Incidents Map

A gas explosion occurred in confined space in coal mine industry

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

At approximately 4 am on Friday June 21, 2019 there was a release of vapor in the PES refinery alkylation unit. The vapor found an ignition source, causing a fire and multiple explosions.

KEY ISSUES:
• MECHANICAL INTEGRITY
• HF CORROSION

Image credit: CSB

Ethanol vapors leaked from piping caught fire and caused an explosion at the Poet Ethanol Plant in Glenville. Two out of four employees that were in the plant were injured. Significant damage to the facility

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

4 killed in a gas explosion happened in the coal mine in Enshi city.

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

An explosion and large fire occurred in the olefins plant Number III at a petrochemical plant. The explosion was felt and heard more than 10 miles away and the ensuing fire burned for approximately 10 hours. The explosion and fire resulted in extensive damage to the facility and several workers received minor injuries. In addition, nearby properties were damaged, nearby transport routes were closed for several hours, and residents were advised to remain indoors. The incident originated at the cracked gas compressor system in the olefins unit and was caused by the structural failure of a 36-inch pneumatically-assisted non-return valve located on a high-pressure light hydrocarbon gas line. The escaping gas formed a vapor cloud and eventually found a source of ignition, resulting in the unconfined vapor cloud explosion.

[ Property Damage $135 Million. Estimated Current Value $250 Million ]

Image credit: Roy Luck

St. Louis was experiencing a heat wave with bright sunlight and temperatures reaching 97 °F (36 °C) on June 24, 2005. Praxair operations proceeded normally during the morning and early afternoon; however, about 3:20 pm, a technician retrieving cylinders from an outside storage area saw a ten-foot high flame coming from a cylinder and activated the fire alarm. Security camera video from the facility shows the release and ignition of gas from a cylinder in the propylene return area.

As workers and customers evacuated, the fire spread to adjacent cylinders. Security camera video shows nearby cylinders igniting in the first minute. At 2 minutes, cylinders begin exploding, flying into other areas of the facility, and spreading the fire. After 4 minutes, the fire covers most of the facility’s flammable gas cylinder area and explosions are frequent.

KEY ISSUES:
• HIGH AMBIENT TEMPERATURES
• RELIEF vs VAPOR PRESSURE
• FLAMMABLE GAS DETECTION
• DELUGE SYSTEMS
• FIRE BARRIERS

ROOT CAUSES:
• Although the official cause is undetermined, the most likely cause was ‘propylene venting due to the prolonged exposure to excessive heat’

Image credit: CSB

An explosion occurred when employees were attempting to isolate a leak on a condensate line between the natural gas liquid (NGL) plant and the refinery. Three crude units were damaged and two reformers were destroyed. The fire was extinguished approximately nine hours after the initial explosion. Five people were killed and 50 others were injured. The initial investigation into the loss indicated a lack of inspection and maintenance of the condensate line, which was not owned by the refinery. A lack of clear understanding of the ownership of the line is thought to have delayed the isolation of it.

[ Property Damage $412 Million. Estimated Current Value $718 Million ]

KEY ISSUES:
• Ownership and responsibility for equipment should be understood
• Third party interfaces must be managed
• Quality maintenance and inspection regimes are critical for plant integrity

Image credit: KNPC

A tank containing chlorine exploded at the Olin Chlor Alkali Products plant in Becancour. Workers in nearby buildings were evacuated, but employees at Olin Chlor Alkali were told to remain at the chemical plant.

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

A natural gas pipeline explosion and fire occurred at a gas booster station as a crew worked on a 4-inch gas line. The workers were replacing some gas lines, repairing a ruptured line.

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: News Channel 10 Amarillo

At approximately 17:10 hours on the 27th June 1976 an explosion occurred killing one man and causing extensive damage to the plant and adjacent buildings.

The explosion involved a detonation of zoalene, which is used as a poultry feed additive.

The following factors may have contributed in the circumstances leading up to the explosion:
– the batch probably contained a higher percentage of impurities than most other batches due to the presence of rewashed material, some of which may have been subjected to a number of heating cycles;
– the long holding period (greater than twenty-four hours) of the material at an elevated temperature in the dryer vessel, when this material was known to have a history of thermal instability;
– the drying vessel was not cooled which was previously carried out during the former manufacturing process. The cooling was undertaken for ease of handling rather than for material safety;
– overheating of the batch material; and
– the absence of accurate process temperature and moisture indication.

The fundamental reason for this incident was a general lack of knowledge of the destructive potential of zoalene at adiabatic conditions. Neither the management nor the operating personnel were criticised for undertaking and conducting the operations that led to the explosion

KEY ISSUES:
• REACTION / PRODUCT TESTING
• PLANT MODIFICATION / CHANGE PROCEDURES

Report: https://www.icheme.org/media/13691/the-explosion-at-appleby-frodingham-steelworks-scunthorpe.pdf

Image Credit: HSE

On the morning of Sunday 27 June 1982 two explosions occurred at the premises of Staveley Chemicals Limited. The source of the explosions was a pit containing drums of sulphur trioxide and of oleum. The drums of sulphur trioxide had been returned from customers more than 10 years previously and had then been stored in the open. Over the following years minor leaks developed through corrosion, and sulphur trioxide vapour began to escape as a visible fume. In November 1981 the company decided to overcome the problem by surrounding the drums with an absorbent solid. A pit was dug out on some open land within the works site, the drums placed within the pit, then covered over with a proprietary absorbent material and topped with crushed blast furnace slag. No special provision was made for drainage of the pit, nor to prevent ingress of ground water or rain. Drums of oleum were included together with the drums of sulphur trioxide in the pit.

