lessons:Asset integrity,Commitment & Culture,Compliance with Standards,Management of Change,Operating Procedures,Risk Assessment,Stakeholder EngagementIndustry:StorageCountry:United KingdomLanguage:ENLoC:Component malfunction Origin: HSE Incident:VCEHazards:FlammableContributory Factors:Component MalfunctionImpact:HUMAN (Offsite Injuries)Effects:< 100 InjuriesMaterial:Petroleum/GasolineTopics:Functional Safety,LOPA

202219DecAll DayT2 Laboratories Reactive Chemical Explosion 2007T2 Laboratories Inc. Jacksonville (US-FL)Lessons:Commitment & Culture,Competency,Compliance with Standards,Emergency Preparedness,Incident Investigation,Management of Change,Risk AssessmentIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Overpressure Origin: CSB Incident:Runaway reaction explosionHazards:ReactiveContributory Factors:Loss of Process ControlImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:MCMTTopics:Chemical Reaction

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

202316JanAll 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

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

February

202307FebAll 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

202307FebAll 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

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 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

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

202323FebAll 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

202322MarAll DayBP (Grangemouth) Hydrocracker Explosion 1987BP Olefins Grangemouth (GB)Lessons:Asset integrity,Control of Work,Management of Change,Operating Procedures,Operational IntegrityIndustry:RefiningCountry:United KingdomLanguage:ENLoC:Overpressure Origin: HSE Incident:VCEHazards:FlammableImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Hydrocarbons

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

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

202308AprAll 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

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

202316AprAll DayHumber Refinery Explosion 2001ConocoPhillips Humber Refinery Killingholme (GB)Lessons:Asset integrity,Management of Change,Process KnowledgeIndustry:RefiningCountry:United KingdomLanguage:ENLoC:Deterioration Origin: HSE Incident:EXPLOSIONHazards:FlammableImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Methane

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

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

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

]
X