June, 2021

This is a repeating event

202118JunAll DayHAOLIANGHE TOXIC RELEASE 2015Haolianghe, Heilongjiang (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:ChemicalsCountry:ChinaLanguage:ENLoC:Operator error Origin: MKOPSC Incident:Gas/vapour/mist/etc release to airHazards:Corrosive,Environmental,ToxicContributory Factors:Organized ProceduresImpact:HUMAN (On Site Fatalities)Effects:1-10 FatalitiesMaterial:Ammonia

Summary

Three killed when feeding additives bnaphthalene sulfonate to a reaction pool at a chemical fertilizer company.

Proximate causes:
• Failure in following procedure (Improper operation)

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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