Lessons: Performance Indicators

One worker died after hazardous chemical vapors released from an over-pressurized reactor burned his respiratory system. The worker charged chemicals inside a reactor vessel and a reaction started before he could close it.

OSHA’s proposed penalties total $87,780

Proximate causes:
• Inadequate management/supervision

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Google Maps

An explosion occurred at one of Petrobras’ refineries. The blast occurred at a hydrogen conduit in an enclosed space, causing a flare and a displacement of air that threw the contract workers against the refinery’s metal structure.

Proximate causes:
• Inadequate maintenance
• Failure following procedures
• Lack of work rules/policies/ standards/procedures
• Physical condition (the accident may have been the result of maintenance work being carried out under tight deadlines and long shifts imposed on refinery workers)
• Mental stress
• Mental state

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Daily Motion

The incident occurred when workers were weighing a barrel of 4-hydroxybenzohydrazide. There was a short circuiting in the weighing scale which led to an explosion.

Proximate causes:
• Defective equipment

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Survival Technologies

A gas leak followed by explosion occurred during an inspection process due to the loose of valve bolt.

Proximate causes:
• Inadequate training/knowledge transfer (Lack of understanding the process);
• Lack of work rules/policies/ standards/procedures (wrong procedures for inspections);
• Inadequate work rules plan (lack of the pre-start safety review before inspection).

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Wikipedia

An explosion occurred when 8 personnel were working on the repair of a catalyst tower.

Proximate causes:
• Inadequate training/knowledge transfer (Lack of understanding the process)
• Lack of work rules/policies/ standards/procedures (wrong procedures for inspections);
• Inadequate work rules plan (lack of the pre-start safety review before inspection).

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)

On February 12, 2014, a mechanical integrity failure released sulfuric acid in the alkylation unit, which burned two Tesoro Martinez refinery employees. Approximately 84,000 pounds of sulfuric acid were released during the incident.

On March 10, 2014, sulfuric acid sprayed and burned two contract workers while they removed piping in the same alkylation unit. The CSB found that this second incident shared similar causation with a 1999 incident at the same refinery, then called the Avon refinery, owned by the Tosco Corporation, that resulted in four fatalities. Similarities between the two incidents suggest that the Tesoro Martinez refinery did not effectively continue to implement or communicate important safety lessons from the 1999 Tosco incident.

KEY ISSUES:
• PROCESS SAFETY CULTURE
• PROCESS SAFETY INDICATORS

ROOT CAUSES:
1. The safety culture at the Tesoro Martinez refinery created conditions conducive to the occurrence and recurrence of process safety incidents that caused worker injuries at the refinery over several years.
2. Prior sulfuric acid exposure incidents at the Tesoro Martinez refinery could have properly been considered leading indicators of an impending serious chemical accident and then triggered preventive inspections and review of the refinery’s safety systems and equipment.

Image & AcciMap Credit: CSB

Image credit: CSB

A rail car with more than 100 tanks of crude bakken oil derailed in West Virginia, generating a huge fireball, the evacuation of hundreds of people and, a spill into the Kanawha River.

Hundreds evacuated – FRE issued CSX and Sperry Rail Service $25.000 fines each

Proximate causes:
• Inadequate tools, equipment & vehicles (rail defect)

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: US Coast Guard

An explosion occurred due to an overflow of a slurry mixing tank, containing potassium sulfide, potassium dihydrogen phosphate, and MAP.

Proximate causes:
• Inadequate training/knowledge transfer (Lack of understanding the process);
• Lack of work rules/policies/ standards/procedures (wrong procedures for inspections);
• Inadequate work rules plan (lack of the pre-start safety review before inspection).

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)

A high-pressure steam (3.7 MPa) discharge occurred during a maintenance process, resulting in three field workers burned to death.

Proximate causes:
• Lack of work rules/policies/ standards/procedures (wrong procedures for inspections);
• Inadequate work rules plan (lack of the pre-start safety review before inspection).

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)

An explosion occurred when 6 personnel were working on the repair of a catalyst tower

Proximate causes:
• Lack of work rules/policies/ standards/procedures (wrong procedures for inspections);
• Inadequate work rules plan (lack of the pre-start safety review before inspection).

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)

At approximately 1:20 p.m. on March 23, 2005, a series of explosions occurred at the BP Texas City refinery during the restarting of a hydrocarbon isomerization unit. Fifteen workers were killed and 180 others were injured. Many of the victims were in or around work trailers located near an atmospheric vent stack. The explosions occurred when a distillation tower flooded with hydrocarbons and was overpressurized, causing a geyser-like release from the vent stack.

KEY ISSUES:
• SAFETY CULTURE
• REGULATORY OVERSIGHT
• PROCESS SAFETY METRICS
• HUMAN FACTORS

ROOT CAUSES:
1. BP Group Board did not provide effective oversight of the company’s safety culture and major accident prevention programs.

2. Senior executives:
• inadequately addressed controlling major hazard risk. Personal safety was measured, rewarded, and the primary focus, but the same emphasis was not put on improving process safety performance;
• did not provide effective safety culture leadership and oversight to prevent catastrophic accidents;
• ineffectively ensured that the safety implications of major organizational, personnel, and policy changes were evaluated;
• did not provide adequate resources to prevent major accidents; budget cuts impaired process safety performance at the Texas City refinery.

3. BP Texas City Managers did not:
• create an effective reporting and learning culture; reporting bad news was not encouraged. Incidents were often ineffectively investigated and appropriate corrective actions not taken.
• ensure that supervisors and management modeled and enforced use of up-to-date plant policies and procedures.
• incorporate good practice design in the operation of the ISOM unit.
• ensure that operators were supervised and supported by experienced, technically trained personnel during unit startup, an especially hazardous phase of operation; or that
• effectively incorporated human factor considerations in its training, staffing, and work schedule for operations personnel.

Image Credit: CSB

A major explosion in a firecracker unit occurred. The unit was run illegally by the owner who was later taken under custody. Explosions in firecracker units have been a prevalent problem in the state of Seemandhra, India which needs to be addressed.

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: PTI

Two employees accidently fell in an aerobic tank sewage treatment station. Two more employees fell into the aerobic tank in the subsequent rescue.

Proximate causes:
• Inadequate tools, equipment & vehicles (Aerobic tank no special ventilation equipment)

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)