Incidents Map

Some 25 miles of Trans-Andean pipeline disappeared in this event, which also damaged natural gas and gasoline pipelines. All 285 producing wells were shut down and oil exports were suspended and swap arrangement made with Venezuelan suppliers. The first earthquake registered 6.0 on the Richter scale, the second 6.8, and there was a total of 10 earthquakes in total. Repairs took several months.

[ Property Damage $120 Million. Estimated Current Value $288 Million ]

Image credit: NAPU

Flooding and capsize of ro-ro passenger ferry Herald of Free Enterprise with loss of 193 lives

On the 6th March 1987 the Roll on/Roll off passenger and freight ferry HERALD OF FREE ENTERPRISE (‘HERALD’) under the command of Captain David Lewry sailed from Number 12 berth in the inner harbour at Zeebrugge at 18.05 G.M.T. The HERALD was manned by a crew of 80 hands all told and was laden with 81 cars, 47 freight vehicles and three other vehicles.

Approximately 459 passengers had embarked for the voyage to Dover, which they expected to be completed without incident in the prevailing good weather. There was a light easterly breeze and very little sea or swell. The HERALD passed the outer mole at 18.24. She capsized about four minutes later. During the final moments the HERALD turned rapidly to starboard and was prevented from sinking totally by reason only that her port side took the ground in shallow water. The HERALD came to rest on a heading of 136° with her starboard side above the surface. Water rapidly filled the ship below the surface level with the result that not less than 150 passengers and 38 members of the crew lost their lives. Many others were injured.

Image Credit: Independent

A hairline crack in a welded seam of piping to the level indicator system on an aldehyde column resulted in a minor ethylene oxide leak on this gas processing plant. As a result of this crack, which was caused by low cycle fatigue, ethylene oxide escaped near the level indicator and formed polyethylene glycols (PEG) in the mineral wool insulation. It is believed that both the leak and accumulation of PEG occurred over a period of time. During repairs to the level indicator, the metal sheathing of the insulation was removed and air contacted the insulation soaked with PEG. Auto-oxidation of the PEG resulted and the insulating material was ignited. The piping to the level indicator system was heated to such a degree that auto-decomposition of the ethylene oxide within the piping occurred. This autodecomposition propagated into the aldehyde column which subsequently exploded. The force of the explosion completely destroyed the distillation section of this plant. The large resulting fire and impact of flying debris to other process sections resulted in extensive damage throughout the plant.

[ Property Damage $79 Million. Estimated Current Value $178 Million ]

Image credit: No credit

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 (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)

A major explosion occurred at a 145,000-barrels-per-day refinery in the north-eastern city of Sendai, hours after the largest earthquake in the country’s history was followed by a tsunami. The fire at the Sendai refinery originated from a land oil product shipping facility. Workers at the refinery were evacuated, and there was no capacity available to extinguish the fire. Fire in the storage and shipping facilities had also damaged a 35,500 barrels-per-day FCC at the refinery.

[ Property Damage $590 Million. Estimated Current Value $651 Million ]

Image credit: JXTG Nippon Oil & Energy

On March 11, 2011, the Great East Japan Earthquake triggered an extremely severe nuclear accident at the Fukushima Daiichi Nuclear Power Plant, owned and operated by the Tokyo Electric Power Company (TEPCO). This devastating accident was ultimately declared a Level 7 (“Severe Accident”) by the International Nuclear Event Scale (INES).

When the earthquake occurred, Unit 1 of the Fukushima Daiichi plant was in normal operation at the rated electricity output according to its specifications; Units 2 and 3 were in operation within the rated heat parameters of their specifications; and Units 4 to 6 were undergoing periodical inspections. The emergency shut-down feature, or SCRAM, went into operation at Units 1, 2 and 3 immediately after the commencement of the seismic activity.

Although there were no immediate fatalities, a worker later died from radiation exposure (https://www.reuters.com/article/us-japan-fukushima-radiation/japan-acknowledges-first-radiation-death-among-fukushima-workers-idUSKCN1LL0OA)

Image Credit: NY Times

A gas leak involving the pipe rack that runs to the terminal of this petrochemical complex led to an explosion, which occurred near the complex chemical plant, causing additional damage to the pipe rack and resulting in a major gas leak. A powerful second explosion occurred that could be felt more than 15 miles from the complex. These explosions and a subsequent fire completely destroyed the chemical plant, caused significant damage to the pipe rack, and resulted in moderate damage to other complex buildings and adjacent third-party facilities. The fire was extinguished after approximately three hours. Because of this incident, the chemical plant at this complex was completely shut down for seven months to allow for the rebuild of the plant and the pipe rack.