The first explosion occurred at 10:45 hours on June 27th. Two drums were blown out of the site, over a public highway, to fall into open ground outside the works boundary and about 300 metres from the containment pit. Fortunately no injury to persons or damage to property was caused by these events. Further, but less intense explosions continued until the following day. A cloud of white acid mist billowed up from the site.

The Fire Brigade could not use water hoses because of the possibility of causing a violent reaction with any escaping oleum or liquid sulphur trioxide within the containment pit. It was decided that the best immediate course of action would be to put anhydrous sodium sulphate powder into the open pit in order to absorb liquid and suppress fuming. Several bags of this powder were thrown in and by 12:00 hours the mist emission was lessening. However, a second explosion occurred at 12:30 hours with a large release of acid mist but without ejecting any drums. There was a third explosion at about 14.30 hours. Tarpaulins were put over the pit to prevent the ingress of rain. The last explosion was at about 03:00 hours, the following morning. This explosion was minor compared with those on the previous day.

On Monday 28 June, a heavy steel grid was placed over the pit to reduce the risk of further drums being ejected. Temperature measurements were made in the pit, and found to be as high as 90°C in places. Subsequently the drums were all taken out of the pit and put on to open ground nearby. There were 32 sound drums remaining, and 25 corroded and empty or nearly empty.

KEY ISSUES:
• DRUM / CYLINDER HANDLING

Image Credit: YouTube (Hollingwood Lad)

During the night of June 27, 2016, the two personnel on duty at PGP – a control board operator and an outside operator – were stopping production of natural gas liquids due to pipeline problems downstream of the facility. Although this was a non-routine activity, the control board operator had experience conducting the procedure. The operators initiated the necessary steps from the control room, when, at 11:22 p.m., a sudden explosion and fire occurred. No abnormal alarms or other indicators warned the two PGP personnel of any problems. Within a minute of the initial explosion, the operators activated the emergency shut down systems at the plant and sheltered in the control room.

Over the course of the incident, the site experienced 13 different ruptures of piping and equipment. The CSB concludes that the first loss of containment most likely originated at a BAHX when it lost core integrity due to accumulated thermal fatigue.

The BAHX of interest was part of A-Train, one of three process lines (A, B, and C) at PGP. The rupture released flammable hydrocarbon into the process area in and around a variety of potential ignition sources. After ignition, emergency systems depressurized the plant and sent much of the process fluids to a flare, but the rupture also caused a portion of A-Train’s contents to continue to feed the fire, which intensified several times over approximately the next 35 minutes as additional piping and equipment failed. Equipment, piping, and vessels in the A-Train process area were extensively damaged .

KEY ISSUES:
• EXCHANGER FAILURE DUE TO THERMAL FATIGUE
• SERVICE LIFE DETERMINATION OF BRAZED ALUMINUM HEAT EXCHANGERS
• SOCIAL MEDIA USE IN EMERGENCY RESPONSE

ROOT CAUSES:
1. The absence of a reliable process to ensure the mechanical integrity of the heat exchanger contributed to the catastrophic failure of the equipment.

Image credit: CSB

Flammable color powder exploded in at a recreational water park in Taiwan

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

An explosion and fire was caused by the failure of ammonia synthesis equipment

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

An explosion occurred in a petrochemical company in Xiangtan Jiuhua Industrial Zone. There was huge smoke

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

On 29 June 2009, shortly before midnight, a train transporting LPG from the oil refinery of Trecate, near Milan, to a LPG storage depot located in Gricignano, near Naples derailed while crossing Viareggio station and five of fourteen rail tankers overturned. Approximately 45 tonnes of LPG was released and the gas cloud spread to the neighbouring residential area before igniting. Thirty-one people died as a result of the accident and the damage caused ran into tens of millions of euros. The accident was the worst railway accident in Italy related to the transportation of dangerous substances, and the most serious accident in Italy involving LPG.

The management faults identified as possible factors in the Viareggio accident point to the need for more emphasis on risk assessment procedures in the rail transport of dangerous substances.

Ref: IChemE Loss Prevention Bulletin, Issue 231, page 4
Image Credit: RTBF

Gas leakage and explosions happened in the Mao Dongsheng industrial zone. It was reported that the spill affected 56 primary schools students and a teacher, and they were then sent to the hospital.

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

The Fateh Field L-3 development well had reached 4,180ft when a “kick” occurred. The kick control effort was terminated and the rig abandoned when gas broke around the 20-inch shoe and bubbled up under the platform.

Eight days after the blowout, the gas ignited, and after two weeks the rig and platform disappeared beneath the waters.

A fire broke out at Algeria’s main liquefied natural gas (LNG) complex in Arzew’s petrochemical hub. The fire was preceded by two explosions that were reported to shake industrial and residential buildings kilometers away. Many people initially took the blasts for an earthquake, because of their intensity. Four people were reportedly injured in the incident.

Several main roads closed after a tanker carrying potentially hazardous chemicals spilled some of its load.

Proximate causes:
• Improperly prepared equipment
• Inadequate engineering/design
• Improper handling of materials (the chemical had leaked from the tanks which were not properly secured)

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

A jack-up sank after the seabed collapsed under one of its three legs. The rig sank while being positioned for drilling operations in approximately 40 meters of water. Some 103 workers were onboard the rig when it suddenly tilted, causing the rig to take on water and capsize. One crew member went missing and six others received minor injuries.

