March, 2015

This is a repeating event

201510MarAll DayCHANGZHOU FIRE 2015Changzhou, Jiangsu (CN)Lessons:Asset integrity,Audits & Reviews,Commitment & Culture,Competency,Control of Work,Emergency Preparedness,Incident Investigation,Operating Procedures,Operational Integrity,Operational Readiness,Process Knowledge,Risk AssessmentIndustry:WarehouseCountry:ChinaLanguage:ENLoC:Fire exposure Origin: MKOPSC Incident:ConflagrationContributory Factors:Component Malfunction,Organized ProceduresImpact:HUMAN (On Site At Risk)Effects:Environmental


Four reactors exploded after an initial fire in a warehouse in the plant. The toxic gas released due to the fire and explosion affected the local community. Electrical short circuit and improper shutdown was the reason that triggered the incident.

Proximate causes:
• Inadequate tools, equipment & vehicles (Electrical appliances shortcut)
• Failure in following procedure (improper shutdown)

Source: A web-based collection and analysis of process safety incidents (


MKOPSCMary Kay O'Connor Process Safety Center