Lessons: Process Knowledge

An explosion ripped through the New Cumberland A.L. Solutions titanium plant in West Virginia on December 9, 2010, fatally injuring three workers. The workers were processing titanium powder, which is highly flammable, at the time of the explosion.

KEY ISSUES:
• FEDERAL COMBUSTIBLE DUST OVERSIGHT
• HAZARD RECOGNITION & TRAINING
• LEARNING FROM PREVIOUS INCIDENTS

ROOT CAUSES:
1. AL Solutions did not mitigate the hazards of metal dust explosions through engineering controls, such as a dust collection system. Specifically, AL Solutions did not adhere to the practices recommended in NFPA 484 for controlling combustible metal dust hazards.

Image credit: CSB

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

On Wednesday, January 11, 2006, three workers continued the roof removal. About 11:15 a.m., the lead mechanic and the third worker were cutting the metal roof directly above the methanol tank vent. Sparks, showering down from the cutting torch, ignited methanol vapors coming from the vent, creating a fireball on top of the tank. The fire flashed through a flame arrester on the vent, igniting methanol vapors and air inside the tank, causing a explosion inside the steel tank.

The explosion inside the methanol storage tank
• rounded the tank’s flat bottom, permanently deforming the tank and raising the side wall about onefoot;
• ripped the nuts from six bolts used to anchor the tank to a concrete foundation;
• blew the flame arrester off the tank vent pipe;
• blew a level sensor off a 4-inch flange on the tank top;
• separated two 1-inch pipes, valves, and an attached level switch from flanges on the side of the tank;
• separated a 4-inch tank outlet pipe from the tank outlet valve; and
• separated a 4-inch tank fill pipe near the top the tank.

Methanol discharged from the separated pipes ignited and burned, spreading the fire. Methanol also flowed into the containment around the tank and through a drain to the WWTP where it was diluted and harmlessly processed. The lead mechanic and the third worker were in the man-lift basket over the methanol tank when the ignition occurred. They were likely burned from the initial fireball and burning methanol vapors discharging from the tank vent under pressure from the explosion. The lead mechanic, fully engulfed in fire, likely jumped or fell from the man-lift. Emergency responders found his body within the concrete containment next to the tank.

The third worker stated that he had been partially out of the man-lift basket leaning over the roof when the fire ignited. On fire, he climbed onto the roof to escape. Co-workers, unable to reach him with a ladder, told him to jump to an adjacent lower roof and then to the ground. He sustained second and third degree burns over most of his body, and was hospitalized for 4 months before being released to a medical rehabilitation facility. Methanol sprayed from separated pipes onto the crane, burning the crane cab with the mechanic inside. On fire, he exited the cab and was assisted by co-workers. He died in the hospital the following day.

KEY ISSUES:
• HAZARD COMMUNICATION
• HOT WORK CONTROL
• PLASTIC PIPE IN FLAMMABLE SERVICE
• FLAME ARRESTER MAINTENANCE
• FLORIDA PUBLIC EMPLOYEE SAFETY PROGRAMS

ROOT CAUSES:
1. The City of Daytona Beach did not implement adequate controls for hot work at the Bethune Point WWTP.
2. The City of Daytona Beach had a hazard communication program that did not effectively communicate the hazards associated with methanol at the Bethune Point WWTP.

Image credit: CSB

On January 13, 2003, at approximately 4:30 pm, a vapor cloud deflagration and pool fire erupted at the BLSR Operating, Ltd. (BLSR), facility located 5 miles north of Rosharon, Texas. Two BLSR employees were killed, and three were seriously burned. Two T&L Environmental Services, Inc. (T&L), truck drivers, who had just delivered gas condensate storage tank basic sediment and water (BS&W) to BLSR, were seriously burned; one of these men died on March 2.

The fire was caused by the release of hydrocarbon vapor during the unloading of BS&W from two vacuum trucks into an open area collection pit. BS&W is an oil/gas exploration and production (E&P) waste liquid. The fire destroyed two 50-barrel (2,100-gallon) vacuum trucks and seriously damaged waste liquid offloading equipment and structures at BLSR. One of the vacuum truck diesel engines was the most likely source of ignition..

