Incidents Map

At approximately 23:00 hours on the 25th September 1982 a major fire broke out in a warehouse used for storing 2,000 tonnes of chemicals including 25 tonnes of sodium chlorate. The fire quickly spread within the warehouse and consumed the sodium chlorate, which violently exploded. The explosion destroyed the warehouse and also caused minor damage to nearby residential property. Several hundred persons were evacuated and 60 received hospital treatment.

The investigation found evidence that intruders started the fire. The speed at which the fire spread was attributed to the presence of a flammable atmosphere. It was recognised that vandalism was a major contributing factor in this incident. However, the investigation identified that the risks could have been significantly reduced if the sodium chlorate had been stored in the recommended manner. No areas within the warehouse were reserved for either a particular product or customer and there was no separation of chemicals from other goods.

The warehouse had no direct control on the level of chemicals delivered to the site therefore the quantity and type of chemical stored could substantially change.

Records detailing the storage of chemicals and other goods within the warehouse were destroyed in the fire.

KEY ISSUES:
• SEGREGATION OF HAZARDOUS MATERIALS
• RAW MATERIALS CONTROL / SAMPLING
• ACTIVE / PASSIVE FIRE PROTECTION
• SITE SECURITY
• WARNING SIGNS

Image Credit: Greater Manchester Fire & Rescue Service

Gas supplies to Australia’s Victoria State were virtually shut down following an explosion and fire at this gas processing plant. The specific cause of the accident was attributed to the rupture of a heat exchanger, following a process upset that was set in motion by the unintended, sudden shutdown of hot oil pumps. The loss of hot oil supply allowed some vessels to be chilled by cold oil, and when the hot oil was re-introduced to the heat exchanger, the vessel ruptured due to a brittle fracture. An initial release of approximately 22,000 pounds of hydrocarbon vapor exploded, and an estimated 26,000 pounds burned as a jet fire. The fire burned for two and a half days.

Operator error and improper training of employees was sited in the report issued by the Longford Royal Commission formed to study the incident. One of the pipes at the plant had sprung a leak and ignited, with the heat bursting other pipes. Five explosions ripped through the gas plant, and, in addition to the 120 workers evacuated from the site, police evacuated houses within a five kilometre radius of the gas plant. The plant has a daily production capacity of 200,000 barrels per day of stabilized crude oil, 40,000 barrels per day of raw LPG, and 450,000 million cubic-feet-per-day of gas to supply natural gas customers. The gas outage has affected 1.4 million users state-wide and forced small and large businesses to temporarily shut down. The estimated insurance payout is US$590 million. It is estimated that the shutdown cost industry nationally up to US$745 million in lost production.

Property Damage $443 Million. Estimated Current Value $813 Million [MARSH]

Image Credit: Fairfax Media | AcciMap Credit: Andrew Hopkins

On Thursday 26 September, a fire took hold of a chemical storage facility in Rouen, a port city on the river Seine – one of France’s biggest rivers – that has a population of more than 110,000.

The incident caused widespread panic and several surrounding towns advised residents to remain indoors.

According to local officials, the fire released mostly natural and organic substances such as hydrocarbons and mercaptan, a colourless additive to natural gas that has a pungent smell – a bit like rotten cabbages.

Most of the particles released into the air were “quickly deposited on the ground in the form of soot”, local authorities said, citing tests carried out to determine the presence of poisonous substances such as carbon monoxide, sulphur dioxide and hydrogen sulphide.

However, other concerns were raised, such as the collapse of the factory roof, which contained asbestos.

The latest information provided by the official website of the Seine-Maritime prefecture states that any risk of distribution of asbestos particles or fibres was “limited by the rapid collapse of the roof” (in French).

Ref: https://www.publicsenat.fr/dossier/incendie-de-lubrizol
Image Credit: SDIS76

A fire started in a 5000-L tank at the Milazzo refinery, which is jointly owned by Italy’s Eni and Kuwait Petroleum. Firefighters controlled the fire but the tank burned until the oil tank was empty. According to the fire department, the fire was caused by the collapse of the tank roof.

Proximate causes:
• Inadequate work planning
• Inadequate maintenance (local media reported that when the refinery caught fire, there was maintenance work going on at the facility)
• Inadequate management/ supervision

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

A fire broke out in a refinery, reported to have started in a pump house used for blending refined products, as it was being prepared for maintenance. Site fire fighters were supported by state fire-authority forces. Non-essential staff were evacuated from the site, and neighboring units were shut down as a precaution. Further fire eruptions and explosions were reported the next morning, and the company began steps to shut down the whole refinery. The fire was reported as finally extinguished late in the evening of the second day, about 34 hours after it was first reported. The production units on the refinery were progressively restarted, and all units were back in production by the end of 2011.

[ Property Damage $150 Million. Estimated Current Value $166 Million ]

Image credit: The Business Times

A chemical reactor blast occurred at a pharmaceutical unit The company produced bulk drugs and intermediates in the pharma unit. This incident was the 6th incident in Pharma hub in past 2 years.

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

An explosion and fire caused extensive damage at a low-density polyethylene plant. The cause was a leak of ethylene at high pressure, due to fatigue failure of a vent connection on the suction of a compressor. Six people were killed, and 13 injured.

