March, 2023

This is a repeating event

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

Summary

A high-pressure steam (3.7 MPa) discharge occurred during a maintenance process, resulting in three field workers burned to death.

Proximate causes:
• 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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