[ Property Damage $182 Million. Estimated Current Value $197 Million ]

Image credit: SAIPEM

Leak from a container of hydrochloric acid when being moved. Firefighters deposited a neutralizing agent on the ground.

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

A single-tank car carrying 24,000 gallons of acrylonitrile, derailed and caught on fire. After burning for hours, the fire was extinguished. Thousands evacuated

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

On Tuesday 3 July 1883 the steam coaster Daphne was launched from the Linthouse Shipyard of Alexander Stephen & Sons. The engine had been installed prior to launch but the boilers had not, although an opening was left on deck so that they could be fitted later at another quay further upriver. As was often the case the management were under pressure to complete the contract on schedule and as a result around 200 of the workforce, many of them just boys, had remained on board during the launch so that they could continue work as the vessel was towed to the fitting-out berth.

After a brief ceremony the iron ship slipped into the river and was brought to a standstill by the action of the drag chains. The small crowd assembled on the bank watched in horror as, after a few seconds, the Daphne heeled to port, recovered momentarily then rolled over completely. Despite frantic efforts only about 70 people were saved and it soon became clear that a total of 124 men and boys had lost their lives in the accident.

A subsequent enquiry found that although the hull design was flawed the large amount of personnel and loose equipment on deck had contributed greatly to the capsize as had water flooding into the boiler access hole. Regulations were brought in and procedures were amended to prevent a recurrence. The only money given to the bereaved families came from public donations.

Source: http://clydeside-images.blogspot.com/2010/11/sinking-of-ss-daphne.html | Image credit: Trinity Mirror

An explosion occurred at a chemical plant. Before the explosion, some workers were welding the interior of waste water storage. The blast tore out the upper structure of the storage facility, which subsequently collapsed

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

An explosion occurred in the final purification column of an ethylene oxide manufacturing plant, resulting in 14 people being injured. The explosion caused several secondary fires on the original units, as well as other units nearby, but all were under control within 30 minutes. The root cause was identified as a rapid overpressurization of the column as a result of decomposition of material within it, although the ignition source was not identified.

[ Property Damage $78 Million. Estimated Current Value $187 Million ]

Image credit: Ineos

The explosion and fire occurred in the kerosene stripper of the crude distillation unit (CDU) at a 80,000 bbl-per-day refinery located in an industrial zone surrounded by residential areas. This resulted in fires in the area, but no injuries were reported. The refinery operator said it would postpone a maintenance shutdown at its refinery, set for late July, to reduce the risk of supply shortages as a result of the fire. The CDU damaged by the fire was replaced within three months.

[ Property Damage $140 Million. Estimated Current Value $153 Million ]

Image credit: Bangkok Post

A fire broke out at Flowchem, a company that makes pipeline additives using synthetic rubber. The site stored flammable alcohol based chemicals and soy bean oil. The fire did not reach them. Shelter-in-place for residents within two miles of the plant

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

The Lowermoor water pollution incident occurred on 6 July 1988 at the South West Water Authority’s (SWWA) water treatment works at Lowermoor, near Camelford, Cornwall. A relief tanker driver discharged 20 tonnes of aluminium sulphate solution into the wrong tank at the unmanned works, subsequently contaminating water supplies to a large area of North Cornwall.

On the afternoon of Wednesday July 6 1988, a delivery of aluminium sulphate solution was made to the unmanned works. This was discharged into the wrong tank i.e. into the chlorine contact tank instead of into a storage tank. The start of the discharge was 5.03pm and it finished at 5.40pm. This tank is immediately upstream of the treated water reservoir for water awaiting distribution through the mains. Water contaminated with high concentrations of aluminium sulphate therefore moved into the treated water reservoir and then entered the distribution system.

Later on in the evening of 6 July, from about 8.00pm onwards, customers began to complain to SWWA that the water had an unpleasant taste and a sticky feel to the touch. These properties are consistent with water of low pH (acidic) and the presence of aluminium sulphate.

Ref: https://cot.food.gov.uk/sites/default/files/cot/lwpiapp811.pdf | Image Credit: BBC

An unattended 74-car freight train carrying Bakken Formation crude oil rolled down a 1.2% grade from Nantes and derailed downtown, resulting in the fire and explosion of multiple tank cars. Forty-two people were confirmed dead, with five more missing and presumed dead. More than 30 buildings in the town’s centre, roughly half of the downtown area, were destroyed, and all but three of the thirty-nine remaining downtown buildings had to be demolished due to petroleum contamination of the townsite. Initial newspaper reports described a 1-kilometre (0.6 mi) blast radius.

Image Credit: TSB Canada

A release and ignition of gas condensate from a section of piping in the gas compression module of this platform set off a chain of fires and explosions, resulting in the almost total destruction of the facility. The condensate was released from the site of a pressure relief valve that had been removed for maintenance when this section of piping was inadvertently pressurized.

The severity of the accident was largely due to the contribution of oil and gas from ruptured pipelines connected to the platform and the disabling of nearly all emergency systems as a result of the initial explosion. The compression module had been retrofitted to the platform adjacent to the control room, which was rendered useless by the initial explosion.

In addition, the firewater pumps had been placed in to manual operation mode due to divers being in the water prior to the accident.

There were 226 people on the platform at the time of the accident; only 61 survived. Contributing to the loss of life was the location of the quarters, which was directly over the site of the initial release and resulting explosion and fire.

