January, 2021

This is a repeating event

202118JanAll DayPETROBRAS (RLAM) EXPLOSION 2015Petrobras, Landulpho Alves Refinery, Salvador (BR) Origin: MKOPSC 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:DeteriorationIncident:EXPLOSIONHazard:FlammableCause:Corrosion/Erosion/Fatigue,Health,Maintenance,Organized ProceduresConsequence:< 100 InjuriesMaterial:HydrogenLive Now

Summary

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)
Image Credit: Daily Motion

Origin

MKOPSCMary Kay O'Connor Process Safety Center

Time

Mon 18 Jan 2021 - Mon 18 Jan 2021

Location

Landulpho Alves

Rodovia BA-523, KM 4, São Francisco do Conde - BA, 43900-000, Brazil

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