[ Property Damage $97 Million. Estimated Current Value $208 Million ]

Image credit: Reuters

A fire broke out in a wet gas scrubber while heavy maintenance on a unit was being carried out. Personnel were evacuated from the site and there were no injuries. The site was conducting a planned shutdown and maintenance of the plant equipment including the polypropylene plant.

[ Property Damage $150 Million. Estimated Current Value $162 Million ]

Image credit: ORPIC

An explosion occurred in the ethylene oxide process unit at this plant. As a result, the ethylene oxide refining column was completely destroyed, the ethylene glycol unit was substantially damaged, and the co-generation unit was partially damaged. A pipe rack near the storage area for liquid ethylene oxide was damaged when a large piece of shrapnel from the explosion hit the rack, rupturing lines which contained methane and other hydrocarbon products.

The subsequent fire that resulted from the released products was the only significant fire to occur during this incident. As a result of the explosion, all utilities at the plant were lost for approximately one week. Additionally, several fixed fire protection systems were damaged by the explosion or inadvertently actuated due to a loss of plant air. These systems were shut off, isolated, or placed back in service, as appropriate. A manual fire fighting effort was used to extinguish the fire in the pipe rack once the lines in the rack were isolated. The polyethylene production was restarted in early April 1991 using imported ethylene. The olefins production unit was restarted in late April 1991.

[ Property Damage $90 Million. Estimated Current Value $194 Million ]

Image credit: Vitaly Shmatikov

Fifteen months before the incident occurred it had been noticed that the flare line isolation valve V17 was passing. It was decided however to wait for a scheduled shutdown of the catalytic cracker unit and No 1 flare before commencing work on the valve. Gases from the remaining operating units were re-routed to No 2 and No 3 flares. This flare arrangement would allow the pipelines at V17 to be isolated.

When senior refinery staff prepared a plan for the isolation of the flare system, they concentrated on the operational and safety requirements of the flare system, making sure that no operational areas of the plant were inadvertently isolated. The details of the removal of V17 were not considered and left to those who would be responsible for the work.

Four workers were involved with the removal of the valve. When the majority of the bolts were undone the joint opened slightly and liquid dripped from a small gap between the flanges. The workers sought advice. The valve was checked and it was concluded that it was safe to carry on. Non ferrous hammers were provided before continuing with the removal. All the bolts were removed and the crane took the weight of a spacer and started to remove it, at which point gallons of liquid poured from the valve. A flammable vapour cloud formed from the rapidly spreading pool. The cloud reached the nearby air compressor, ignited and flashed back around the working area.

Two workers managed to escape the fire but a fitter and a rigger were engulfed by the flames and killed. The fire was allowed to burn in a controlled manner for almost two days while the rest of the refinery was shut down and the flare system purged with nitrogen

KEY ISSUES:
• DESIGN CODES – PIPEWORK
• MAINTENANCE PROCEDURES
• ISOLATION

Report: https://www.icheme.org/media/13700/the-fires-and-explosion-at-bp-oil-grangemouth-refinery-ltd.pdf

Image Credit: HSE

On March 13, 2001, three people were killed as they opened a process vessel containing hot plastic at the BP Amoco Polymers plant in Augusta, Georgia. They were unaware that the vessel was pressurized. The workers were killed when the partially unbolted cover blew off the vessel, expelling hot plastic. The force of the release caused some nearby tubing to break. Hot fluid from the tubing ignited, resulting in a fire.

KEY ISSUES:
• RECOGNITION OF REACTIVE HAZARDS
• LEARNING FROM NEAR-MISS INCIDENTS
• OPENING OF PROCESS EQUIPMENT

ROOT CAUSES:
1. Amoco, the developer of the Amodel process, did not adequately review the conceptual process design to identify chemical reaction hazards.
2. The Augusta facility did not have an adequate review process for correcting design deficiencies.
3. The Augusta site system for investigating incidents and nearmiss incidents did not adequately identify causes or related hazards. This information was needed to correct the design and operating deficiencies that led to the recurrence of incidents.

Image Credit: CSB

A fire occurred on one of the two hydrotreaters on an oil sands upgrader facility. The fire was reported to be as a result of the failure of a pipe, resulting in a releaser of naphtha. One worker was seriously injured as a result of the fire, which was extinguished after two days.

[ Property Damage $220 Million. Estimated Current Value $220 Million ]

Image credit: CBC

The world’s largest offshore production facility was rocked by a series of explosions caused by a gas release. The explosions knocked out a support pillar of the semi-submersible platform allowing seawater to enter the vessel. Workers pumped in nitrogen and compressed air and tried to pump out almost 3,000 metric tons of seawater to keep the rig afloat, but were unsuccessful. On March 20, 2001, the rig sank to the sea floor. The incident killed 11 workers.