KEY ISSUES:
• RECOGNIZING FLAMMABILITY HAZARDS OF EXPLORATION & PRODUCTION WASTE LIQUIDS
• SAFE HANDLING OF FLAMMABLE LIQUIDS

ROOT CAUSES:
1. Noble Energy, Inc., the shipper, failed to identify the flammability hazard of BS&W generated at its gas well production facility, and also failed to communicate the hazard to employees and contractors who were required to handle the flammable liquid.
2. T&L management did not require Noble Energy to provide vacuum truck drivers with a material safety data sheet or other document listing the potential flammability hazard of BS&W, nor did it identify the flammability hazard of the mixture in the vacuum truck tank.
3. BLSR management did not have effective hazard communication practices in place to recognize the potential flammability hazard of each shipment of BS&W, nor did it implement safe handling practices when offloading flammable liquid onto the mud disposal and washout pad area.

Image Credit: CSB

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

On January 29, 2003, an explosion and fire destroyed the West Pharmaceutical Services plant in Kinston, North Carolina, causing six deaths, dozens of injuries, and hundreds of job losses. The facility produced rubber stoppers and other products for medical use. The fuel for the explosion was a fine plastic powder, which accumulated above a suspended ceiling over a manufacturing area at the plant and ignited.

KEY ISSUES:
• HAZARD RECOGNITION & COMMUNICATION
• GOOD ENGINEERING PRACTICE
• LOCAL AMENDMENTS TO FIRE CODES

ROOT CAUSES:
1. West did not perform adequate engineering assessment of the use of powdered zinc stearate and polyethylene as antitack agents in the rubber batchoff process.
2. West engineering management systems did not ensure that relevant industrial fire safety standards were consulted.
3. West management systems for reviewing material safety data sheets did not identify combustible dust hazards.
4. The Kinston plant’s hazard communication program did not identify combustible dust hazards or make the workforce aware of such.

Image Credit: CSB

On January 30, 2007, a propane explosion at the Little General Store in Ghent, West Virginia, killed two emergency responders and two propane service technicians, and injured six others. The explosion leveled the store, destroyed a responding ambulance, and damaged other nearby vehicles.

On the day of the incident, a junior propane service technician employed by Appalachian Heating was preparing to transfer liquid propane from an existing tank, owned by Ferrellgas, to a newly installed replacement tank. The existing tank was installed in 1994 directly next to the store’s exterior back wall in violation of West Virginia and U.S. Occupational Safety and Health Administration regulations.

When the technician removed a plug from the existing tank’s liquid withdrawal valve, liquid propane unexpectedly released. For guidance, he called his supervisor, a lead technician, who was offsite delivering propane. During this time propane continued releasing, forming a vapor cloud behind the store. The tank’s placement next to the exterior wall and beneath the open roof overhang provided a direct path for the propane to enter the store.

About 15 minutes after the release began, the junior technician called 911. A captain from the Ghent Volunteer Fire Department subsequently arrived and ordered the business to close. Little General employees closed the store but remained inside. Additional emergency responders and the lead technician also arrived at the scene. Witnesses reported seeing two responders and the two technicians in the area of the tank, likely inside the propane vapor cloud, minutes before the explosion.

Minutes after the emergency responders and lead technician arrived, the propane inside the building ignited. The resulting explosion killed the propane service technicians and two emergency responders who were near the tank. The blast also injured four store employees inside the building as well as two other emergency responders outside the store.

KEY ISSUES:
• EMERGENCY EVACUATION
• HAZARDOUS MATERIALS INCIDENT TRAINING FOR FIREFIGHTERS
• 911 CALL CENTER RESOURCES
• PROPANE COMPANY PROCEDURES
• PROPANE SERVICE TECHNICIAN TRAINING

ROOT CAUSES:
1. The Ferrellgas inspection and audit program did not identify the tank location as a hazard. Consequently, the tank remained against the building for more than 10 years.
2. Appalachian Heating did not formally train the junior technician, and on the day of incident he was working alone.
3. Emergency responders were not trained to recognize the need for immediate evacuation during liquid propane releases.

Image credit: CSB

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

Three combustible dust incidents over a six month period occurred at the Hoeganaes facility in Gallatin, TN, resulting in fatal injuries to five workers. The facility produces powdered iron and is located about twenty miles outside of Nashville.

KEY ISSUES:
• HAZARD RECOGNITION AND TRAINING
• ENGINEERING CONTROLS
• FIRE CODES/ENFORCEMENT
• REGULATORY OVERSIGHT

ROOT CAUSES:
1. Hoeganaes facility management were aware of the iron powder combustibility hazard two years prior to the fatal flash fire incidents but did not take necessary action to mitigate the hazard through engineering controls and housekeeping.
2. Hoeganaes did not institute procedures – such as combustible gas monitoring – or training for employees to avoid flammable gas fires and explosions

Image credit: CSB

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)

Employees at the plant were carrying out their normal duties when two chemical compounds came into contact. An explosion occurred releasing a toxic cloud into the air. Toxic cloud

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

Explosion in an oil and gas production ship rented by Petrobras. The explosion occurred aboard the FPSO unit. A leak of flammable substance in the pump room was the cause of the explosion.