On October 2, 2007, a chemical fire inside a permit-required confined space1 at Xcel Energy’s hydroelectric plant in a remote mountain location 45 miles (72 kilometers) west of Denver, Colorado, killed five and injured three workers. Industrial painting contractors were in the initial stages of recoating the 1,530-foot (466-meter) steel portion of a 4,300-foot (1,311-meter) enclosed penstock2 tunnel with an epoxy coating product when a flash fire occurred. Flammable solvent being used to clean the epoxy application equipment in the open penstock atmosphere ignited, likely from a static spark. The initial fire quickly grew as it ignited additional buckets of solvent and substantial amounts of combustible epoxy material, trapping and preventing five of the 11 workers from exiting the single point of egress within the penstock. Fourteen community emergency response teams responded to the incident. The five trapped workers communicated using handheld radios with co-workers and emergency responders for approximately 45 minutes before succumbing to smoke inhalation.

KEY ISSUES:
• SAFE LIMITS FOR WORKING IN CONFINED SPACE FLAMMABLE ATMOSPHERES
• PRE-JOB SAFETY PLANNING OF HAZARDOUS MAINTENANCE WORK
• CONTRACTOR SELECTION & OVERSIGHT
• EMERGENCY RESPONSE AND RESCUE

ROOT CAUSES:
1. Xcel and RPI management did not ensure effective planning and coordination of the Cabin Creek penstock recoating project to control or eliminate the serious confined space hazards that were present.
2. Xcel’s and RPI’s corporate safety policies and permits did not effectively establish safe limits for flammable atmospheres in permit-required confined spaces that would prohibit entry or occupancy when those limits were exceeded.
3. Early in the planning process, Xcel identified the Cabin Creek penstock’s single point of egress in the event of an emergency as a major concern; RPI personnel also raised safety issues about a single exit. However, neither Xcel nor RPI management took remedial action.
4. Xcel management did not provide effective oversight of RPI to ensure the penstock recoating work was safely conducted.

Image credit: CSB

At around 10:30 am on 3rd October 1996, a tanker containing what was believed to be epichlorohydrin began off-loading at the Albright & Wilson site in Avonmouth, Bristol. Soon after, a series of explosions destroyed both the storage tank and the road tanker and started a fire, which persisted for an hour. It was later discovered that the road tanker in fact contained sodium chlorite, which reacts explosively with epichlorohydrin. The fire generated a 100m black plume of smoke containing hydrogen chloride, which drifted across the Severn estuary closing local motorways and rail services.

Three weeks before the delivery was due, the company received a quality certificate confirming the number of the tank container in which the epichlorohydrin would be delivered. However due to a mix-up by the haulier, a different numbered tank containing sodium chlorite was sent by mistake. No crosschecks were made against the original documentation, which would have highlighted that the wrong chemical had been delivered. By the time the haulier notified the company of the mistake, off-loading of the road tanker haD commenced.

KEY ISSUES:
• RAW MATERIALS CONTROL / SAMPLING

Image Credit: South West News Services (SWNS).

At 9:38 pm on October 5, 2006, a citizen driving past the EQ facility called 911 to report a haze with a ‘strong chlorine smell’ The Apex 911 center dispatched emergency personnel to investigate.

Responding Apex Fire Department personnel discovered a chemical cloud coming from one of several businesses on Investment Boulevard. The Apex Fire Chief, acting as the Incident Commander (IC), sent two firefighter reconnaissance teams in personal protective equipment to investigate the source of the cloud.

Firefighters located a small ‘sofa-size’ fire in one of the hazardous waste bays at the EQ facility. Within minutes, the fire spread to the flammable liquid storage area, causing 55-gallon drums of flammable hazardous waste to explode and sending fireballs hundreds of feet into the air. The hazardous waste building ultimately collapsed (cover photograph).

During the incident, about 30 people (including 13 first responders) sought medical attention at local hospitals for respiratory distress and nausea. Some were treated; none was admitted. .

KEY ISSUES:
• FACILITY FIRE DETECTION
• FACILITY FIRE PROTECTION
• EMERGENCY PLANNING

ROOT CAUSES:
1. The EQNC hazardous waste building was not equipped with fire or smoke detection sensors, automated fire suppression equipment, or fire barriers.
2. EQNC had not provided the fire department or county emergency agency with written information on the types, quantities, and locations of the hazardous materials in the facility prior to the incident.

Image credit: CSB

An explosion occurred in a chemical plant. 70 firefighters and 22 fire engines were used to prevent the flames from reaching a nearby warehouse containing 50 tons of flammable chemicals, including sodium chlorate.

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

At about 3:05 PM on October 6, 2005, a trailer being towed by a forklift snagged and pulled a small drain valve out of a strainer in a liquid propylene system. Escaping propylene rapidly vaporized, forming a large flammable vapor cloud.

Operators immediately began to shut the plant down and attempt to isolate the leak. They tried to reach and close manual valves that could stop the release; however, the advancing vapor cloud forced them to retreat. At the same time, control room operators shut off pumps, closed control valves, and vented equipment to the flare stack to direct flammable gases away from the fire.

At about 3:07 PM, the vapor ignited, creating an explosion.2 The explosion knocked down several and burned two (one seriously) operators exiting the unit. Flames from the fire reached more than 500 feet in the air.