[ Property Damage $500 Million. Estimated Current Value $851 Million ]

Ref: http://www.anp.gov.br/noticias/2342-anp-marinha-comissao-conjunta

Image credit: Petrobras

On Sunday, March 17, 2019, at approximately 10:00 am, a large fire erupted at the Intercontinental Terminals Company, LLC (ITC) bulk liquid storage terminal located in Deer Park, Texas (Figure 1). The fire originated in the vicinity of Tank 80-8, an 80,000-barrel aboveground atmospheric storage tank that held naphtha, a flammable liquid, typically used as a feedstock or blend stock for production of gasoline. ITC was unable to isolate or stop the release of naphtha product from the tank, and the fire continued to burn, intensify, and progressively involved additional tanks in the tank farm. The fire was extinguished on the morning of March 20, 2019.

The incident did not result in any injuries to either ITC personnel or emergency responders. However, the local community experienced disruptions, including several shelter-in-place notifications, which prompted local schools and businesses either to close or operate under modified conditions.

KEY ISSUES:
• RELEASE DETECTION
• RELEASE ISOLATION
• PROLONGED EMERGENCY RESPONSE

Image credit: CSB

An explosion occurred when 6 personnel were working on the repair of a catalyst tower

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)

Contract personnel were installing a pig trap on an 18-inch-diameter export gas pipeline on the platform. As a cold cut was made into the pipeline, hydrocarbons sprayed from the cut and ignited. The explosion and fire burned the main structure and caused subsequent explosions when six other pipelines ruptured due to the intense heat. The accident resulted in the total destruction of the platform and seven fatalities. It took two years to replace the platform.

[ Property Damage $400 Million. Estimated Current Value $899 Million ]

Image credit: ARCO

An accident occurred at a methylcellulose manufacturing facility. An explosion occurred and was followed by a fire, which was extinguished about seven hours later. A total of 17 people working at the site were injured in this accident; three critically, five seriously, and nine with minor injuries. There was one minor injury off site. Ignition of the methylcellulose powder is though to have been due to static electricity, resulting in a powder dust explosion. All methylcellulose operations were suspended for two months before sequentially restarting.

[ Property Damage $240 Million. Estimated Current Value $306 Million ]

Image credit: Shin-Etsu

On 20 March 1990 the halogen exchange reactor on the Fluoroaromatics plant was ruptured by the pressure generated by a runaway reaction. The plant was partially destroyed and missiles were projected over 500m. Six employees were injured and one subsequently died from post-operative complications.

A batch had been charged into the vessel and was being heated up as normal. When it reached 165oC, the temperature continued to rise and the operators adjusted the jacket temperature. The display screen in use did not display pressure and they were unaware of a corresponding rise in pressure. By the time they were alerted to the rise in pressure the pressure relief valves had lifted. Before any other corrective action could be taken, the reactor exploded. The pressure in the vessel reached a value of about 60-80 barg compared with the relief valve set pressure of 5 barg.

The resulting blast was enhanced by the formation of a fireball, which occurred when the contents of the reactor ignited within the plant structure. This started local fires and initiated what became a major conflagration in an adjacent unit where vessels containing xylene were damaged by the blast/missile effects. The ensuing fires were brought under control in four hours by the Shell fire team and Cheshire fire service.

The initial cause of the incident was the ingress of excessive water into the process leading to the formation of acetic acid which, upon recycle to the reactor, reacted vigorously with the reactor contents initiating the explosion. Water was present as a part of the process, however a massive incursion led to the formation of a separate layer in the process vessel which was not removed but recycled back into reactor.

KEY ISSUES:
• CONTROL ROOM DESIGN
• RAW MATERIALS CONTROL / SAMPLING
• REACTION / PRODUCT TESTING
• RELIEF SYSTEMS / VENT SYSTEMS

Image Credit: The Leader

On 21 March 2019, a major explosion occurred at a chemical plant in Chenjiagang Chemical Industry Park, Chenjiagang, Xiangshui County, Yancheng, Jiangsu, China. According to reports published on March 25, 78 people were killed and 617 injured.

The State Council of China officially recognized the severity of the accident, often referred to as “3.21 Explosive Accident”.

The explosion occurred at a local time of 14:48 (06:48 GMT). 78 people were killed, and at least 94 were severely injured, 32 of whom were critically injured. Around 640 people required hospital treatment and were taken to 16 hospitals. The injured included children at a local kindergarten. CENC detected an ML2.2 artificial earthquake whose epicenter is at 34.331°N 119.724°E.

