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)
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