Because of the size of the fire, Formosa initiated a site-wide evacuation. Fourteen workers sustained minor injuries including scrapes and smoke inhalation. The extensive damage shut down Olefins II unit for 5 months.

KEY ISSUES:
• HAZARD REVIEWS
• FLAME RESISTANT CLOTHING
• USE OF CURRENT STANDARDS

ROOT CAUSES:
1. Reviews did not fully address protection of specific process equipment from vehicle impact or the use of remotely actuated valves to control a catastrophic release.
2. Formosa did not require FRC for operators working within the unit, even though the large flammable liquid and gas inventory may put operators at risk of injury from flash fires.
3. The design was not updated to incorporate improved recommended practices with respect to fireproofing structural steel that supports critical safety systems

Image credit: CSB

An explosion originating in the hydrogen processing unit occurred in this 75,000 bbl/d refinery. Extensive damage was caused to the hydrocracker, hydrodesulphurization, and hydrogen processing units by the explosion and subsequent fires. The fires were fuelled by hydrocarbons released from the damaged process column and equipment. The explosion, which damaged nearby buildings and shattered windows several miles away, was recorded as a ‘sonic boom’ at the California Institute of Technology in Pasadena, approximately 20 miles from the refinery.

The explosion resulted from the rupture of a the outside radius of a six-inch-diameter carbon steel 90° elbow and the release of a hydrocarbon-hydrogen mixture to the atmosphere. The vapor cloud ignited within seconds of the rupture. There were no out-of-range or warning indications relevant to the incident until after the failure of the pipe elbow. An inspection after the failure found the line at nearly full design thickness a short distance away from the failure. On these facts, it was concluded that the line failure was the result of the thinning of the carbon steel elbow due to long-term erosion/corrosion. The fire-fighting effort was coordinated by the refinery emergency response team, with the Los Angeles City and Los Angeles County Fire Departments utilizing the Joint Incident Command System. The refinery emergency response team placed booms in the Dominguez Channel storm drain to stop oily water run-off generated by the fire fighting effort from reaching the Los Angeles Harbor. The fire was finally extinguished after three days. The refinery’s gasoline production was reduced to 35,000 bbl/d (approximately 70% of rated capacity) until repairs to the damaged process units were completed.

[ Property Damage $78 Million. Estimated Current Value $165 Million ]

Image credit: Tesoro

An explosion and flash fires occurred at the US Ink manufacturing facility in East Rutherford, New Jersey, on Tuesday, October 9, 2012. Seven workers suffered burn injuries when they congregated at the entrance to the ink mixing room after hearing a loud thump from the newly installed dust collection system on the top of the facility and seeing signs of an initial flash fire from a bag dumping station. A second flash fire then occurred that led to the employee injuries.

KEY ISSUES:
• COMBUSTIBLE DUST
• ENGINEERING DESIGN
• MANAGEMENT OF CHANGE
• PROCESS HAZARD ANALYSIS
• HAZARD COMMUNICATION
• MANAGEMENT OVERSIGHT
• REGULATORY OVERSIGHT

ROOT CAUSES:
1. Inadequate automatic fire alarm systems
2. New installations & modifications did not consider PHA, MOC, documentation, contractors & training
3. Organisational change management & knowledge transfer deficiencies

Image credit: CSB

At approximately 0400 hrs on the 9th October 1995 the fire alarm sounded in ICI’s Wilton Site Emergency Services Control Centre, alerting of a fire in the BASF warehouse which was used for storing polypropylene finished products. Almost an hour later a major emergency on the site was declared and the full on-site emergency plan initiated. The fire generated a large black plume of smoke, although this was declared non-toxic. Police alerted the public situated down wind of the fire to stay indoors and to close windows. The ‘Redcar’ trunk road was closed and employees of adjacent companies, including those on-site, were advised not to report to work.

The warehouse facility met the building regulations and was equipped with a range of fire safety features. This included fire doors, operated both by fusible links and smoke detection, which failed to close during the fire. No cause was established for this. However, it may have been attributed to the fact that the warehouse did not become completely smoke logged, as smoke was vented through the roof. Hence, the smoke failed to activate the detectors, which would have closed the doors.

No direct root causes for the fire was determined. However, the results of the investigation by BASF and the Cleveland County Fire Brigade suggests the probable cause was a fluorescent light fitting overheating, causing the ignition of its Perspex refectory which dropped flaming molten plastic onto stored product below. The warehouse lighting was in continuous use.

No injuries or ill health were reported.

The perceived risk was low and therefore no formal risk assessment for dealing with a major fire for the warehouse was undertaken. Following the incident it took several days to re-establish the inventory and its layout, as all local records were destroyed in the fire.

Because the warehouse was sited in the middle of the ICI complex there was potential for escalation into a much more serious event. The incident clearly highlighted the value of having a well-defined emergency plan and procedures in place as well as trained personal to execute it.