The force of the blast started numerous fires in Yancheng, knocked down several buildings, and reportedly destroyed windows several kilometers away. The fire was reported to have been controlled by 03:00 local time. Considerable damage was caused to nearby factories and offices; the roof of Henglida Chemical Factory, 3 km from the explosion, fell in. At least one of the people killed was in another building destroyed by the blast. Windows are reported to have been blown out up to 6 km away from the explosion, and houses and other buildings were damaged in the nearby village-level administrative divisions including Hai’an Town (Haianju) (海安社区) and Shadang (沙荡社区). This explosion was strong enough that it registered on earthquake sensors and could be seen by satellites. The blast created a crater resulting in a magnitude 2.2 seismic shock that took over 900 firefighters to get the fire under control.

Ref: https://en.wikipedia.org/wiki/2019_Xiangshui_chemical_plant_explosion
Image Credit: Reuters

On March 21, 2011, during calcium carbide production at the Carbide Industries plant in Louisville, KY, an electric arc furnace exploded, ejecting solid and powdered debris, flammable gases, and molten calcium carbide at temperatures near 3800°F (2100°C). Two workers died and two others were injured.

KEY ISSUES:
• FACILITY SITING
• NORMALIZATION OF DEVIANCE
• CONSENSUS STANDARDS

ROOT CAUSES:
1. Despite past incidents, neither the previous owners nor Carbide Industries identified that the control room should be relocated and cameras installed to better protect workers while they remotely monitored the furnace.
2. Carbide Industries issued 26 work orders for leak repair for water leaks on the furnace cover in the five months prior to the March 2011 incident, but continued operating the furnace despite the hazard from ongoing water leaks.
3. The company did not adequately address past explosive incidents, which normalized blows as routine events.
4. The company did not have a process safety management program in place that required the elimination of overpressure incidents in the furnace.

Image credit: CSB

At 09.45 on 22 March 1989 a vehicle carrying approximately 800 kg of mixed explosives exploded at the premises of Vibroplant Ltd on the Fengate Industrial Estate, Peterborough. The explosion caused the death of a fireman and injuries to at least 107 other people, 84 of whom received hospital treatment. Two of the injured were admitted to intensive care.

The vehicle was a standard commercial model specially modified to carry explosives, operated by Nobels Explosives Company (NEC), a subsidiary of ICI. It had entered the Vibroplant yard, in order to turn round off the road, when a minor explosion occurred inside the load compartment, causing a fire. The fire brigade was called and took up position. The fire increased and after approximately 12 minutes the entire load, apart from a small number of detonators, detonated en masse.

The vehicle did not carry any external placarding to tell emergency services that it contained explosives, but this did not contravene the legislation in force at the time. The fire brigade was told that the vehicle was carrying commercial explosives before firemen arrived on the scene.

Report: https://www.icheme.org/media/13701/the-peterborough-explosion.pdf

Image Credit: HSE

On Saturday 21 March 1987 the hydrocracker unit was being recommissioned following a routine shut down. During the recommissioning a plant trip occurred. This was thought to be a spurious trip and the plant operators started to bring up the unit to normal operating conditions. From then on until the time of the incident the plant was held in stand by condition with no fresh feed.

At 07:00 hours the following morning there was a violent explosion and subsequent fire. The explosion could be heard and felt up to 30km away. The explosion centred on a low pressure (LP) separator vessel, V306, which was fabricated from 18mm steel plate and weighed 20 tonnes.

The investigation of the accident suggested that an air operated control valve on the high pressure (HP) separator had been opened and closed on manual control at least three times. Liquid level in the LP separator fell and the valve was opened. This action allowed the remaining liquid in the HP separator to drain away and for high pressure gas to break through into the LP separator. As the pressure relief on the LP separator had been designed for a fire relief case, not gas breakthrough the vessel subsequently exploded.

The control valve did not close automatically because the low low level trip on the HP separator had been disconnected several years earlier. The operators did not trust the main level control reading and referred to a chart recorder for a back up level reading. There was an offset on this chart recorder which led them to assume that the level in the HP separator was normal.

KEY ISSUES:
• MAINTENANCE PROCEDURES
• CONTROL SYSTEMS
• OPERATING PROCEDURES
• PLANT MODIFICATION / CHANGE PROCEDURES
• ALARM / TRIPS / INTERLOCKS
• RELIEF SYSTEMS / VENT SYSTEMS
• ISOLATION

Report: https://www.icheme.org/media/13700/the-fires-and-explosion-at-bp-oil-grangemouth-refinery-ltd.pdf

Image Credit: HSE

At approximately 1:20 p.m. on March 23, 2005, a series of explosions occurred at the BP Texas City refinery during the restarting of a hydrocarbon isomerization unit. Fifteen workers were killed and 180 others were injured. Many of the victims were in or around work trailers located near an atmospheric vent stack. The explosions occurred when a distillation tower flooded with hydrocarbons and was overpressurized, causing a geyser-like release from the vent stack.