Proximate causes:
• Failure in following procedures
• Lack of work rules/policies/ standards/procedures (breach of operational procedures for the pumping of fluids)
• Inadequate engineering/design
• Inadequate management/ supervision (installation of equipment in pipe without proper technical specification and registration of the change)
• Work exposure to hazardous chemicals (flammable substances) Inadequate assessment of needs and risks

Marsh (https://www.marsh.com/us/insights/research/100-largest-losses-in-the-hydrocarbon-industry.html):

An explosion on a FPSO off the coast of Brazil resulted in nine fatalities and multiple wounded. The accident happened as the vessel was anchored in the Atlantic Ocean 120 kilometres from the coast of Espirito Santos, Brazil. The FPSO is a converted very large crude oil tanker (VLCC), designed to produce up to 10 million cubic meters of natural gas. It is understood that a condensate leak during a fluid transfer operation released a cloud of flammable vapor into the engine room, resulting in an explosion in the machinery space. The majority of fatalities were believed to be part of the emergency response team. FPSO took on water, but the explosion did not result in a breach of the hull of the vessel.

[ Property Damage $250 Million. Estimated Current Value $264 Million ]

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

On February 19, 1999, a process vessel containing several hundred pounds of hydroxylamine exploded at the Concept Sciences Inc. production facility near Allentown, Pennsylvania. Employees were distilling an aqueous solution of hydroxylamine and potassium sulfate, the first commercial batch to be processed at the facility. After the distillation process was shut down, the HA in the process tank and associated piping explosively decomposed, most likely due to high concentration and temperature. Four CSI employees and a manager of an adjacent business were killed. Two CSI employees survived the blast with moderate-to-serious injuries. Four people in nearby buildings were injured. The explosion also caused significant damage to other buildings in the Lehigh Valley Industrial Park and shattered windows in several nearby homes.

KEY ISSUES:
• HAZARDS OF PROCESSING HYDROXYLAMINE
• PROCESS HAZARDS EVALUATION
• CHEMICAL FACILITY SITING

ROOT CAUSES:
1. CSI’s process safety management systems were insufficient to properly address the hazards inherent in its HA manufacturing process and to determine whether these hazards presented substantial risks.
2. Inadequate collection and analysis of process safety information contributed to CSI’s failure to recognize specific explosion hazards.
3. Basic process safety and chemical engineering practices – such as process design reviews, hazard analyses, corrective actions, and reviews by appropriate technical experts – were not adequately implemented.
4. The existing system of siting approval by local authorities allowed a highly hazardous facility to be inappropriately located in a light industrial park.

Image Credit: CSB

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 February 20, 2003, dust explosion at the CTA Acoustics, Inc. (CTA) facility in Corbin, Kentucky, killed seven and injured 37 workers. This incident caused extensive damage to the production area of the 302,000-square-foot plant. Nearby homes and an elementary school were evacuated, and a 12-mile section of Interstate 75 was closed. The largest CTA customer, Ford Motor Company, temporarily suspended operations at four automobile assembly plants because CTA had produced acoustic insulation products for those plants, as well as for other industrial and automotive clients.

KEY ISSUES:
• COMBUSTIBLE DUST HAZARD AWARENESS
• WORK PRACTICES
• BUILDING DESIGN
• PRODUCT STEWARDSHIP

ROOT CAUSES:
1. CTA management did not implement effective measures to prevent combustible dust explosions.
2. The CTA cleaning and maintenance procedures for production lines did not prevent the accumulation of unsafe levels of combustible dust on elevated flat surfaces.
3. The CTA incident investigation program did not ensure that all oven fires were investigated and that underlying causes were identified and resolved.
4. The Borden Chemical product stewardship program did not explicitly convey to CTA the explosive hazards of phenolic resins.
5. The original building design and subsequent building modifications did not effectively address the fire and explosion hazards associated with combustible dusts.

Image Credit: CSB

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)

Four reactors exploded after an initial fire in a warehouse in the plant. The toxic gas released due to the fire and explosion affected the local community. Electrical short circuit and improper shutdown was the reason that triggered the incident.

