Lessons Commitment & Culture

Process Safety Culture | Leadership Commitment and Responsibility.

December

202207DecAll DayNDK Crystal Explosion 2009NDK Crystal Belvidere (US-IL)Lessons:Commitment & Culture,Compliance with Standards,Incident InvestigationIndustry:ManufacturingCountry:United StatesLanguage:ENLoC:Deficiency Origin: CSB Incident:Pressure burstHazards:Mechanical/Kinetic/PotentialContributory Factors:Corrosion/Erosion/FatigueImpact:HUMAN (Offsite Fatalities)Effects:1-10 FatalitiesMaterial:Quartz

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

202211DecAll DayEnvironmental Enterprises Toxic Release 2002Environmental Enterprises Cincinnati (US-OH)Lessons:Asset integrity,Commitment & Culture,Operating Procedures,Workforce InvolvementIndustry:Waste TreatmentCountry:United StatesLanguage:ENLoC:Material incompatibility Origin: CSB Incident:Gas/vapour/mist/etc release to airHazards:Flammable,ToxicContributory Factors:Organized ProceduresImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Hydrogen Sulfide

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

202302JanAll DayCatalyst Systems Reactive Explosion 2003Catalyst Systems Gnadenhutten (US-OH)Lessons:Commitment & Culture,Risk AssessmentIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Overpressure Origin: CSB Incident:Runaway reaction explosionHazards:OxidisingContributory Factors:UNKNOWNImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Benzoyl PeroxideTopics:Chemical Reaction

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

202307JanAll DaySierra Chemical Explosion 1998Sierra Chemical Co. Mustang (US-NV)Lessons:Commitment & Culture,Competency,Risk Assessment,Workforce InvolvementIndustry:ExplosivesCountry:United StatesLanguage:ENLoC:Confined explosion Origin: CSB Incident:Explosive decompositionHazards:ExplosiveContributory Factors:ErrorImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Explosives

202308JanAll DayGREEN VALLEY CHEMICAL EXPLOSION 2015Green Valley Chemical, Creston (US-IA)Lessons:Asset integrity,Commitment & Culture,Competency,Compliance with Standards,Control of Work,Operating Procedures,Risk AssessmentIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:UNKNOWN Origin: MKOPSC Incident:Pressure burstHazards:Mechanical/Kinetic/PotentialImpact:HUMAN (Offsite Fatalities)Effects:1-10 FatalitiesMaterial:Compressed Air

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

202322JanAll DayPryor Trust Blowout & Fire 2018Pryor Trust Pittsburg County (US-OK)Lessons:Asset integrity,Commitment & Culture,Compliance with Standards,Operating Procedures,Operational Integrity,Operational ReadinessIndustry:Onshore Oil & GasCountry:United StatesLanguage:ENLoC:Overpressure Origin: CSB Incident:EXPLOSIONHazards:FlammableContributory Factors:Containment FailureImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Methane

202331JanAll DayLINYI EXPLOSION 2015Linyi Huasheng Group, Shandong (CN)Lessons:Commitment & Culture,Competency,Compliance with Standards,Control of Work,Operating Procedures,Operational Integrity,Operational Readiness,Performance Indicators,Process Knowledge,Risk Assessment,Workforce InvolvementIndustry:Metal ProcessingCountry:ChinaLanguage:ENLoC:Deterioration Origin: MKOPSC Incident:EXPLOSIONHazards:FlammableContributory Factors:Organization Inadequate,Organized Procedures,Training/InstructionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Coke

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

202308FebAll DayLIAOCHENG EXPLOSION 2015Liaocheng, Shandong (CN)Lessons:Commitment & Culture,Competency,Compliance with Standards,Control of Work,Operating Procedures,Operational Integrity,Operational Readiness,Performance Indicators,Process Knowledge,Risk Assessment,Workforce InvolvementIndustry:PetrochemicalsCountry:ChinaLanguage:ENLoC:Maintenance error Origin: MKOPSC Incident:VCEHazards:FlammableContributory Factors:Organization Inadequate,Organized Procedures,Training/InstructionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Ethanol