KEY ISSUES:
• EMERGENCY RESPONSE / SPILL CONTROL
• PLANT LAYOUT
• ACTIVE / PASSIVE FIRE PROTECTION

Image Credit: Cleveland Fire Brigade

Just after 3:00 pm on Saturday, October 11, 2008, a tank located in a storage building at the INDSPEC Chemical Corporation (INDSPEC) resorcinol facility in Petrolia, Pennsylvania, overflowed during an oleum transfer. Oleum, a mixture of sulfuric acid and sulfur trioxide, filled the exhaust ventilation system (vent system) connected to the tank and eventually released into the storage building. The release of oleum created a cloud of sulfuric acid mist that filled the building and flowed out of the facility into the community.

As the oleum storage tank overflowed, the storage building filled with a dense mist, and liquid oleum spilled from the vent system. Faced with an uncontrolled release, the INDSPEC incident commander declared a plant-wide emergency, notified local fire departments, and requested mutual aid services. Facility personnel evacuated.

While INDSPEC emergency responders managed the onsite incident, at 5:14 pm community emergency responders ordered the evacuation or shelter-in-place of about 2,500 nearby residents from the towns of Petrolia, Bruin, and Fairview. The evacuation order continued until about 2:00 am.

KEY ISSUES:
• TEMPORARY CHANGE EVALUATION
• SAFEGUARD EVALUATION
• PROCESS HAZARD ANALYSIS

ROOT CAUSES:
1. The facility did not evaluate the significance of a change to the emergency power supply.
2. The facility gave operators only verbal instruction on the use of the emergency power supply.
3. The oleum transfer work practice was never recorded in written operating procedures.
4. PHA teams were unable to evaluate the consequences of emergency power supply use.

Image credit: CSB

The fire on the vacuum distillation unit (VDU) weakened the main vacuum distillation column supports, allowing it to collapse onto the heat exchange train. The VDU was shutdown completely and the refinery was left running but at a much reduced capacity. An investigation identified that the fire was caused by a leak from a branch on the column that was fabricated from an incorrect material.

[ Property Damage $143 Million. Estimated Current Value $191 Million ]

Image credit: ORLEN

An explosion and fire in a 562 megawatt (MW)-capacity integrated gasification combined cycle electricity generating plant at a refinery caused a fire in the gasification unit on a refinery. No one was injured as a result of the explosion and fire, but the loss resulted in the temporary closure of the refinery.

[ Property Damage $150 Million. Estimated Current Value $179 Million ]

Image credit: ISAB

The rupture of a 145-foot-tall distillation column (C-501) used to refine mononitrotoluene (MNT) caused the October 13, 2002, explosion and fire at the First Chemical Corporation (FCC) facility in Pascagoula, Mississippi. The column was thought to be isolated and in standby mode at the time of the explosion (approximately 5:25 am) though it contained a significant amount of MNT.

Debris from the explosion, including metal fragments and packing from the column, was scattered throughout the facility and propelled offsite. One large fragment of the distillation column punctured a nearby para-MNT storage tank and ignited its contents, which burned for almost 3 hours. A 6-ton column segment was hurled 1,100 feet and landed near a crude oil storage tank at a refinery across the highway. Flying glass injured three FCC employees, who were in the unit control room at the time of the explosion. All three employees received first-aid, and one required additional medical treatment.

The FCC fire brigade fought the onsite fires, including the large para-MNT storage tank fire and numerous fires initiated by burning material on ejected column packing. Local community emergency responders provided backup and firefighting support for numerous small fires outside the facility. The sheriff’s department provided traffic control. FCC personnel, the U.S. Environmental Protection Agency (EPA), and the U.S. Coast Guard monitored the air around the facility.

KEY ISSUES:
• EVALUATION OF REACTIVE HAZARDS
• APPLYING LESSONS LEARNED
• LAYERS OF PROTECTION
• WORK PRACTICES
• FACILITY SITING
• COMMUNITY NOTIFICATION

ROOT CAUSES:
1. The FCC Pascagoula facility did not have an adequate system for evaluating the hazards of processing mononitrotoluene (MNT) in its continuous process and did not apply lessons learned from hazard analyses conducted on similar processes in the plant.
2. FCC did not have a system to ensure that the #1 MNT column (C-501) was equipped with sufficient layers of protection to prevent a catastrophic release.
3. The Pascagoula facility had no effective system for ensuring consistent work practices when isolating equipment.
4. FCC did not have an adequate program to prevent leakage from isolation valves in the steam line connected to the #1 MNT column (C-501).

Image Credit: CSB

An explosion and subsequent fire resulted in significant property damage at this 146,500 bbl per day refinery. The explosion occurred following a heat exchanger failure in the hydrodesulphurization unit for light oil. The channel cover and lock ring of this heat exchanger were hurled into an adjacent factory, which was located approximately 650 feet from this plant. The channel cover and lock ring were each five feet in diameter, and weighed 4,000 lb and 2,000 lb, respectively. The hydrodesulphurization unit was being restarted following catalyst exchanging work when plant personnel noticed that hydrocarbon was being released from the heat exchanger. Plant personnel were working to complete the additional tightening work required on the heat exchanger bolts due to thermal expansion when the explosion occurred. The subsequent fire was brought under control in two hours and 45 minutes by firefighters using 15 fire trucks.

