September, 2015

This is a repeating event

201515SepAll DaySALTERS CARTAGE EXPLOSION 2015Salters Cartage, Wiri (NZ)Lessons:Audits & Reviews,Commitment & Culture,Competency,Compliance with Standards,Contractor Management,Control of Work,Emergency Preparedness,Incident Investigation,Operating Procedures,Operational Integrity,Process Knowledge,Risk Assessment,Stakeholder Engagement,Workforce InvolvementIndustry:Waste TreatmentCountry:New ZealandLanguage:ENLoC:Maintenance error Origin: MKOPSC Incident:VCEContributory Factors:Maintenance,Organization Inadequate,Organized Procedures,Staffing,Training/InstructionImpact:HUMAN (On Site Fatalities)Effects:1-10 Fatalities

Summary

Unauthorized welding at the top of the tank with flammable vapors leading to explosion. Debris

Proximate causes:
• Failure in following procedure (welding work was incorrectly started)
• Inadequate assessment of required skill level
• Inadequate training/knowledge transfer Inadequate management/ supervision
• Inadequate contractor selection & oversight Inadequate work planning
• Lack of rules/policies/standards/ procedures
• Lack of communication

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

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Origin

MKOPSCMary Kay O'Connor Process Safety Center

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