KEY ISSUES:
• SAFETY CULTURE
• REGULATORY OVERSIGHT
• PROCESS SAFETY METRICS
• HUMAN FACTORS

ROOT CAUSES:
1. BP Group Board did not provide effective oversight of the company’s safety culture and major accident prevention programs.

2. Senior executives:
• inadequately addressed controlling major hazard risk. Personal safety was measured, rewarded, and the primary focus, but the same emphasis was not put on improving process safety performance;
• did not provide effective safety culture leadership and oversight to prevent catastrophic accidents;
• ineffectively ensured that the safety implications of major organizational, personnel, and policy changes were evaluated;
• did not provide adequate resources to prevent major accidents; budget cuts impaired process safety performance at the Texas City refinery.

3. BP Texas City Managers did not:
• create an effective reporting and learning culture; reporting bad news was not encouraged. Incidents were often ineffectively investigated and appropriate corrective actions not taken.
• ensure that supervisors and management modeled and enforced use of up-to-date plant policies and procedures.
• incorporate good practice design in the operation of the ISOM unit.
• ensure that operators were supervised and supported by experienced, technically trained personnel during unit startup, an especially hazardous phase of operation; or that
• effectively incorporated human factor considerations in its training, staffing, and work schedule for operations personnel.

Image Credit: CSB

On March 24, 1989, shortly after midnight, the oil tanker Exxon Valdez struck Bligh Reef in Prince William Sound, Alaska, spilling more than 11 million gallons of crude oil. The spill was the largest in U.S. history and tested the abilities of local, national, and industrial organizations to prepare for, and respond to, a disaster of such magnitude. Many factors complicated the cleanup efforts following the spill. The size of the spill and its remote location, accessible only by helicopter and boat, made government and industry efforts difficult and tested existing plans for dealing with such an event.

The spill posed threats to the delicate food chain that supports Prince William Sound’s commercial fishing industry. Also in danger were ten million migratory shore birds and waterfowl, hundreds of sea otters, dozens of other species, such as harbor porpoises and sea lions, and several varieties of whales.

Image Credit: EPA

An apparent failure of a propane intercooler liquid level control during unsupervised maintenance led to an explosion and fire. The control room on the main platform was destroyed and adjacent platforms were affected by the blast wave. There were 11 fatalities.

[ Property Damage $100 Million. Estimated Current Value $194 Million ]

Image credit: PDVSA

This explosion was caused by the failure of a valve bonnet in a high-pressure section of a 60,000 bbl-per-day hydrocracker. A vapor cloud formed from the release, ignited, and was followed by a large fire fed by escaping hydrocarbons at high pressure. The explosion resulted in the collapse of a large section of pipe rack and destruction of a large fin-fan cooler mounted above the rack. Many pumps were destroyed and a separator was badly damaged. Approximately 300 fire fighters and 33 fire trucks participated in the two and a half-hour effort to control the fire. Foam concentrate consumed totalled 3,200 US gallons. The hydrocracker was out of service for 12 months.

[ Property Damage $113 Million. Estimated Current Value $205 Million ]

Image credit: SF Gate

Blaze in a warehouse next to oil factory. Fire created massive plumes of smoke in the area. Fire spread to adjacent paint factory. Damaged buildings

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Twitter / News24

The Alexander L Kielland was a semi-submersible platform accommodating the workers of the bridge-linked Edda oil rig in the Ekofisk field, approximately 235 miles east of Dundee, Scotland, in the Norwegian Continental Shelf. The Phillips Petroleum-operated platform capsized in March 1980, killing 123 people.

Only 89 out of 212 workers survived the accident and most died by drowning as the platform turned upside-down in deep waters. The platform capsized after the failure of one of the bracings attached to one leg of the five-legged platform structure after strong winds created waves of up to 12 m high on the day of the accident.

Ref: https://en.wikipedia.org/wiki/Alexander_L._Kielland_(platform)

Image Credit: Norwegian Petroleum Museum

On March 27, 1998, at approximately 12:15 pm, two workers at Union Carbide Corporation’s Taft/Star Manufacturing Plant (the plant) in Hahnville, Louisiana, were overcome by nitrogen gas while performing a black light inspection at an open end of a 48-inch-wide horizontal pipe. The 48-inch pipe was open because chemical-processing equipment had been shut down and opened for major maintenance. Nitrogen was being injected into the process equipment primarily to protect new catalyst in reactors from exposure to moisture. The nitrogen was also flowing through some of the piping systems connected to the reactors. The nitrogen was venting from one side of the open pipe where it had formerly been connected to an oxygen feed mixer. No warning sign was posted on the pipe opening identifying it as a confined space or warning that the pipe contained potentially hazardous nitrogen.

