Lessons MONITORING & IMPROVEMENT

Learn from Experience | Review and Improvement

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

202209DecAll DayAL Solutions Dust Explosion 2010A.L. Solutions New Cumberland (US-WV)Lessons:Incident Investigation,Process Knowledge,Risk AssessmentIndustry:Metal ProcessingCountry:United StatesLanguage:ENLoC:Operator error Origin: CSB Incident:Dust explosionHazards:FlammableContributory Factors:Component MalfunctionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:TitaniumTopics:Chemical Reaction,Combustible Dust

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

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 DayHoeganaes Fires 2010Hoeganaes Gallatin (US-TN)Lessons:Compliance with Standards,Incident Investigation,Process KnowledgeIndustry:Metal ProcessingCountry:United StatesLanguage:ENLoC:Operator error Origin: CSB Incident:Dust explosionHazards:FlammableContributory Factors:MaintenanceImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:IronTopics:Combustible Dust

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

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

202307FebAll DayKleen Energy Explosion 2010Kleen Energy Middletown (US-CT)Lessons:Competency,Compliance with Standards,Control of Work,Incident InvestigationIndustry:Fossil PowerCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:EXPLOSIONHazards:FlammableContributory Factors:MaintenanceImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Methane

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

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

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

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 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

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

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

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

202313MarAll DayBP Amoco Thermal Decomposition 2001BP Amoco Augusta (US-GA)Lessons:Incident Investigation,Operational Integrity,Risk AssessmentIndustry:Plastics & PolymersCountry:United StatesLanguage:ENLoC:Operator error Origin: CSB Incident:Runaway reaction explosionHazards:ReactiveContributory Factors:MaintenanceImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:PolymersTopics:Chemical Reaction

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

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

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

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

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

202323AprAll DayFormosa Plastics (Illiopolis) Explosion 2004Formosa Plastics Corporation Illiopolis (US-IL)Lessons:Emergency Preparedness,Incident Investigation,Operational Integrity,Process KnowledgeIndustry:Plastics & PolymersCountry:United StatesLanguage:ENLoC:Operator error Origin: CSB Incident:VCEHazards:Flammable,ToxicContributory Factors:ErrorImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Vinyl Chloride Monomer

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