Proximate causes:
• Inadequate tools, equipment & vehicles (Electrical appliances shortcut)
• Failure in following procedure (improper shutdown)

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)

On 20 March 1990 the halogen exchange reactor on the Fluoroaromatics plant was ruptured by the pressure generated by a runaway reaction. The plant was partially destroyed and missiles were projected over 500m. Six employees were injured and one subsequently died from post-operative complications.

A batch had been charged into the vessel and was being heated up as normal. When it reached 165oC, the temperature continued to rise and the operators adjusted the jacket temperature. The display screen in use did not display pressure and they were unaware of a corresponding rise in pressure. By the time they were alerted to the rise in pressure the pressure relief valves had lifted. Before any other corrective action could be taken, the reactor exploded. The pressure in the vessel reached a value of about 60-80 barg compared with the relief valve set pressure of 5 barg.

The resulting blast was enhanced by the formation of a fireball, which occurred when the contents of the reactor ignited within the plant structure. This started local fires and initiated what became a major conflagration in an adjacent unit where vessels containing xylene were damaged by the blast/missile effects. The ensuing fires were brought under control in four hours by the Shell fire team and Cheshire fire service.

The initial cause of the incident was the ingress of excessive water into the process leading to the formation of acetic acid which, upon recycle to the reactor, reacted vigorously with the reactor contents initiating the explosion. Water was present as a part of the process, however a massive incursion led to the formation of a separate layer in the process vessel which was not removed but recycled back into reactor.

KEY ISSUES:
• CONTROL ROOM DESIGN
• RAW MATERIALS CONTROL / SAMPLING
• REACTION / PRODUCT TESTING
• RELIEF SYSTEMS / VENT SYSTEMS

Image Credit: The Leader

Blaze in a warehouse next to oil factory. Fire created massive plumes of smoke in the area. Fire spread to adjacent paint factory. Damaged buildings

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Twitter / News24

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

A fire started inside a depot with 3 million liters of diesel and the flames spread to four neighboring storage tanks. The fire lasted for 9 days.

Fine of around USD $6.4 million (R$ 22.5 million). Environmental impact causing death of thousands of fish

Proximate causes:
• Inadequate management/ supervision
• Inadequate work planning

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

Fire in a chemical plant fueled by unidentified chemicals. Two explosions were reported, one of them was a cylinder. Smoke and debris

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

A blast occurred in a pumping station, after leaking oil caught fire. 177 fire engines and more than 800 firefighters were rushed to the blaze, and more than 14,000 residents in the surrounding area were evacuated.

Proximate causes:
• Improper use of protective methods (Improper welding of conveying pipe)

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

On April 8, 2011, at approximately 8:50 am, an explosion and fire occurred at a magazine known as ‘A-21’ located at Waikele Self Storage in Waipahu, Hawaii. Five Donaldson Enterprises, Inc. (DEI) employees were fatally injured and a sixth sustained minor injuries.

DEI, a small unexploded ordnance (UXO) clearance company based on the island of Oahu, was using the magazine to store seized contraband fireworks and prepare them for disposal. On the morning of the incident, five DEI personnel were disassembling one-inch contraband firework tubes on a cement loading dock located directly in front of the magazine entrance, while a sixth remained inside the magazine cleaning and organizing . To accomplish the disassembly work, DEI personnel cut into the individual firework tubes by hand using a PVC pipe cutter or knife and separated the individual explosive components contained within each tube, the aerial shells and the black powder (which functions as a lift charge) into cardboard boxes.

According to witness statements, around 8:30 am it began to rain heavily, and the DEI workers quickly moved materials involved in the disassembly process – including tools, chairs, and boxes containing aerial shells, black powder, and partially disassembled firework tubes – to just inside the magazine entrance. While five of the workers remained inside, the project supervisor went outside to the front left corner of the loading dock to make a phone call. While he was on the phone, an explosion occurred inside the magazine, and a fire ensued.

The five individuals located inside the magazine at the time of the incident did not survive. Three DEI employees sustained fatal burn injuries while two succumbed to carbon monoxide poisoning. The project supervisor sustained minor injuries.