202308FebAll DayPCA (Deridder) Explosion 2017PCA DeRidder (US-LA)Lessons:Asset integrity,Commitment & Culture,Control of Work,Risk AssessmentIndustry:Pulp & PaperCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:VCEHazards:FlammableContributory Factors:MaintenanceImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Hydrocarbons

202312FebAll DayTesoro (Martinez) Toxic Release 2014Tesoro Martinez (US-CA)Lessons:Commitment & Culture,Performance IndicatorsIndustry:RefiningCountry:United StatesLanguage:ENLoC:Deterioration Origin: CSB Incident:Fluid release to groundHazards:CorrosiveContributory Factors:MaintenanceImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Sulfuric Acid

202319FebAll DayHUBEI FUSHENG CHEMICAL EXPLOSION 2015Hubei Fusheng Chemical Co., Yichang, Hubei (CN)Lessons:Commitment & Culture,Competency,Compliance with Standards,Control of Work,Operating Procedures,Operational Integrity,Operational Readiness,Performance Indicators,Process Knowledge,Risk Assessment,Workforce InvolvementIndustry:ChemicalsCountry:ChinaLanguage:ENLoC:Component malfunction Origin: MKOPSC Incident:Explosive decompositionHazards:ExplosiveContributory Factors:Organization Inadequate,Organized Procedures,Training/InstructionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Nitro-based fertilizer,Urea-based fertilizer

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

202303MarAll DayTIARUN EXPLOSION 2015Tianrun Chemical Fertilizer Co, Ordos, Inner Mongolia (CN)Lessons:Commitment & Culture,Competency,Compliance with Standards,Control of Work,Operating Procedures,Operational Integrity,Operational Readiness,Performance Indicators,Process Knowledge,Risk Assessment,Workforce InvolvementIndustry:PetrochemicalsCountry:ChinaLanguage:ENLoC:Maintenance error Origin: MKOPSC Incident:Pressure burstHazards:Corrosive,Environmental,Flammable,ToxicContributory Factors:Organization Inadequate,Organized ProceduresImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Ammonia,Hydrogen

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

202318MarAll DayBINZHOU EXPLOSION 2015Binzhou, Shandong (CN)Lessons:Commitment & Culture,Competency,Compliance with Standards,Control of Work,Operating Procedures,Operational Integrity,Operational Readiness,Performance Indicators,Process Knowledge,Risk Assessment,Workforce InvolvementIndustry:ChemicalsCountry:ChinaLanguage:ENLoC:Maintenance error Origin: MKOPSC Incident:VCEHazards:Corrosive,OxidisingContributory Factors:Organization Inadequate,Organized ProceduresImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Hydrogen Peroxide

202323MarAll DayBP Texas City Refinery Explosion 2005BP Texas City (US-TX)Lessons:Commitment & Culture,Compliance with Standards,Operating Procedures,Operational Integrity,Performance Indicators,Risk AssessmentIndustry:RefiningCountry:United StatesLanguage:ENLoC:Genuine release Origin: CSB Incident:VCEHazards:FlammableContributory Factors:Organized ProceduresImpact:HUMAN (On Site Fatalities)Effects:11 – 100 FatalitiesMaterial:HydrocarbonsTopics:Occupied Buildings

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 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

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 DayECHOTECH III EXPLOSION 2015Echotech III, Delhi (IN)Lessons:Commitment & Culture,Competency,Contractor Management,Control of Work,Incident Investigation,Operating Procedures,Operational Integrity,Operational Readiness,Process Knowledge,Risk AssessmentIndustry:ManufacturingCountry:IndiaLanguage:ENLoC:Deterioration Origin: MKOPSC Incident:Runaway reaction explosionImpact:HUMAN (On Site Fatalities)Effects:1-10 Fatalities

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

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

202317AprAll DayALFREBO EXPLOSION 2015Alfrebro LLC, Monroe (US-OH)Lessons:Commitment & Culture,Competency,Compliance with Standards,Operating Procedures,Operational Integrity,Risk AssessmentIndustry:Food & DrinkCountry:United StatesLanguage:ENLoC:Operator error Origin: MKOPSC Incident:Runaway reaction explosionHazards:FlammableImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Acetal

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

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

]
X