The two workers had placed a sheet of black plastic over the end of the pipe to provide shade to make it easier to conduct the black light test during daylight. While working just outside the pipe opening and inside of the black plastic sheet, the two workers were overcome by nitrogen. One worker died from asphyxiation. The other worker survived but was severely injured.

KEY ISSUES:
• USE OF NITROGEN IN CONFINED SPACES
• SAFETY OF TEMPORARY ENCLOSURES

ROOT CAUSES:
1. Procedures to control potential hazards created by erecting temporary enclosures around nitrogen-containing equipment were inadequate.
2. Nitrogen and confined space hazard warnings were inadequate.

Image Credit: CSB

The Three Mile Island Unit 2 reactor, near Middletown, PA., partially melted down on March 28, 1979. This was the most serious accident in U.S. commercial nuclear power plant operating history, although its small radioactive releases had no detectable health effects on plant workers or the public. Its aftermath brought about sweeping changes involving emergency response planning, reactor operator training, human factors engineering, radiation protection, and many other areas of nuclear power plant operations. It also caused the NRC to tighten and heighten its regulatory oversight. All of these changes significantly enhanced U.S. reactor safety.

A combination of equipment malfunctions, design-related problems and worker errors led to TMI-2’s partial meltdown and very small off-site releases of radioactivity.

Image Credit: History.com

A major explosion in a firecracker unit occurred. The unit was run illegally by the owner who was later taken under custody. Explosions in firecracker units have been a prevalent problem in the state of Seemandhra, India which needs to be addressed.

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

A complex of six platforms located in 30 meters of water in the Gulf of Mexico was subject to a major fire. The fire originated on the lower decks of the production platform and resulted in major damage to that platform, radiation and fire damage to an adjacent compression platform, the loss of bridge links and pipelines, and radiation damage to other bridge links. The root-cause investigation required by the government identified corrosion of a small bore pipeline as the cause of the initial failure.

[ Property Damage $500 Million. Estimated Current Value $650 Million ]

Image credit: PEMEX

A fire started inside a depot with 3 million liters of diesel and the flames spread to four neighboring storage tanks. The fire lasted for 9 days.

Fine of around USD $6.4 million (R$ 22.5 million). Environmental impact causing death of thousands of fish

Proximate causes:
• Inadequate management/ supervision
• Inadequate work planning

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

On Tuesday, April 2, 2019, just before 10:46 am, a vapor cloud of isobutylene formed at the KMCO, LLC (‘KMCO’) facility in Crosby, Texas after a three-inch gray iron (a type of cast iron) y-strainer, a piping component, failed.

Shortly after 10:50 am, the vapor cloud found an ignition source and ignited, causing an explosion. The explosion killed one KMCO worker and seriously burned two others. On the day of the incident, more than 200 KMCO employees, contract workers, and visitors were onsite. The incident injured at least 30 workers (seven KMCO employees and 23 contract workers). A shelter-in-place was issued to community members within one mile of the KMCO facility.

KEY ISSUES:
• MECHANICAL INTEGRITY

Image credit: CSB

On April 2, 2010, the Tesoro Refining and Marketing Company LLC (‘Tesoro’) petroleum refinery in Anacortes, Washington (‘the Tesoro Anacortes Refinery’), experienced a catastrophic rupture of a heat exchanger in the Catalytic Reformer / Naphtha Hydrotreater unit (‘the NHT unit’). The heat exchanger, known as E-6600E (‘the E heat exchanger’), catastrophically ruptured because of High Temperature Hydrogen Attack (HTHA). Highly flammable hydrogen and naphtha at more than 500 degrees Fahrenheit (°F) were released from the ruptured heat exchanger and ignited, causing an explosion and an intense fire that burned for more than three hours. The rupture fatally injured seven Tesoro employees (one shift supervisor and six operators) who were working in the immediate vicinity of the heat exchanger at the time of the incident. To date this is the largest fatal incident at a US petroleum refinery since the BP Texas City accident in March 2005.

The NHT unit at the Tesoro Anacortes Refinery contained two parallel groups, or banks, of three heat exchangers (A/B/C and D/E/F) used to preheat process fluid before it entered a reactor, where impurities were treated for subsequent removal. The E heat exchanger was constructed of carbon steel.

At the time of the release, the Tesoro workers were in the final stages of a startup activity to put the A/B/C bank of heat exchangers back in service following cleaning. The D/E/F heat exchangers remained in service during this operation. Because of the refinery’s long history of frequent leaks and occasional fires during this startup activity, the CSB considers this work to be hazardous and nonroutine. While the operations staff was performing the startup operations, the E heat exchanger in the middle of the operating D/E/F bank catastrophically ruptured. .