[ Property Damage $161 Million. Estimated Current Value $339 Million ]

Image credit: FOC

On October 17, 2017 a rapid release of ammonia occurred within the mechanical room at the Fernie Memorial Arena and resulted in estimated concentrations of ammonia exceeding 20,000 ppm. Three people were in the room at the time of the release and were found deceased. The incident resulted in a local state of emergency for the community and an evacuation of the area around the arena.

Following the incident, Technical Safety BC conducted an investigation to determine factors that contributed to the ammonia release. The objective of the investigation was to identify causes and contributing factors to inform an understanding and management of safety risks associated with refrigeration systems.

The investigation identified three areas where evidence indicates causal and contributing factors leading to the incident and the subsequent impact to the arena and surrounding community:

• Failure of refrigeration system equipment
• Operational decisions that contributed to the incident
• Impact of inadequate ventilation and discharge systems following the incident

Image Credit: TSBC

​On October 17, 2016, shortly after 9:00 p.m. local time, an 8-inch-diameter underground transmission pipeline ruptured and released 2,587 barrels (108,654 gallons) of liquid anhydrous ammonia on private property adjacent to milepost (MP) 263.32 on County Road P in Burt County, near Tekamah, Nebraska. The pipeline was owned and operated by Magellan Midstream Partners, LP, (Magellan). Upon release and exposure to the atmosphere, the ammonia vaporized and produced a toxic plume. A local resident who had left his home to investigate the accident scene died of respiratory failure due to exposure to the ammonia vapor; additionally, two people sustained minor injuries. A total of 29 households, involving 49 people, were evacuated. U.S. Highway 75, a main roadway in the area, was closed for several days.

The ammonia pipeline was operated and monitored from a control center located in Tulsa, Oklahoma. Low pressure alerts were received in the control center at 9:03 p.m., and a rupture alarm first occurred at 9:14 p.m.At 9:21 p.m., control center personnel received a third-party report of strong ammonia odor and a vapor cloud located 8.5 miles north of Tekamah, Nebraska.

Image Credit: NTSB

On Monday, October 17, 2016, there was an explosion and subsequent fires at the North Harbor in Ludwigshafen. “We mourn two colleagues from the fire department and the seaman who died in the fire. Our deepest sympathy is with their families and friends. Many people were injured, some of them severely. Our thoughts are with them and their families and friends. We hope that they are on the way to recovery,” said Dr. Kurt Bock, Chairman of the Board of Executive Directors of BASF at a press conference in Ludwigshafen, Germany.

The following information is currently known about the accident:

Victims: Two employees of the BASF fire department and an employee of a tanker which was anchored in the harbor died in the accident. Eight people were seriously injured, 22 others were slightly injured. One of the seriously injured has been released from the hospital.

Course of events: The course of events is still being investigated by the public prosecutor’s office of Frankenthal. The incident site is still locked. A few days prior to the accident, a specialized pipeline construction company began to conduct assembly works on a deflated and secured ethylene pipeline route. The aim of the assembly works was to exchange several parts of the pipeline as a preventive maintenance measure. On October 17, a fire started at 11:30 a.m. near the assembly works. Forces of the BASF fire department, emergency service and environment protection arrived a few minutes later at the incident area and immediately started emergency operations. During the initiation of emergency operations an explosion, most likely at the ethylene pipeline, occurred. The explosion led to subsequent fires at various points along the pipeline trench, damaging further product and supply pipelines. Additional emergency forces immediately began rescue measures as well as extinguishing and cooling measures. “The emergency forces operated in an extreme situation. Their effort cannot be expressed in words,” said Margret Suckale, Member of the Board and Site Director of Ludwigshafen.

The fire brigade performed controlled burning of the leaking products in accordance with the fire-fighting concept for compressed gases. The pipelines that burned included those used for ethylene, propylene, a butylene product mix (raffinate), pyrolysis gasoline and ethylhexanol. As of October 17, 9.30 p.m., the emergency forces extinguished the fire.

Environmental impact: Following the start of the fire, comprehensive air measurements were conducted at the site gate and in areas surrounding the site in Ludwigshafen and Mannheim. The measurements showed no elevated levels of hazardous substances, as confirmed by the environmental ministry of Rheinland-Pfalz and the city of Ludwigshafen. Additional measurements conducted by the cities of Speyer, Worms and Frankenthal showed no elevated levels. Elevated levels measured locally were restricted to the immediate area of the incident. BASF has published the results of the air measurements as well as an overview map online. Water samples also showed no elevated levels of hazardous substances. A contamination of the ground at the incident site is likely.

Status of the investigation: On October 26, the District Attorney of Frankenthal/Palatinate and the Police Headquarters of Rheinpfalz announced the following information on the progress of the investigation:

“In the course of intensive investigations directly at the scene of the incident, it has been established that there was a cut made in a pipeline. This was apparently done with a cutting disc. Maintenance work using an angle grinder was in progress on an adjacent pipeline. The cut pipeline was not part of this work. This pipeline contained flammable raffinate.” (Excerpt of the press release from District Attorney of Frankenthal/Palatinate and the Police Headquarters of Rheinpfalz, translated by BASF).

According to the current, preliminary evaluation, this could be the chain of causes: The cut pipeline contained a butylene mixture. BASF assumes that this butylene mixture leaked out and ignited due to the sparks produced by the angle grinder. This could have led to the fire, which caused the described explosion. BASF will continue to support the relevant authorities during the investigation into the cause of the accident.