KEY ISSUES:
• HAZARDS OF FIREWORKS DISPOSAL & THE ACCUMULATION OF EXPLOSIVE FIREWORKS COMPONENTS
• LACK OF REGULATIONS & INDUSTRY STANDARDS ADDRESSING FIREWORKS DISPOSAL
• INSUFFICIENT CONTRACTOR SELECTION & OVERSIGHT REQUIREMENTS FOR HAZARDOUS ACTIVITIES

ROOT CAUSES:
1. DEI’s hazard analysis of its fireworks disposal process was insufficient. The company failed to identify key hazards of handling, disassembling, and storing contraband commercial display fireworks, and did not adequately control the identified and evaluated hazards.
2. DEI personnel disposing of the fireworks lacked the training, experience, and knowledge of procedural safeguards for the safe conduct of the fireworks disposal.
3. DEI’s modifications to the fireworks disposal process accumulated substantially large quantities of explosive material in boxes, greatly increasing the potential explosion hazard. This change to the disposal process was not adequately reviewed for safety implications.

Image & AcciMap Credit: CSB

Image credit: CSB

A chemical drum which is speculated to have contained an old chemical exploded at Echotech fiber manufacturing factory workshop.

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

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)

On the night of April 12, 2004, during an attempt to make the first production batch of triallyl cyanurate (TAC) at MFG Chemical, Inc. (MFG) in Dalton, Georgia, a runaway chemical reaction released highly toxic and flammable allyl alcohol and toxic allyl chloride into the nearby community. The fire department ordered an evacuation of residents and businesses within a halfmile of the facility. The release forced more than 200 families from their homes. One MFG employee sustained minor chemical burns and 154 people received decontamination and treatment at the local hospital for chemical exposure, including 15 police and ambulance personnel assisting with the evacuation. Five residents required overnight hospitalization for breathing difficulties. The reactor continued venting toxic vapor for nearly eight hours and the evacuation order lasted more than nine hours.

KEY ISSUES:
• REACTIVE CHEMICALS PROCESS DESIGN
• PROCESS SCALE-UP
• EMERGENCY PLANNING & RESPONSE

ROOT CAUSES:
1. MFG did not understand or anticipate the reactive chemistry hazards. They did not make use of readily available literature on the hazards of reactive chemistry, or conduct a comprehensive literature search of the reactive chemistry specifically involved in manufacturing the product, which would have alerted them to the hazards involved in manufacturing TAC.
2. MFG did not perform a comprehensive process design and hazard review of the laboratory scale-up to full production before attempting the first production run.
3. MFG did not prepare and implement an adequate emergency response plan. They did not train or equip employees to conduct emergency mitigation actions.
4. MFG did not implement the EPA Risk Management Program or the OSHA Process Safety Management program prior to receiving the allyl alcohol. The regulations require comprehensive engineering analyses of the process, emergency planning, a pre-startup safety review, and coordination with the local community before receiving the covered chemical at the site and introducing the covered chemical into the process.

Image Credit: CSB

A natural gas pipeline that was situated within a plowed field exploded and caused a fire. The location of the explosion helped crews keep it contained. One home was voluntarily evacuated

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: News Channel 10 Amarillo

The incident took place on Easter Monday the 16th April 2001. During the morning the SGP was operating normally and the Central Control Room (CCR) reported a quiet shift, with no alarms showing for the SGP. In the early afternoon there were only 185 people on site, rather than a normal weekday figure of about 800. Most of the staff were inside buildings preparing for the shift handover, which was due to occur at 3pm. A number of people were working in the open air.

At approximately 14.20 hrs a catastrophic failure of a section of pipework on the SGP plant occurred at an elbow just downstream of a water-into-gas injection point. The six inch diameter pipe P4363, (the overhead line carrying flammable gas under high pressure),ruptured releasing a huge cloud containing around 90% ethane/propane/butane. About 20-30 seconds later the gas cloud ignited. As a result a massive explosion and fire followed.

KEY LESSONS:

Management of Pipework Inspection
• Effective pipework inspection systems are a vital major accident prevention measure for high hazard pipework.
• Such systems should at least meet current industry good practice standard.
• Decisions on inspection intervals should be informed by suitable and sufficient information on process conditions and previous inspection findings.

Management of Change
• Effective management of change systems, which consider both plant and process modifications, are essential to prevent major accidents.
• Particular care is needed to ensure that ‘quick fix’ modifications, during the commissioning and early operation phases of new plant, are covered.

Management of Corrosion
• Systematic and thorough arrangements are necessary for the effective management of corrosion on major hazard installations.
• Such arrangements should ensure that any available information on relevant corrosion degradation mechanisms is identified and acted on.
• Adequate resource, including relevant expertise, should be applied to ensure that adequate standards are achieved and maintained.

Communication
• Effective communication is an important element of any safety management system. In the context of major hazard establishments the accurate recording and effective sharing of information and data relevant to plant corrosion is essential for major accident prevention.
• Communication systems should aim to actively involve the workforce in the prevention of major accidents as part of an adequately resourced process safety management system.