KEY ISSUES:
• INHERENTLY SAFER DESIGN
• TESORO PROCESS SAFETY CULTURE
• CONTROL OF NONROUTINE WORK
• MECHANICAL INTEGRITY INDUSTRY STANDARD DEFICIENCIES
• REGULATORY OVERSIGHT OF PETROLEUM REFINERIES

ROOT CAUSES:
1. High Temperature Hydrogen Attack
2. NHT Heat Exchanger Flanges – A History of Leaking
3. Hazardous Nonroutine Work
4. Process Hazard Analyses Failed to Prevent or Reduce the Consequences

Image credit: CSB

A fire broke out in the 188,000 barrels-per-day refinery, caused by flash-floods during heavy rain. The rain overwhelmed the storm drainage system on the refinery, resulting in hydrocarbons being washed out of the drains and around the site. An explosion was reported in the crude distillation unit. There were two fires in the crude distillation unit (CDU), one in the coking plant and two in the topping distillation plant. The government agency said the incident had been caused by hydrocarbons exploding in one of the coke manufacturing furnaces. The furnaces had been shut down, but were still hot enough to ignite the hydrocarbon. It took eight hours to extinguish the fire and 10 hours before the incident was under control. There were no fatalities or injuries.

[ Property Damage $225 Million. Estimated Current Value $243 Million ]

Image credit: YPF

At approximately 7:20 a.m. on April 3, 2017, the bottom of a steam condensate (hot water) storage tank catastrophically failed at the Loy-Lange Box Company (LLBC), located at 222 Russell Boulevard in St. Louis, Missouri. The 1952-pound, 30-inch diameter by 17-½-feet long steel tank, called a Semi-Closed Receiver (SCR)4 contained about 510 gallons condensed steam (water at about 330 °F and 100 psig.) Condensate from the vertically-mounted SCR was normally sent to two associated steam generators.

As the pressure in the tank suddenly dropped due to the failure of the tank bottom, a portion of the water in the SCR instantaneously exploded into steam, resulting in an increase in volume of about 75 times the volume of the SCR. A steam explosion of this type is extremely hazardous. The energy released was equivalent to about 350 pounds of TNT. Some of that energy dissipated when the escaping steam condensed to water, but the surveillance video from a nearby custom work truck shop clearly shows the power of the explosion and the effect on the building, as does the damage evident after the event.

The force of the steam explosion exiting the bottom of the SCR destroyed a large portion of the LLBC facility, and launched the storage tank like a rocket through the roof. One LLBC employee was fatally injured, and a second was left in critical condition.

Even after pulling loose from all of the piping and floor attachments, and crashing up through the structure of the building and out through the roof, the 1952-pound SCR was still traveling at about 120 mph. It rose to about 425 feet above street level and traveled laterally across about 520 feet. It remained airborne for over 10 seconds. As it fell, the SCR crashed through the roof of Faultless Healthcare Linen’s property at 2030 S. Broadway, fatally injuring three individuals.

KEY ISSUES:
• CORROSION
• MECHANICAL INTEGRITY & INSPECTION

ROOT CAUSES:
1. Steam generator repairs.

Image credit: CSB

On 5 April 1975 at 11.lO hrs there was an explosion at the factory of Laporte Industries Ltd, Uphall Road , llford, Essex. It occurred in the process plant called a Lurgi Electrolytor and as a result of uncontrolled release of the caustic electrolyte used in the plant one man subsequently died from his injuries. The plant itself was extensively damaged by the explosion and there was some local damage to the building on the site.

The purpose of the electrolytor is to produce hydrogen by the electrolysis of potassium hydroxide solution. The process also produces oxygen which is discharged as a waste product.

On Saturday 5 April the operator on duty was R Church. He had come on duty at 06.30 hrs. At about 11.10 hrs there was an explosion in the oxygen separator drum which ruptured. This liberated a large quantity of caustic solution which splashed over the operator and covered most of his body. He was alone in the room at the time in accordance with normal practice. He was heard shouting for help by the shift supervisor (FW Howe) who was nearby and had hurried to the building after hearing a loud noise. Mr Howe found Mr Church kneeling on the floor of the building and led him outside. The factory rescue team took him to the washroom and put him in the shower. Shortly afterwards he was taken to hospital and died later as a result of caustic burns. Mr Howe and RJ McCool who assisted Mr Church both received burns as a result of contact with the caustic solution on his clothing, and RS Boxall, a lorry driver who was passing the building at the time was also splashed with caustic on the head and arms. He was detained in hospital for a few days, but all three men were able to resume their work in a short time.

Report: https://www.icheme.org/media/13690/the-explosion-at-laporte-industries-ilford.pdf

Image Credit: HSE

Fire in a chemical plant fueled by unidentified chemicals. Two explosions were reported, one of them was a cylinder. Smoke and debris

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

A blast occurred in a pumping station, after leaking oil caught fire. 177 fire engines and more than 800 firefighters were rushed to the blaze, and more than 14,000 residents in the surrounding area were evacuated.

