Lessons Process Knowledge

Process Knowledge Management | Documentation, Records and Knowledge Management.

December

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

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

202311JanAll DayBethune Point Explosion 2006City of Daytona Beach Bethune Point (US-FL)Lessons:Asset integrity,Control of Work,Process Knowledge,Workforce InvolvementIndustry:Water TreatmentCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:VCEHazards:Flammable,ToxicContributory Factors:MaintenanceImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Methanol

202313JanAll DayBLSR Operating Fire 2003BLSR Rosharon (US-TX)Lessons:Compliance with Standards,Contractor Management,Operating Procedures,Process KnowledgeIndustry:Waste TreatmentCountry:United StatesLanguage:ENLoC:Operator error Origin: CSB Incident:VCEHazards:FlammableContributory Factors:Training/InstructionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:BS&W

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

202329JanAll DayWest Pharmaceutical Services Dust Explosion 2003West Pharmaceutical Services Kinston (US-NC)Lessons:Compliance with Standards,Process KnowledgeIndustry:Plastics & PolymersCountry:United StatesLanguage:ENLoC:Operator error Origin: CSB Incident:Dust explosionHazards:FlammableContributory Factors:HousekeepingImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:PolyethyleneTopics:Combustible Dust

202330JanAll DayLittle General Store Explosion 2007Little General Store Ghent (US-WV)Lessons:Emergency Preparedness,Process Knowledge,Stakeholder EngagementIndustry:MiscellaneousCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:VCEHazards:FlammableContributory Factors:SupervisionImpact:HUMAN (Offsite Fatalities)Effects:1-10 FatalitiesMaterial:Propane

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

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

February

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 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

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

202319FebAll DayConcept Sciences Explosion 1999Concept Sciences Allentown (US-PA)Lessons:Emergency Preparedness,Process Knowledge,Risk Assessment,Stakeholder EngagementIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Overpressure Origin: CSB Incident:Runaway reaction explosionHazards:ReactiveContributory Factors:Loss of Process ControlImpact:HUMAN (Offsite Fatalities)Effects:1-10 FatalitiesMaterial:HydroxylamineTopics:Chemical Reaction,Occupied Buildings

202320FebAll DayCTA Acoustics Dust Explosion 2003CTA Acoustics, Inc. Corbin (US-KY)Lessons:Asset integrity,Control of Work,Process Knowledge,Risk AssessmentIndustry:ManufacturingCountry:United StatesLanguage:ENLoC:Operator error Origin: CSB Incident:Dust explosionHazards:FlammableContributory Factors:HousekeepingImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Phenolic resinTopics:Chemical Reaction

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

202320MarAll DayShell Stanlow Explosion 1990Shell Stanlow (GB)Lessons:Asset integrity,Operational Integrity,Process Knowledge,Risk AssessmentIndustry:RefiningCountry:United KingdomLanguage:ENLoC:Overpressure Origin: HSE Incident:VCEHazards:Flammable,ToxicImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:ChlorofluoroanilineTopics:Chemical Reaction

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

202305AprAll DayCARBOGEN AMCIS EXPLOSION 2015Carbogen Amcis, Manchester (GB)Lessons:Competency,Control of Work,Operating Procedures,Operational Integrity,Operational Readiness,Process Knowledge,Risk AssessmentIndustry:Life SciencesCountry:United KingdomLanguage:ENLoC:Fire exposure Origin: MKOPSC Incident:EXPLOSIONImpact:HUMAN (On Site At Risk)Effects:Environmental

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 DayDonaldson Enterprises Explosion 2011Donaldson Enterprises Waipahu (US-HI)Lessons:Compliance with Standards,Contractor Management,Process KnowledgeIndustry:ExplosivesCountry:United StatesLanguage:ENLoC:Confined explosion Origin: CSB Incident:Explosive decompositionHazards:ExplosiveContributory Factors:Training/InstructionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Explosives

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

202312AprAll DayMFG Chemical (Dalton) Toxic Release 2004MFG Chemical, Inc. Callahan Rd. Dalton (US-GA)Lessons:Emergency Preparedness,Process Knowledge,Stakeholder EngagementIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Genuine release Origin: CSB Incident:Runaway reaction explosionHazards:FlammableContributory Factors:Loss of Process ControlImpact:HUMAN (Offsite Injuries)Effects:≥ 100 InjuriesMaterial:Allyl alcohol,Allyl chlorideTopics:Chemical Reaction

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

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

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

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

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

202326AprAll DayHusky Energy Refinery Explosion 2018Husky Superior (US-WI)Lessons:Process KnowledgeIndustry:RefiningCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:VCEHazards:FlammableContributory Factors:MaintenanceImpact:HUMAN (Offsite Injuries)Effects:< 100 InjuriesMaterial:Hydrocarbons

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