February, 2023

This is a repeating event

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

Summary

An explosion occurred when 8 personnel were working on the repair of a catalyst tower.

Proximate causes:
• Inadequate training/knowledge transfer (Lack of understanding the process)
• Lack of work rules/policies/ standards/procedures (wrong procedures for inspections);
• Inadequate work rules plan (lack of the pre-start safety review before inspection).


Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)

Origin

MKOPSCMary Kay O'Connor Process Safety Center

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