Image Credit: HSE

On April 17, 2013, a fire and explosion occurred at the West Fertilizer Company (WFC), a fertilizer blending, retail, and distribution facility in West, Texas. The violent detonation fatally injured 12 emergency responders and three members of the public. Local hospitals treated more than 260 injured victims, many of whom required hospital admission. The blast completely destroyed the WFC facility and caused widespread damage to more than 150 offsite buildings. The WFC explosion is one of the most destructive incidents ever investigated by the U.S. Chemical Safety and Hazard Investigation Board (CSB) as measured by the loss of life among emergency responders and civilians; the many injuries sustained by people both inside and outside the facility fenceline; and the extensive damage to residences, schools, and other structures. Following the explosion, WFC filed for bankruptcy.

The explosion happened at about 7:51 pm central daylight time (CDT), approximately 20 minutes after the first signs of a fire were reported to the local 911 emergency response dispatch center. Several local volunteer fire departments responded to the facility, which had a stockpile of between 40 and 60 tons (80,000 to 120,000 pounds) fertilizer grade ammonium nitrate (FGAN), not counting additional FGAN not yet offloaded from a railcar.

More than half of the structures damaged during the explosion were demolished to make way for reconstruction. The demolished buildings include an intermediate school (552 feet southwest of the facility), a high school (1,263 feet southeast), a two-story apartment complex with 22 units (450 feet west) where two members of the public were fatally injured, and a 145-bed nursing home (500 feet west) where many of the seriously injured civilians resided. A middle school (2,000 feet southwest) also sustained serious but reparable damage. Section 3 describes the incident and its consequences in detail.

KEY ISSUES:
• REGULATORY OVERSIGHT
• HAZARD AWARENESS
• EMERGENCY PLANNING & RESPONSE
• FERTILIZER GRADE AMMONIUM NITRATE STORAGE PRACTICES
• LAND USE PLANNING & ZONING

ROOT CAUSES:
1. The presence of combustible materials used for construction of the facility and the fertilizer grade ammonium nitrate (FGAN) storage bins, in addition to the West Fertilizer Company (WFC) practice of storing combustibles near the FGAN pile, contributed to the progression and intensity of the fire and likely resulted in the detonation.
2. The WFC facility did not have a fire detection system to alert emergency responders or an automatic sprinkler system to extinguish the fire at an earlier stage of the incident.
3. Regulatory, Insurance, Emergency Response, Emergency & Land Use Planning deficiencies.

Image credit: CSB

A fire occurred in a company producing ammonia, and other chemical products. The facility was severely damaged in the catastrophic fire.

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

An explosion occurred in a glycol unit refining tower of a petrochemical plant

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

On April 23, 2004, an explosion and fire killed five and seriously injured three workers at the Formosa Plastics Corporation, IL (Formosa-IL) PVC manufacturing facility in Illiopolis, Illinois. The explosion occurred after a large quantity of highly flammable vinyl chloride monomer (VCM) was inadvertently released from a reactor and ignited. The explosion and fire that followed destroyed much of the facility and burned for two days. Local authorities ordered residents within one mile of the facility to evacuate.

KEY ISSUES:
• HUMAN FACTORS
• HAZARD EVALUATION
• INCIDENT INVESTIGATION
• EMERGENCY RESPONSE

ROOT CAUSES:
1. Borden Chemical did not adequately address the potential for human error.
2. Formosa-IL did not adequately address the potential for human error.
3. Formosa-IL relied on a written procedure to control a hazard with potentially catastrophic consequences.

Image Credit: CSB

On April 26, 2018, an explosion and subsequent fire occurred at the Superior Refinery Company LLC refinery in Superior, Wisconsin (‘Husky Superior Refinery’). The incident occurred in the refinery’s Fluid Catalytic Cracking Unit (FCCU). In preparation for the shutdown, the refinery brought in hundreds of contractors and increased operations staffing. The contractors were performing many tasks such as electrical work, preparing for chemical cleaning, building scaffolding, and welding. As a result of the explosion, thirty-six people sought medical attention, including eleven refinery and contract workers who suffered OSHA recordable injuries. In addition, a large portion of Superior, Wisconsin was evacuated. The refinery was shutting down in preparation for a five-week turnaround when an explosion occurred, sending several people to area hospitals with injuries.

KEY ISSUES:
• PYROPHORIC IRON SULFIDE

Image credit: CSB