Source: BASF (https://www.basf.com/global/en/media/news-releases/2016/10/p-16-359.html) | Image Credit: Reuters

A boiler explosion occurred in Kaka Chemical factory which manufactures chemicals required for making soaps

Proximate causes:
• Inadequate personal protective equipment
• Inadequate isolation of process or equipment

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

On October 21, 2016, a chemical release occurred at the MGPI Processing plant in Atchison, Kansas. MGPI Processing produces distilled spirits and specialty wheat proteins and starches. The release occurred when a chemical delivery truck, owned and operated by Harcros Chemicals, was inadvertently connected to a tank containing incompatible material. The plume generated by the chemical reaction led to a shelter-in-place order for thousands of residents. At least 120 employees and members of the public sought medical attention.

KEY ISSUES:
• DESIGN OF CHEMICAL TRANSFER EQUIPMENT
• AUTOMATED & REMOTE EMERGENCY SHUT-OFFS
• PIPE MARKINGS
• CHEMICAL UNLOADING PROCEDURES
• HUMAN FACTORS
• EMERGENCY PLANNING

ROOT CAUSES:
1. Design of connections & markings.
2. Inadequate procedures & training

Image credit: CSB

The Texas floods along the San Jacinto River shutdown the site, involving 650,000 tons-per-year ethylene, 200,000 tons-per-year linear low-density polyethene (LLDPE), 280,000 tons-per-year low-density polyethene (LDPE) plants, and general utilities. The loss of utilities affected further downstream clients. Flood water breached dikes around the main substation and inundated control rooms and offices.

[ Property Damage $130 Million. Estimated Current Value $259 Million ]

Image credit: Houston Chronicle

There was an explosion in the firecracker production unit. 24 workers were on the premises out of which 17 were killed. The unit had applied for its license renewal around the time this incident occurred. Chief Minister of the state announced ~3000 USD to each victim’s family as compensation for loss

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

An explosion occurred while polypropylene polymerization was being carried out in three parallel reaction trains (A,B,C) at this petrochemicals plant. The reactants were carried in a hexane solvent with several catalysts and processed onto pellets. As a result of a maintenance error, a 100 millimetre plug valve was blown out of a line in train A, releasing hydrocarbons and polymers. The vapor cloud rose upward, carried by a light wind into the finishing building, where the explosion occurred. Further fires resulted from broken flammable liquid lines in the process area and from the released products in the finishing area. The loss included the three trains, the control building, the compressor building, and part of the finishing building.

[ Property Damage $45 Million. Estimated Current Value $147 Million ]

Image credit: Leo S. Matkins

A chemical spill shut down portions of Interstate 75 in northern Madison County. A tanker truck was leaking ferric chloride solution from one of its valves

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

Gas leaked out of a pipeline, which had been damaged by excavation work. Local news reported that the pipe exploded when it was hit by a digger. It caught fire followed by an explosion. An entire neighborhood was devastated

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

At approximately 1:00 p.m. on the 23rd October 1989 Phillips’ 66 chemical complex at Pasadena, near Houston (USA) experienced a chemical release on the polyethylene plant. A flammable vapour cloud formed which subsequently ignited resulting in a massive vapour cloud explosion. Following this initial explosion there was a series of further explosions and fires.

The consequences of the explosions resulted in 23 fatalities and between 130 – 300 people were injured. Extensive damage to the plant facilities occurred.

The day before the incident scheduled maintenance work had begun to clear three of the six settling legs on a reactor. A specialist maintenance contractor was employed to carry out the work. A procedure was in place to isolate the leg to be worked on. During the clearing of No.2 settling leg part of the plug remained lodged in the pipework. A member of the team went to the control room to seek assistance. Shortly afterwards the release occurred. Approximately 2 minutes later the vapour cloud ignited.

KEY ISSUES:
• MAINTENANCE PROCEDURES
• LEAK / GAS DETECTION
• PLANT LAYOUT
• PERMIT TO WORK SYSTEMS
• ACTIVE / PASSIVE FIRE PROTECTION
• WARNING SISGNS
• EMERGENCY RESPONSE / SPILL CONTROL

Image Credit: Houston Chronicle

On the night of October 23, 2009, a large explosion occurred at the Caribbean Petroleum Corporation (CAPECO) facility in Bayamon, Puerto Rico, during offloading of gasoline from a tanker ship, the Cape Bruny, to the CAPECO tank farm onshore. A 5-million gallon aboveground storage tank (AST) overflowed into a secondary containment dike. The gasoline spray aerosolized, forming a large vapor cloud, which ignited after reaching an ignition source in the wastewater treatment (WWT) area of the facility. The blast and fire from multiple secondary explosions resulted in significant damage to 17 of the 48 petroleum storage tanks and other equipment onsite and in neighborhoods and businesses offsite. The fires burned for almost 60 hours. Petroleum products leaked into the soil, nearby wetlands and navigable waterways in the surrounding area.

