Lessons LEADERSHIP

Commitment to Process Safety | Process Safety Leadership

December

202203DecAll DayBhopal Toxic Release 1984Union Carbide Bhopal Madhya Pradesh (IN)Lessons:Asset integrity,Control of Work,Emergency Preparedness,Management of Change,Risk Assessment,Stakeholder EngagementIndustry:ChemicalsCountry:IndiaLanguage:ENLoC:Genuine release Origin: HSE Incident:Gas/vapour/mist/etc release to airHazards:Corrosive,Flammable,ToxicImpact:HUMAN (Offsite Fatalities)Effects:> 100 FatalitiesMaterial:Methyl IsocyanateTopics:Chemical Reaction

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 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

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

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

202309JanAll DayFreedom Industries Toxic Release 2014Freedom Industries Charleston (US-WV)Lessons:Asset integrity,Compliance with Standards,Emergency PreparednessIndustry:StorageCountry:United StatesLanguage:ENLoC:Deterioration Origin: CSB Incident:Fluid release to waterHazards:Harmful/IrritantContributory Factors:Containment FailureImpact:HUMAN (Offsite Injuries)Effects:≥ 100 InjuriesMaterial:MCHM

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

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

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

202325JanAll DayASCO Explosion 2005Acetylene Services Company (ASCO) Perth Amboy (US-NJ)Lessons:Asset integrity,Competency,Operating Procedures,Operational IntegrityIndustry:ManufacturingCountry:United StatesLanguage:ENLoC:Operator error Origin: CSB Incident:EXPLOSIONHazards:FlammableContributory Factors:Component MalfunctionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Acetylene

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

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 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

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

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

202313FebAll DayUniversal Freight Fire 1982Universal Freight Woodkirk (GB)Lessons:Emergency Preparedness,Risk Assessment,Stakeholder EngagementIndustry:WarehouseCountry:United KingdomLanguage:ENLoC:Fire exposure Origin: HSE Incident:Pool fireHazards:FlammableImpact:HUMAN (Offsite At Risk)Effects:EnvironmentalMaterial:Octyl PhenolTopics:Chemical Reaction

202316FebAll DayValero (Sunray) Refinery Fire 2007Valero Sunray (US-TX)Lessons:Compliance with Standards,Management of Change,Risk AssessmentIndustry:RefiningCountry:United StatesLanguage:ENLoC:Undertemperature Origin: CSB Incident:FIREHazards:FlammableContributory Factors:Containment FailureImpact:HUMAN (On Site At Risk)Effects:< 100 InjuriesMaterial:PropaneTopics:Natural Hazards

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 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

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

202302MarAll DayRimbey Pipeline Flammable Release 1979Rimbey Pipeline Mill Woods (CA-AB)Lessons:Emergency Preparedness,Stakeholder EngagementIndustry:PipelinesCountry:CanadaLanguage:ENLoC:Deficiency Origin: HSE Incident:VCEHazards:FlammableImpact:HUMAN (Offsite At Risk)Effects:EnvironmentalMaterial:Propane

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

202311MarAll DayFukushima Damage & Release 2011Fukushima Daiichi (JP)Lessons:Competency,Emergency Preparedness,Risk Assessment,Workforce InvolvementIndustry:Nuclear PowerCountry:JapanLanguage:ENLoC:Overtemperature Origin: IAEA Incident:Gas/vapour/mist/etc release to airHazards:RadiologicalContributory Factors:Natural EventImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:RadioisotopesTopics:Natural Hazards

202317MarAll DayITC Tank Fire 2019ITC Deer Park (US-TX)Lessons:Emergency Preparedness,Operational Integrity,Stakeholder EngagementIndustry:StorageCountry:United StatesLanguage:ENLoC:Deterioration Origin: CSB Incident:FIREHazards:FlammableContributory Factors:Containment FailureImpact:HUMAN (Offsite At Risk)Effects:EnvironmentalMaterial:Naptha

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

202321MarAll DayCarbide Industries Fire 2011Carbide Industries Louisville (US-KY)Lessons:Compliance with Standards,Operational Integrity,Risk Assessment,Workforce InvolvementIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Overpressure Origin: CSB Incident:Rapid phase-transition explosionHazards:ReactiveContributory Factors:Component MalfunctionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Calcium CarbideTopics:Occupied Buildings

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

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

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 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

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 DayHerrig Brothers Explosion 1998Herrig Brothers Albert City (US-IA)Lessons:Asset integrity,Compliance with Standards,Emergency Preparedness,Stakeholder EngagementIndustry:AgricultureCountry:United StatesLanguage:ENLoC:Impact Origin: CSB Incident:BLEVEHazards:FlammableContributory Factors:Object impactImpact:HUMAN (Offsite Fatalities)Effects:1-10 FatalitiesMaterial:Propane

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

202311AprAll DayD.D. Williamson Catastrophic Vessel Failure 2003D.D. Williamson Louisville (US-KY)Lessons:Asset integrity,Competency,Operating Procedures,Risk AssessmentIndustry:Food & DrinkCountry:United StatesLanguage:ENLoC:Overpressure Origin: CSB Incident:Pressure burstHazards:Corrosive,Environmental,ToxicContributory Factors:Loss of Process ControlImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:AmmoniaTopics:Pressure Systems

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

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 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

202325AprAll DayKaltech Explosion 2002Kaltech Industries New York City (US-NY)Lessons:Compliance with Standards,Contractor Management,Control of WorkIndustry:ManufacturingCountry:United StatesLanguage:ENLoC:Confined explosion Origin: CSB Incident:Runaway reaction explosionHazards:Corrosive,ReactiveContributory Factors:HousekeepingImpact:HUMAN (Offsite Injuries)Effects:< 100 InjuriesMaterial:Nitric acid

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