[ Property Damage $850 Million. Estimated Current Value $1963 Million ]

KEY ISSUES:
• MANAGEMENT OF CHANGE
• PERSONAL SAFETY OVER PROCESS SAFETY
• ISOLATION AND PERMITS FOR MAINTENANCE
• HANDOVER
• SAFETY CULTURE
• EMERGENCY RESPONSE

Image Credit: Press Association

This event occurred on a crude unit at this 360,000 bbl per day refinery. A furnace was undergoing maintenance when a worker performed a hot cut and material was released. Inadequate flushing and blinding and a work scope that did not meet normal industry practices appear to have been the likely causes.

[ Property Damage $100 Million. Estimated Current Value $199 Million ]

Image credit: Rosneft

Hurricane Dennis passed through the area where the platform was located, causing it to partially sink. A seawater valve in a ballast tank had been wrongly installed, resulting in excess water in the tanks. The platform had already been evacuated and there was no leakage of oil, fuel, or other hazardous substances. The loss resulted in the project commencing production three years behind schedule. The company retrieved and rebuilt all the seabed production equipment after a series of tests revealed metallurgical failure in components of the field subsea systems.

[ Property Damage $250 Million. Estimated Current Value $350 Million ]

Image credit: US Coast Guard

At approximately 12:37 on Saturday 10th July 1976 a bursting disc on a chemical reactor ruptured. Maintenance staff heard a whistling sound and a cloud of vapour was seen to issue from a vent on the roof. A dense white cloud, of considerable altitude drifted offsite.
Among the substances in the white cloud was a small deposit of 2,3,7,8-Tetrachlorodibenzo-p-dioxin (‘TCDD’ or ‘dioxin’), a highly toxic material.

The release lasted for some twenty minutes. Over the next few days following the release there was much confusion due to the lack of communication between the company and the authorities in dealing with this type of situation.

The nearby town of Seveso, located 15 miles from Milan, had some 17,000 inhabitants. No human deaths were attributed to TCDD but many individuals fell ill. 26 pregnant women who had been exposed to the release had abortions. Thousands of animals in the contaminated area died and many thousands more were slaughtered to prevent TCDD entering the food chain.

KEY ISSUES:
• OPERATING PROCEDURES
• RELIEF SYSTEMS / VENT SYSTEMS
• CONTROL SYSTEMS
• ALARMS / TRIPS / INTERLOCKS
• REACTION / PRODUCT TESTING
• DESIGN CODES – PLANT
• SECONDARY CONTAINMENT
• EMERGENCY RESPONSE / SPILL CONTROL

Image Credit: ICMESA
Report: https://www.aria.developpement-durable.gouv.fr/fiche_detaillee/5620_en/?lang=en

Explosion as a result of a build-up of toxic fumes with ignition causing a fire ball. The men were killed while working in a confined unit. Damaged buildings

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

An explosion occurred in an aerospace company in Newport which caused huge damages in the structure of the facility. Newport city manager estimate $1 million in damages to the plant

Proximate causes:
• Inadequate tools, equipment & vehicles

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

A massive explosion occurred in a chemical plant. 130 firefighters came to control the blaze. The explosion occurred after a large-size tank containing liquid hydrogen caught fire

Proximate causes:
• Inadequate tools, equipment & vehicles (leak of a 1000 square meters tank containing petrochemical product)

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

On July 17, 2007, at about 9 a.m., an explosion and fire occurred at the Barton Solvents Wichita facility in Valley Center, Kansas. Eleven residents and one firefighter received medical treatment. The incident triggered an evacuation of Valley Center (approximately 6,000 residents); destroyed the tank farm; and significantly interrupted Barton’s business. An investigation by the U.S. Chemical Safety and Hazard Investigation Board (CSB) has concluded that the initial explosion occurred inside a vertical above-ground storage tank that was being filled with Varnish Makers’ and Painters’ (VM&P) naphtha. VM&P naphtha is a National Fire Protection Association (NFPA) Class IB flammable liquid that can produce ignitable vapor-air mixtures inside tanks and, because of its low electrical conductivity, can accumulate dangerous levels of static electricity.

KEY ISSUES:
• NONCONDUCTIVE FLAMMABLE LIQUIDS CAN ACCUMULATE STATIC ELECTRICITY DURING TRANSFER & STORAGE.
• STATIC SPARKS CAN READILY IGNITE FLAMMABLE VAPOR-AIR MIXTURES INSIDE STORAGE TANKS.
• MATERIAL SAFETY DATA SHEETS (MSDSS) OFTEN DO NOT ADEQUATELY COMMUNICATE HAZARD DATA AND PRECAUTIONS.

ROOT CAUSES:
1. Stop-start filling, air in the transfer piping, and sediment and water (likely present in the tank) caused a rapid static charge accumulation inside the VM&P naphtha tank.
2. The tank had a liquid level gauging system float with a loose linkage that likely separated and created a spark during filling.
3. The MSDS for the VM&P naphtha involved in this incident did not adequately communicate the explosive hazard.

Image credit: CSB

On July 17, 2001, an explosion occurred at the Motiva Enterprises LLC Delaware City Refinery (DCR) in Delaware City, Delaware. Jeffrey Davis, a boilermaker with The Washington Group International, Inc. (WGI), the primary maintenance contractor at DCR, was killed; eight others were injured.

A crew of WGI contractors was repairing grating on a catwalk in a sulfuric acid (H2SO4) storage tank farm when a spark from their hot work ignited flammable vapors in one of the storage tanks. The tank separated from its floor, instantaneously releasing its contents. Other tanks in the tank farm also released their contents. A fire burned for approximately one-half hour; and H2SO4 reached the Delaware River, resulting in significant damage to aquatic life. .

