September, 2014

This is a repeating event

201407SepAll DayJIEMEI FENGYOU CHEMICAL TOXIC RELEASE 2014Jiemei Fengyou, Ningxia (CN)Lessons:Audits & Reviews,Commitment & Culture,Competency,Compliance with Standards,Control of Work,Operating Procedures,Operational Integrity,Operational Readiness,Performance Indicators,Process Knowledge,Risk AssessmentIndustry:PetrochemicalsCountry:ChinaLanguage:ENLoC:Component malfunction Origin: MKOPSC Incident:Gas/vapour/mist/etc release to airHazards:Corrosive,Environmental,ToxicContributory Factors:Component Malfunction,Management Attitude,Organized Procedures,Training/InstructionImpact:HUMAN (Offsite Injuries)Effects:< 100 InjuriesMaterial:Ammonia


Ammonia gas and highly concentrated ammonia liquids spurted out from a flare piping in the southeast corner of the plant after the flare was extinguished.

Proximate causes:
• Inadequate tools, equipment & vehicles (Mal-function of Ammonia compressor);
• Inadequate training/knowledge transfer
• Lack of communication (hazards identification and communication)
• Lack of work rules/policies/ standards/procedures

Source: A web-based collection and analysis of process safety incidents (
Image Credit: Millenium Post


MKOPSCMary Kay O'Connor Process Safety Center