Lessons Control of Work

Safe Work Practices | Work Control, Permit to Work and Task Risk Management.

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

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

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

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

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

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

202301FebAll DayAssociated Octel Fire 1994Associated Octel Ellesmere Port (GB)Lessons:Asset integrity,Control of Work,Operational IntegrityIndustry:ChemicalsCountry:United KingdomLanguage:ENLoC:Deterioration Origin: HSE Incident:Jet flameHazards:FlammableImpact:HUMAN (Offsite Injuries)Effects:< 100 InjuriesMaterial:Ethyl chloride

202302FebAll DayBethlehem Steel Fire 2001Bethlehem Steel Corp. Chesterton (US-IN)Lessons:Control of Work,Operational Integrity,Operational ReadinessIndustry:Metal ProcessingCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:FIREHazards:FlammableContributory Factors:MaintenanceImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Coke gas

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 DayTechnic Explosion 2003Technic Inc. Cranston (US-RI)Lessons:Control of Work,Emergency Preparedness,Management of Change,Risk AssessmentIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Confined explosion Origin: CSB Incident:Dust explosionHazards:FlammableContributory Factors:HousekeepingImpact:HUMAN (On Site Injuries)Effects:< 100 InjuriesMaterial:VariousTopics:Chemical Reaction

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

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

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

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

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

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

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

202313MarAll DayBP (Grangemouth) Refinery Fire 1987BP Oil Grangemouth (GB)Lessons:Asset integrity,Control of Work,Operational IntegrityIndustry:RefiningCountry:United KingdomLanguage:ENLoC:Maintenance error Origin: HSE Incident:Flash fireHazards:FlammableImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Hydrocarbons

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

202327MarAll DayUnion Carbide (Hahnville) Asphyxiation 1998Union Carbide Hahnville (US-LA)Lessons:Control of WorkIndustry:ChemicalsCountry:United StatesLanguage:ENLoC:Maintenance error Origin: CSB Incident:AsphyxiationHazards:AsphyxiantContributory Factors:Organized ProceduresImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Nitrogen

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 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 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

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

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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