KEY ISSUES:
• MECHANICAL INTEGRITY
• ENGINEERING MANAGEMENT
• MANAGEMENT OF CHANGE
• HOT WORK SYSTEMS

ROOT CAUSES:
1. Motiva did not have an adequate mechanical integrity management system to prevent and address safety and environmental hazards from the deterioration of H2SO4 storage tanks.
2. Motiva engineering management and MOC systems inadequately addressed conversion of the tanks from fresh to spent acid service.
3. The Motiva hot work program was inadequate.

Image Credit: CSB

A fire in the alkylation unit at CITGO’s Corpus Christi refinery led to a release of hydrofluoric acid (HF). The alkylation unit makes high-octane blending components for gasoline. One worker was critically burned.

KEY ISSUES:
• ENSURE ADEQUATE WATER SUPPLY TO THE HF MITIGATION SYSTEM
• AUDIT FACILITIES AGAINST AP 751

ROOT CAUSES:
1. Inadequate water supply

Image credit: CSB

Explosion at a fertilizer factory from a gas entrapment in a steam boiler. The stairway where the steam boilers were located had collapsed along with the lift instalments. Facility damage

Proximate causes:
• Inadequate work plan
• Inadequate engineering design
• Inadequate assessment of needs and risk

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

On July 20, a chlorine cooler at the Baton Rouge plant failed, leaking chlorine into the Genetron 143a refrigerant (G-143a) coolant system. The coolant system itself then failed, releasing chlorine to the atmosphere, which overwhelmed operators located both inside and outside the control room and caused them to leave the area. Seven plant workers were injured. The entire plant was evacuated, and authorities were notified. Because chlorine had been released to the atmosphere, the East Baton Rouge OHSEP initiated its community notification system and issued a shelter-in-place advisory for residents within a 0.5-mile radius. The release lasted approximately 3.5 hours, largely because:
• Operators were forced to evacuate the area before they could diagnose the problem and isolate the source of the leak.
• Chlorine entered the control room and damaged process control equipment.
• Unit emergency shutdown procedures did not completely isolate the chlorine supply.

During the July 20 chlorine release, all units at the Baton Rouge plant were shut down. Chlorine had corroded the process control system, which needed to be replaced. Work at the facility during the days that followed consisted mainly of maintenance, shipping activities, and the return of process equipment to a safe, normal state. On July 29, an operator working in the ton-cylinder area of the plant was preparing empty 1-ton refrigerant cylinders for offsite testing. During this procedure, he removed a plug from a 1-ton cylinder he likely believed to be empty. The cylinder was actually full, and its contents were released. The operator was engulfed in a cloud later determined to be contaminated antimony pentachloride; he died the following day, July 30.

Following the July 20 and 29 incidents at the Baton Rouge facility, the president of the Honeywell Specialty Materials group ordered a review of all facility operations prior to restarting operations. While Honeywell was investigating the two incidents and reviewing overall plant safety systems, plant activities were limited to maintenance and inspection. During the July 20 chlorine release, the plant’s G-22 unit was rapidly shut down using emergency procedures. Some equipment, such as an HF vaporizer, was left in an abnormal shutdown state (i.e., it contained liquid hydrogen fluoride). For the next few weeks, operations personnel started returning equipment to normal conditions. On August 12, operators began using a venturi stick to remove liquid hydrogen fluoride from a vaporizer in the G-22 process. This activity resulted in an HF release on August 13 that injured one employee and exposed one operator.

KEY ISSUES:
• HAZARD ANALYSIS
• NONROUTINE SITUATIONS
• OPERATING PROCEDURES

ROOT CAUSES:
1. The Honeywell Baton Rouge plant management systems did not protect against failures in the chlorine cooler.
2. The consequences of chlorine entering the coolant system were not fully evaluated.

1. Honeywell had no program to identify and address potential hazards in the ton-cylinder area.
2. Honeywell and C&MI have no systematic processes for positively verifying the contents of cylinders rejected by C&MI.
3. The Honeywell systems for segregating and storing 1-ton cylinders did not include procedures for identifying and handling abnormal cylinders.

1. Honeywell had no procedures for identifying and planning for nonroutine job situations.

Image Credit: CSB

The seat of the fire was located in a raw materials warehouse at Allied Colloids site in Low Moor, Bradford. The warehouse itself had two rooms allocated for the storage of oxidising and flammable products known as No.1 and No. 2 oxystores. No. 2 oxystore had steam heating as it was originally designed to store frost sensitive products.

On the morning of the incident steam heated blowers in the warehouse had been turned on to dry out moisture. It is thought that a steam condensate line was responsible for heating a number of AZDN kegs, which were stored at height in the No. 2 oxystore. The heating effect caused two or three of the AZDN kegs to rupture and spill white powder all over the floor. A passing employee thought that the powder was smoke and raised the alarm. It was determined that no immediate hazard was present and the AZDN data sheet was referred to before a clean up plan was devised. While waiting for confirmation from the appropriate vacuum cleaner manufacturer an employee noticed a plume of smoke/vapour and a hissing noise coming from a bag of SPS that was located underneath the AZDN kegs. Before the employee could douse the SPS with water the vapour plume ignited and became a jet flame of about 300 mm in length. Within a few seconds the jet flame became a flash fire which was transmitted all around the room.

It was determined later that the AZDN powder probably mixed with unintended spills of SPS and other oxidising products. AZDN in contact with SPS is likely to have been ignited by an impact, possibly from a lid and associated metal ring closure from one of the damaged AZDN kegs falling onto a bag or the floor.

