Lessons Operating Procedures

Operating Manuals and Procedures.

December

202203DecAll DayMarcus Oil & Chemical Explosion 2004Marcus Oil and Chemical Houston (US-TX) Lessons:Asset integrity,Operating ProceduresIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Deficiency Origin: CSB Incident:VCEHazards:FlammableContributory Factors:Containment FailureImpact:HUMAN (Offsite Injuries)Effects:< 100 InjuriesMaterial:Polyethylene

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

202213DecAll DayPort Neal Explosion 1994Terra International Port Neal (US-IA)Lessons:Operating Procedures,Risk AssessmentIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Confined explosion Origin: Marsh Incident:Explosive decompositionHazards:ExplosiveImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Ammonium Nitrate

January

202304JanAll DayFeyzin LPG Explosion 1966Total Feyzin (FR)Lessons:Asset integrity,Emergency Preparedness,Operating ProceduresIndustry:LPGCountry:FranceLanguage:ENLoC:Operator error Origin: HSE Incident:VCEHazards:FlammableImpact:HUMAN (On Site Fatalities)Effects:11 – 100 FatalitiesMaterial:Propane

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

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

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

202316JanAll DayGeorgia-Pacific Toxic Release 2002Georgia-Pacific Pennington (US-AL)Lessons:Emergency Preparedness,Management of Change,Operating Procedures,Risk AssessmentIndustry:Pulp & PaperCountry:United StatesLanguage:ENLoC:Material incompatibility Origin: CSB Incident:Gas/vapour/mist/etc release to airHazards:Flammable,ToxicContributory Factors:Organized ProceduresImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Hydrogen SulfideTopics:Chemical Reaction

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

202323JanAll DayHavkong Grounding 1993Havkong Braefoot Bay (GB)Lessons:Asset integrity,Emergency Preparedness,Operating Procedures,Operational IntegrityIndustry:ShippingCountry:United KingdomLanguage:ENLoC:Natural event Origin: HSE Incident:COLLISIONHazards:FlammableImpact:COST (On Site)Effects:FinancialMaterial:Butane

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

202331JanAll DayLINYI EXPLOSION 2015Linyi Huasheng Group, Shandong (CN)Lessons:Commitment & Culture,Competency,Compliance with Standards,Control of Work,Operating Procedures,Operational Integrity,Operational Readiness,Performance Indicators,Process Knowledge,Risk Assessment,Workforce InvolvementIndustry:Metal ProcessingCountry:ChinaLanguage:ENLoC:Deterioration Origin: MKOPSC Incident:EXPLOSIONHazards:FlammableContributory Factors:Organization Inadequate,Organized Procedures,Training/InstructionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Coke

February

202306FebAll DayWARSAW CHEMICAL EXPLOSION 2015Warsaw Chemical, Warsaw (US-IN)Lessons:Asset integrity,Audits & Reviews,Commitment & Culture,Control of Work,Emergency Preparedness,Operating Procedures,Risk Assessment,Stakeholder EngagementIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Overpressure Origin: MKOPSC Incident:VCEHazards:Flammable,ToxicImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Methanol

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

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

202318FebAll DayExxonmobil (Torrance) Refinery Explosion 2015ExxonMobil Torrance (US-CA)Lessons:Asset integrity,Operating Procedures,Operational Integrity,Risk AssessmentIndustry:RefiningCountry:United StatesLanguage:ENLoC:Confined explosion Origin: CSB Incident:VCEHazards:FlammableContributory Factors:MaintenanceImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:Hydrocarbons

202319FebAll DayHUBEI FUSHENG CHEMICAL EXPLOSION 2015Hubei Fusheng Chemical Co., Yichang, Hubei (CN)Lessons:Commitment & Culture,Competency,Compliance with Standards,Control of Work,Operating Procedures,Operational Integrity,Operational Readiness,Performance Indicators,Process Knowledge,Risk Assessment,Workforce InvolvementIndustry:ChemicalsCountry:ChinaLanguage:ENLoC:Component malfunction Origin: MKOPSC Incident:Explosive decompositionHazards:ExplosiveContributory Factors:Organization Inadequate,Organized Procedures,Training/InstructionImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Nitro-based fertilizer,Urea-based fertilizer

March

202303MarAll DayTIARUN EXPLOSION 2015Tianrun Chemical Fertilizer Co, Ordos, Inner Mongolia (CN)Lessons:Commitment & Culture,Competency,Compliance with Standards,Control of Work,Operating Procedures,Operational Integrity,Operational Readiness,Performance Indicators,Process Knowledge,Risk Assessment,Workforce InvolvementIndustry:PetrochemicalsCountry:ChinaLanguage:ENLoC:Maintenance error Origin: MKOPSC Incident:Pressure burstHazards:Corrosive,Environmental,Flammable,ToxicContributory Factors:Organization Inadequate,Organized ProceduresImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Ammonia,Hydrogen

202304MarAll DaySonat Exploration Vessel Overpressurization 1998Sonat Exploration Co. Pitkin (US-LA)Lessons:Asset integrity,Operating Procedures,Risk AssessmentIndustry:Onshore Oil & GasCountry:United StatesLanguage:ENLoC:Overpressure Origin: CSB Incident:FIREHazards:FlammableContributory Factors:Containment FailureImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:HydrocarbonsTopics:Pressure Systems

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

202322MarAll DayBP (Grangemouth) Hydrocracker Explosion 1987BP Olefins Grangemouth (GB)Lessons:Asset integrity,Control of Work,Management of Change,Operating Procedures,Operational IntegrityIndustry:RefiningCountry:United KingdomLanguage:ENLoC:Overpressure Origin: HSE Incident:VCEHazards:FlammableImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Hydrocarbons

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

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

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

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

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

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 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

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