KEY ISSUES:
• TANK OVERFILL PREVENTION
• COMMUNITY IMPACT
• HAZARD ASSESSMENT
• SAFETY MANAGEMENT SYSTEM
• REGULATION GAPS: NO RISK ASSESSMENT CONSIDERING PROXIMITY TO COMMUNITIES
• REGULATION GAPS: NO ADHERENCE TO RAGAGEP
• REGULATION GAPS: NO REDUNDANT OR INDEPENDENT SAFEGUARDS TO PREVENT OVERFILLING A TANK

ROOT CAUSES:
1. Deficient Management System.
2. Production Pressure.
3. Lack of reliable instruments:Level control failure due to inaccurate available volume calculation.
4. No high-level alarm to notify ship to stop transfer or divert flow.
5. No AOPS with ability to shut down or divert flow into tank.

Image credit: CSB

A fire broke out at the SRC at around 1.30 pm on 25 October 1988. It was the refinery’s second major fire; the first occurred on 16 August 1984. Even though the 1988 fire did not claim any lives, it injured 25 people, mostly firefighters, including five who were seriously hurt.

The fire lasted about five days before it was completely extinguished at about 7 am on 30 October. Damages, loss of profit, loss of raw materials (especially naphtha) and construction costs of new tanks were initially estimated by insurers to be between S$15 and S$20 million. In November 1988, then Director of the Singapore Fire Service Arthur Lim estimated damages to be around S$30 million. The fire and temporary closure of SRC caused the price of naphtha to rise by US$15 per tonne in the Far East.

Ref: https://eresources.nlb.gov.sg/infopedia/articles/SIP_1007_2010-05-07.html
Image Credit: SCDF

A release of hydrogen sulfide led to the death of one worker as well as a member of the public..

The CSB’s investigation is still ongoing – currently the board plans to release its final report in 2020.

Image credit: CSB

An aluminum dust explosion and fire on October 29, 2003 at the Hayes Lemmerz International Huntington, Inc. (Hayes) facility, Huntington, Indiana killed one employee and burned two other employees, one critically. Three other Hayes employees and one contractor received minor injuries.

The facility manufactures cast aluminum alloy wheels. The U.S. Chemical Safety and Hazard Investigation Board (CSB) determined that the dust that exploded originated in a scrap re-melting system. The explosion completely destroyed the dust collection equipment outside the building and damaged equipment inside the building. The explosion also lifted a portion of the building roof above one furnace and ignited a fire that burned for several hours.

KEY ISSUES:
• ALUMINUM DUST HAZARD AWARENESS
• DUST COLLECTOR EXPLOSION PROTECTION
• INCIDENT INVESTIGATION
• MANAGEMENT OF CHANGE

ROOT CAUSES:
1. Did not perform a review to address why the chip system was releasing excess dust. The hazards of aluminum dust were neither identified nor addressed.
2. Did not ensure the proper design of the dust collector system.
3. Did not ensure that the dust collector design and installation followed the guidance in National Fire Protection Association (NFPA) 651.
4. Had no formal, documented program to investigate and implement corrective action for incidents involving fires in the foundry area, especially those fueled by aluminum dust.

Image Credit: CSB

On October 29, 2007, at about 1 p.m., a fire and series of explosions occurred at the Barton Solvents Des Moines, Iowa, chemical distribution facility. The initial fire started in the packaging area while a 300-gallon portable steel tank, known as a tote, was being filled with ethyl acetate, a flammable solvent.

An operator placed the fill nozzle in the fill opening on top of the tote and suspended a steel weight on the nozzle to keep it in place.1 After opening the valve to begin the filling process, the operator walked across the room to do other work. As the tote was filling, he heard a ‘popping’ sound and turned to see the tote engulfed in flames and the fill nozzle laying on the floor discharging ethyl acetate. Before evacuating, employees tried unsuccessfully to extinguish the fire with a handheld fire extinguisher. The fire spread rapidly to the wood-framed warehouse, igniting a large volume of flammable and combustible liquids.

One employee received minor injuries and one firefighter was treated for a heat-related illness. A large plume of smoke and rocketing barrels and debris triggered an evacuation of the businesses surrounding the facility. The main warehouse structure was destroyed and Barton’s business was significantly interrupted. .

KEY ISSUES:
• ENSURE THAT EQUIPMENT, SUCH AS FILL NOZZLES AND HOSES, IS BONDED & GROUNDED AND DESIGNED FOR FLAMMABLE SERVICE
• USE DIP PIPES WHEN TOP-FILLING PORTABLE TANKS
• INSTALL FIRE SUPPRESSION SYSTEMS IN FLAMMABLE PACKAGING AREAS
• SEPARATE FLAMMABLE PACKAGING AREAS FROM BULK STORAGE AREAS

ROOT CAUSES:
1. The fill nozzle and hose used at Barton were not designed to be bonded and grounded, and were not intended for flammable service.
2. A fire suppression system in the packaging area likely would have stopped the rapid spread of the fire to the warehouse.
3. Proper separation from the warehouse by fire-rated walls and doors would have helped prevent the fire from spreading to the warehouse.

Image credit: CSB

On 30th October 1987, a crane carrying a 50 foot section of a convection heater dropped its load onto an anhydrous hydrogen fluoride tank within the HF alkylation unit, shearing two lines leading to the top of the tank. This resulted in an air release of hydrofluoric acid at the Marathon Petroleum Company refinery in Texas City.