The fire spread throughout the warehouse and smoke was blown towards nearby motorways. The fire was contained that day and the fire brigade was not stood down until 18 days later due to risk of re-ignition during clean up. Considerable environmental damage to the Aire and Calder rivers resulted from the firewater run off.

KEY ISSUES:
• SEGREGATION OF HAZARDOUS MATERIALS
• RAW MATERIALS CONTROL / SAMPLING
• PLANT MODIFICATION / CHANGE PROCEDURES
• ACTIVE / PASSIVE FIRE PROTECTION
• EMERGENCY RESPONSE / SPILL CONTROL
• SECONDARY CONTAINMENT

Report: https://www.icheme.org/media/13703/the-fire-at-allied-colloids-limited.pdf

Image Credit: Richard Vogel

On July 22, 2010, an explosion and fire killed two workers at the Horsehead Holding Company zinc recycling facility located in Monaca, PA. The facility recycles and purifies zinc through a high temperature distillation process and is located approximately 35 miles north of Pittsburgh.

KEY ISSUES:
• SUMP DESIGN WITH RESTRICTED CLEARANCE
• POORLY EXECUTED COLUMN COMMISSIONING
• HUMAN FACTORS

Image credit: CSB

Just prior to the rupture of a 55-feet-tall, 8.5-feet diameter monoethanolamine absorber column, a refinery operator noted a six-inch-long horizontal crack at a circumferential weld which was leaking propanes. As the operator attempted to close the inlet valve, the crack spread to about 24 inches. The area was being evacuated and the plant fire brigade was arriving when the column failed massively. Propane at 200 psig at 100°F propelled most of the 20-tonvessel 3,500 feet where it struck and toppled a 138,000-volt power transmission tower. The weld separation occurred along a lower girth weld joint made during a repair to the column 10 years earlier. The vessel was constructed of one-inch thick SA 516 Gr 70 steel plates rolled and welded with full penetration submerged arc joints, but without post-weld heat treatment. This explosion resulted in severe fires in the unsaturated gas plant, and the FCC and the alkylation units. After about 30 minutes, a BLEVE occurred in a large process vessel in the alkylation unit. One piece of this vessel travelled 500 feet, shearing off pipelines before striking a tank in the water treatment unit. Another fragment landed in a unifining unit over 600 feet away, causing a major fire where it landed. The first explosion, believed to be from an unconfined vapor cloud, broke windows up to six miles from the plant, caused extensive structural damage to refinery service buildings and disrupted all electric power at the refinery, rendering a 2,500 US gallons per minute electric fire pump inoperable. One explosion sheared off a hydrant barrel, resulting in a reduction of fire water pressure from the two 2,500 US gallons per minute diesel engine driven fire pumps, which were operating. The refinery’s blast resistant control center, approximately 400 feet northeast of the absorber, sustained little structural damage. An estimated 30 paid and volunteer public fire departments, together with equipment from refineries and chemical plants within a 20-mile radius, responded promptly. Many of the pumpers took suction from the adjoining canal and from a quarry. The pumpers and a 12,000 US gallons/min fireboat eventually provided water at pressures sufficient for fire fighting.

[ Property Damage $191 Million. Estimated Current Value $484 Million ]

Image credit: TWI

The series of events that led to the accident started on the morning of Sunday 24 July 1994. A severe electrical storm caused plant disturbances that affected the vacuum distillation, alkylation and butamer units as well as the fluidised catalytic cracking unit (FCCU). The crude distillation unit that provided feed to the Pembroke Cracking Company (PCC) units was shut down as a result of a fire, which had been started by a lightning strike. During the course of the morning all PCC units except the FCCU were shut down.

However the direct cause of the explosion that occurred some five hours later was a combination of failures in management, equipment and control systems during the plant upset. These led to a release of about 20 tonnes of flammable hydrocarbons from the outlet pipe of the flare knock out drum of the FCCU.

The explosion was caused by flammable hydrocarbon liquid being continuously pumped into a process vessel that, due to a valve malfunction, had its outlet closed. The only means of escape for this hydrocarbon once the vessel was full was through the pressure relief system and then to the flare line. The flare system was not designed to cope with this excursion from normal operation and due to liquid breakthrough at the FCCU flare knock out drum, a failure occurred in the outlet pipe.

A total of 20 tonnes of a mixture of hydrocarbon liquid and vapour was released, which found a source of ignition about 110 m from the flare drum and subsequently exploded. This caused a major hydrocarbon fire at the flare drum outlet itself and a number of secondary fires. The fires were effectively contained and escalation prevented by cooling nearby vessels that contained flammable liquids. As the explosion had incapacitated the flare relief system, the safest course of action was to allow the fires to continue to burn which they did, finally being extinguished on the evening of Tuesday 26 July 1994.

KEY ISSUES:
• CONTROL SYSTEMS
• MAINTENANCE PROCEDURES
• PLANT MODIFICATION / CHANGE PROCEDURES
• CONTROL ROOM DESIGN
• EMERGENCY RESPONSE / SPILL CONTROL

Report: https://www.icheme.org/media/13706/the-explosion-and-fires-at-the-texaco-refinery-milford-haven.pdf

Image Credit: Western Mail & Echo

Three technicians were in the middle of transferring fireworks from two storage buildings to a pickup truck when a series of three explosions occurred at a fireworks factory. The three technicians were killed and the two buildings were destroyed. Alarmed by the explosions, local residents contacted the firefighters. Despite the danger, the operator of the factory did not evacuate its employees. Forty minutes later, a third fireworks storage building exploded, killing a fourth person. This explosion was triggered by burning debris that had been sent flying by the first explosions. Due to the narrow lanes at the site, the firefighters encountered difficulties in responding to the accident. The fires that broke out in the site’s green spaces were brought under control. The last flames were extinguished nine hours later.