Proximate causes:
• Improper use of protective methods (Improper welding of conveying pipe)

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

On April 7, 2003, at about 8:55 p.m., central daylight time, an 80,000-barrel storage tank at ConocoPhillips Company’s Glenpool South tank farm in Glenpool, Oklahoma, exploded and burned as it was being filled with diesel. The tank, designated tank 11, had previously contained gasoline, which had been removed from the tank earlier in the day. The tank contained between 7,397 and 7,600 barrels of diesel at the time of the explosion.

The resulting fire burned for about 21 hours and damaged two other storage tanks in the area. The cost of the accident, including emergency response, environmental remediation, evacuation, lost product, property damage, and claims, was $2,357,483. There were no injuries or fatalities. Nearby residents were evacuated, and schools were closed for 2 days.

Image Credit: NTSB

On April 8, 2004, four workers were seriously injured when highly flammable gasoline components were released and ignited at the Giant Industries Ciniza refinery, east of Gallup, New Mexico. The release occurred as maintenance workers were removing a malfunctioning pump from the refinery’s hydrofluoric acid (HF) alkylation unit. Unknown to personnel, a shut-off valve connecting the pump to a distillation column was apparently in the open position, leading to the release and subsequent explosions.

KEY ISSUES:
• MECHANICAL INTEGRITY
• CORROSION & SCALE FORMATION
• VALVE DESIGN
• HUMAN FACTORS CONSIDERATION
• MANAGEMENT OF CHANGE
• LOCKOUT/TAGOUT & ISOLATION

ROOT CAUSES:
1. An MOC hazard analysis was not conducted.
2. the facility lacked procedures to verify that the pump had been isolated, depressurized and drained.
3. Instead of determining the cause of frequent pump malfunctions and then implementing a program that would prevent problems before they occurred, Giant used breakdown maintenance by making repeated repairs to the pump seals after failure.

Image Credit: CSB

On April 8, 2011, at approximately 8:50 am, an explosion and fire occurred at a magazine known as ‘A-21’ located at Waikele Self Storage in Waipahu, Hawaii. Five Donaldson Enterprises, Inc. (DEI) employees were fatally injured and a sixth sustained minor injuries.

DEI, a small unexploded ordnance (UXO) clearance company based on the island of Oahu, was using the magazine to store seized contraband fireworks and prepare them for disposal. On the morning of the incident, five DEI personnel were disassembling one-inch contraband firework tubes on a cement loading dock located directly in front of the magazine entrance, while a sixth remained inside the magazine cleaning and organizing . To accomplish the disassembly work, DEI personnel cut into the individual firework tubes by hand using a PVC pipe cutter or knife and separated the individual explosive components contained within each tube, the aerial shells and the black powder (which functions as a lift charge) into cardboard boxes.

According to witness statements, around 8:30 am it began to rain heavily, and the DEI workers quickly moved materials involved in the disassembly process – including tools, chairs, and boxes containing aerial shells, black powder, and partially disassembled firework tubes – to just inside the magazine entrance. While five of the workers remained inside, the project supervisor went outside to the front left corner of the loading dock to make a phone call. While he was on the phone, an explosion occurred inside the magazine, and a fire ensued.

The five individuals located inside the magazine at the time of the incident did not survive. Three DEI employees sustained fatal burn injuries while two succumbed to carbon monoxide poisoning. The project supervisor sustained minor injuries.

KEY ISSUES:
• HAZARDS OF FIREWORKS DISPOSAL & THE ACCUMULATION OF EXPLOSIVE FIREWORKS COMPONENTS
• LACK OF REGULATIONS & INDUSTRY STANDARDS ADDRESSING FIREWORKS DISPOSAL
• INSUFFICIENT CONTRACTOR SELECTION & OVERSIGHT REQUIREMENTS FOR HAZARDOUS ACTIVITIES

ROOT CAUSES:
1. DEI’s hazard analysis of its fireworks disposal process was insufficient. The company failed to identify key hazards of handling, disassembling, and storing contraband commercial display fireworks, and did not adequately control the identified and evaluated hazards.
2. DEI personnel disposing of the fireworks lacked the training, experience, and knowledge of procedural safeguards for the safe conduct of the fireworks disposal.
3. DEI’s modifications to the fireworks disposal process accumulated substantially large quantities of explosive material in boxes, greatly increasing the potential explosion hazard. This change to the disposal process was not adequately reviewed for safety implications.

Image & AcciMap Credit: CSB

Image credit: CSB

A chemical drum which is speculated to have contained an old chemical exploded at Echotech fiber manufacturing factory workshop.

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