Explosion of chlorine cylinder at the Lamingo Water Board Treatment Plant. The explosion happened at 4 a.m. caused an excess chlorine inhalation by the nearby residents.

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

A leak and explosion occurred in a distillation unit with a 3 million ton annual capacity in China National Petroleum corporation Qin Yang Location. This incident happened after a 9 days inspection and maintenance

Proximate causes:
• Inadequate tools, equipment & vehicles (mechanical failure of a small component caused the leak of oil)

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

A vapor-cloud explosion centered in the Cryogenic Unit No. 2 and two subsequent explosions in the Cryogenic Unit No. 1 occurred at this gas-processing complex. As a result of the explosions, the Cryogenic Unit No. 2 and liquid petroleum gas (LPG) product pumps in the Cryogenic Unit No. 1 were extensively damaged, the control rooms for both units were destroyed, and the remainder of the Cryogenic Unit No. 1 experienced minor damage.

Plant personnel noticed that one of the two LPG product pumps in the Cryogenic Unit No. 1 had a seal leak. Consequently, plant personnel decided to have the faulty seal replaced. In preparation for the maintenance work on the LPG product pump, the motor-operated valve (MOV) in the suction line and the isolation valve in the discharge line of this pump were manually closed. A spectacle blind was then inserted into the pump flange on the suction side of the pump. After the seal was replaced, plant personnel removed the blind and were in the process of tightening the flange bolts when LPG product began to leak from this flange. A vapor cloud formed and drifted into the Cryogenic Unit No. 2. It was ignited and resulted in the initial explosion. Following the explosions, it was determined that the MOV in the suction line of the pump was in the open position, which allowed the LPG product to reach the pump flange. The fire brigades successfully extinguished the fire following the explosions after approximately three hours, and protected the adjacent LPG spheres. If these spheres had failed due to BLEVE, the property plant damage would have been substantially greater. Although the explosions damaged the electric power in the plant and rendered the electric motor-driven fire water pumps non-operational, fire water was provided by two diesel engine driven fire water pumps. Because of this incident, the 2.13 billion-cubic-feet-per-year gas-processing capacity at this complex was shut down, disrupting one third of Mexico’s total gas-processing capacity.

[ Property Damage $137 Million. Estimated Current Value $260 Million ]

Image credit: PEMEX

A total of 22 people were killed when a fire completely destroyed an oil platform. It is believed that a multi-purpose support vessel, which was evacuating a worker to a medical center, hit the platform’s riser causing an explosion. The vessel also caught fire and sank, but two nearby platforms were saved when connecting bridges collapsed. The 150 people on board managed to transfer to a nearby water injection platform and a further 348 people were evacuated from the oil platform. However, the rescue operation was hampered by bad weather. A cantilever jack-up rig, linked by a bridge to the process platform, was also involved in the fire. Some 73 people were evacuated from the rig however, one employee died during the evacuation. Meanwhile, six divers in a saturation chamber on the vessel were rescued 36 hours later.

[ Property Damage $370 Million. Estimated Current Value $518 Million ]

Image credit: ONGC

Three workers were killed in an explosion at the Packaging Corporation of America (PCA) fiberboard manufacturing facility while they were welding on a temporary metal clamp to stabilize a damaged flange connection. The flange was located on top of an 80-foot tall storage tank that contained recycled water and fiber waste.

Facility personnel were unaware of the potential presence of flammable gas from the decomposition of the organic material in the tank, and combustible gas monitoring was not typically required or performed prior to starting work. At the time of the accident, three workers were on a catwalk above the tank; one began welding the flange into place when sparks from the welding ignited flammable vapors inside the tank. The resulting explosion ripped open the tank lid, knocking two of the workers to the ground 80 feet below. All three workers died of traumatic injuries. A fourth worker, who had been observing the work from a distance, survived with minor injuries.

KEY ISSUES:
• ANALYZE THE HAZARDS
• MONITOR THE ATMOSPHERE
• TEST THE AREA

ROOT CAUSES:
1. Anaerobic bacteria
2. Hot work

Image credit: CSB

Around 8:15 am, fire-fighters were notified about a “gas leak” in a zone of the Belgian city of Ghislenghien, approximately 50 km from Brussels. This leak on the 100-cm diameter gas pipeline (DN 1000) was evidenced by a loud hissing, a tremor and the sudden creation of a cavity in the ground.

At 8:30 am, fire-fighters requested the assistance of the gas utility crew and set up a safety perimeter. Several tens of workers were present on a plant construction site and in a number of neighbouring companies. The leak increased in intensity, forming a whitish spray shooting some fifteen metres high.

At about 9:00 am, an explosion occurred; two minutes later, technicians were able to isolate the pipe segment between the two sectional valves. The gas cloud ignited, producing a “fireball” that subsequently transformed into a long flare whose height was estimated at 150-200 m. Depending on the estimation source, a temperature of around 3,000°C was reached in the middle of the fireball.

A number of individuals, including fire-fighters and police officers, were thrown tens of metres. Showers of debris fell onto the roofs of businesses in the industrial park. Within a radius of 150 to 200 m, tens of vehicles caught fire and the roof coverings of nearby commercial property actually liquefied. A packaging company occupying 3,000 m² of space and located roughly 60 metres away also caught on fire.

An 11-m pipeline section weighing more than a tonne was projected a distance of 150 m against the enclosure of an industrial pastry shop, whose facade blistered. Rescue teams stayed close to their vehicles some 150 m from the scene while sprinkling their polyester cistern, which had become warped due to the thermal radiation.

With a human toll of 24 dead, including 5 fire-fighters, 1 police officer and 5 employees killed on the spot, plus 132 injured, this accident was qualified as Belgium’s most serious industrial disaster in half a century.

Image credit: DPA

A fire and explosion occurred to the storage tanks containing raw material

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

Platform was struck by the vessel “Stad Sea”

A massive explosion in an aluminum plant in Missouri created a monumental smoke column due to the fire.

Proximate causes:
• Hazardous work exposure

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

An explosion at a warehouse storing ammonium nitrate in Beirut, Lebanon, has killed at least 135 people and injured at least 5,000.

Two explosions occurred at around 18:00 local time on 4 August. According to local media and video footage, the initial explosion caused white smoke to rise from the warehouse in Beirut port, followed by a huge second explosion which sent a shockwave out from the blast site. A pillar of reddish-brown smoke was seen rising from the site, the colour being characteristic of nitrogen dioxide. A video from The Guardian shows the devastating nature of the blast.

The shockwave shattered windows and damaged buildings several kilometres away from the blast site. Rescuers are still reportedly searching through the rubble for missing people. Hospitals across the city – reported by the BBC as already struggling to cope with Covid-19 – are overwhelmed, according to Reuters. The New York Times reported that one hospital was so badly damaged by the blast that it had to shut down and send patients elsewhere.

According to BBC, Lebanon’s President Michel Aoun said that 2,750 t of ammonium nitrate had been stored at a warehouse in the port since 2014 without any safety measures in place. The ammonium nitrate had been impounded from a ship that brought it into the port in 2013.

Image Credit: EPA
Image Credit: Visual Capitalist (Source – Zhe Han Thermal Stability Studies of Ammonium Nitrate)

A nitrogen tank exploded and a building collapsed at a chemical plant. Explosion caused a leakage of titanium dioxide and nitrogen, but no high levels of chemicals were detected in the area. 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 / Kani_West

Two methylbenzene storage tanks exploded

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

On August 6, 2012, the Chevron U.S.A. Inc. Refinery in Richmond, California (‘the Chevron Richmond Refinery’) experienced a catastrophic pipe rupture in the #4 Crude Unit. The incident occurred from piping referred to as the ‘4-sidecut’ stream, one of several process streams exiting the refinery’s C-1100 Crude Unit Atmospheric Column. The pipe rupture occurred on a 52-inch long component of the 4- sidecut 8-inch line (the 52-inch component). At the time of the incident, light gas oil was flowing through the 8-inch line at a rate of approximately 10,800 barrels per day (bpd).

The ruptured pipe released flammable, high temperature light gas oil, which then partially vaporized into a large, opaque vapor cloud that engulfed 19 Chevron U.S.A. Inc. (Chevron) employees. At 6:33 p.m., approximately two minutes following the release, the released process fluid ignited. Eighteen of the employees safely escaped from the vapor cloud just before ignition; one employee, a Chevron refinery firefighter, was inside a fire engine that was caught within the fireball when the process fluid ignited. Because he was wearing full-body fire-fighting protective equipment, he was able to make his way through the flames to safety. Six Chevron employees suffered minor injuries during the incident and subsequent emergency response efforts.

KEY ISSUES:
• PROCESS SAFETY PROGRAMS
• EMERGENCY RESPONSE
• MECHANICAL INTEGRITY INDUSTRY STANDARD DEFICIENCIES
• LEAK EVALUATION & RESPONSE INDUSTRY STANDARD DEFICIENCIES

ROOT CAUSES:
1. Chevron did not effectively implement internal recommendations to help prevent pipe failures due to sulfidation corrosion.

Image & AcciMap Credit: CSB

Fire in a chemical factory in Chakeri area of Kanpur, Uttar Pradesh, India. It took more than 5 h for 15 fire fighting vehicles to extinguish the fire. A large portion of the factory and a storehouse adjacent to it were destroyed.

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

A fire broke out during drilling operations at an offshore gas production platform following a well control incident. The fire on the production platform, initially under control, spread to a nearby jack-up drilling rig, owned by a major drilling contractor, which suffered major damage and collapsed. All 79 people on board the drilling rig were safely evacuated. The production platform, with 150 people onboard, had been evacuated before the fire spread. The drilling rig sank and was not salvageable. The platform was damaged beyond repair and its destruction was ordered by the state.

[ Property Damage $190 Million. Estimated Current Value $279 Million ]

Image credit: Petrobel

Fire broke out at 10:50 pm at the site of a logistics company, operating since 2011 in the Tianjin port sector with a floor area covering 46,000 m². At the time of the accident, the company had been storing on-site several types of hazardous substances: calcium carbide, toluene diisocyanate, ammonium nitrates, potassium and sodium, as well as 700 tonnes of sodium cyanide.

As fire-fighters were attacking the blaze with water, 2 explosions occurred around 11:30 pm. The first had the equivalent force of 3 tonnes of TNT, while the second was more powerful at 21 tonnes. A tremendous plume of smoke formed, followed by a massive fire. The resultant emergency response comprised several thousand fire-fighters, soldiers and police officers.

On 21st August, a full 9 days later, 4 new fire outbreaks occurred adjacent to the sites of the explosions.

Investigation Report (LEARN MORE): ARIA