One line was a 4-inch acid truck loading line, and the other was a 2-inch tank pressure relief line. The tank was at the normal operating pressure of approximately 125 psi, so that when the incident occurred a cloud of HF was produced which moved with the prevailing wind. The tank originally contained 35,700 gallons of AHF, of which about 6,548 gallons was released over a 44 hour period, although the majority of the release took place during the first two hours as the tank depressurised. The release also included some light hydrocarbons (primarily isobutane) and water vapour.

The first mitigation action was to place stationary fire monitor nozzles and to erect a water spray curtain about 10 feet downwind of the release to control the HF acid vapour plume.

Approximately 4,000 people were evacuated from the residential areas threatened by the plume and the three area hospitals treated 1,037 patients, of which nearly 100 were hospitalised. There was extensive damage to trees and vegetation in the residential area.

KEY ISSUES:
• LIFTING PROCEDURES

Image Credit: Bloomberg

At about 1.25 am on the fourth of November 1975 the foreman at the Queen Victoria Blast Furnace, Appleby-Frodingham Works started a cast that was intended to fill two torpedo ladles. Conditions at the time were normal; the shift manager was in attendance.

Shortly before 2.00 am some 175 tonnes of metal had been run into the first torpedo and the iron stream diverted to the second ladle. Some 10 to 15 minutes later the blow pipe at the No. 3 tuyere position started to burn down on the side facing on to No. 2 tuyere hearth cooler. The burning developed rapidly with intense flame and sparks despite efforts by the furnace keeper to cool the pipe by spraying it with water.

Whilst the pipe was burning down, a substantial water leak from the furnace or fittings was observed. The source of the leak could not be identified because the face of the furnace was obscured by flame. For the same reason men could not approach the leak to take remedial action. The leak of water was under pressure and fell outwards from the furnace towards the edge of the hob; from the hob the water ran down the slope of the cast house floor joining eventually with the iron runnel Water entered the full torpedo ladle.

Within a few minutes of the blow pipe starting to burn down progressive action was being taken by the furnace crew to bring the furnace off blast so that a new pipe could be fitted.

Shortly before 2.47 am instructions from the shift manager were passed via Traffic Control to a loco driver and shunter to remove the full torpedo ladle from the vicinity of the furnace. Traffic personnel were made aware that water was running into the torpedo. As the loco was coupled to the ladle, water was seen to be coming from the iron runner. An explosion occurred as the ladle was moved. An eye witness identified the throat of the ladle as the seat of the explosion. The incident was timed at 2.47 am.

As a result of the explosion there were four immediate fatalities and 15 hospital admissions. Subsequently a further seven employees died as a result of injuries received.

At the time of the explosion 23 persons were working in the Queen Victoria furnace area. This number included four extra helpers standing by to assist in changing No. 3 blast pipe. Casting to the second torpedo was sti11 proceeding at the time of the explosion.

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

Image Credit: HSE

Sustained casing head pressure leaked from the production casing into the outer casing strings, resulting in the failure of one of the casing strings. This caused an underground blowout that resulted in extensive damage to the platform and a gas plume around the platform. The well was killed to stabilize conditions on the seabed.

[ Property Damage $200 Million. Estimated Current Value $479 Million ]

Image credit: Shell

The Valero Delaware City refinery asphyxiation death of two contractor employees who were preparing to reassemble a pipe on a pressure vessel while it was being purged with nitrogen. The first worker, in an attempt to retrieve a roll of tape from inside the vessel, was overcome by nitrogen, collapsed in the vessel, and died. His co-worker, the crew foreman, was asphyxiated while attempting to rescue him.

KEY ISSUES:
• OXYGEN-DEFICIENT ATMOSPHERE HAZARDS OUTSIDE CONFINED SPACE OPENINGS
• NITROGEN HAZARD AWARENESS
• UNPLANNED CONFINED SPACE RESCUE

ROOT CAUSES:
1. Workers suddenly involved in emergency activities allow emotions to override safe work procedures and training.

Image credit: CSB

Offshore gas alarms were triggered on this floating production unit. Upon investigation, it was established that a leak was emanating from one of the production risers. Upon further investigation, five other risers were found to be similarly affected. Remedial work was subsequently carried out.

[ Property Damage $185 Million. Estimated Current Value $248 Million ]

Image credit: No credit

An explosion in a chemical facility. A gas cloud was seen above the area immediately after the explosion. Damaged about 20 buildings and left a crater in the facility’s backyard

Proximate causes:
• Inadequate tools, equipment & vehicles
• Inadequate engineering/design

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

Early on 7 November 1975, start-up of the Naphtha cracker commenced on the ethylene plant at the Dutch State Mines (DSM) works at Beek. At 06:00 hours compressed gas was sent to the low temperature system. At 09:48 hours an escape of vapour occurred from the depropaniser which ignited, resulting in a massive vapour cloud explosion. The explosion caused significant damage and started numerous fires around the plant. 14 people were killed and a total of 107 people injured, three of whom were outside of the site.

The investigation was hampered by the destruction of instrument records in the incident but evidence suggested that the release was due to low temperature embrittlement at the depropaniser feed drum. It was thought that the initial fracture had occurred on a 40 mm pipe connecting the feed drum to its relief valve. The normal operating temperature of the drum was 65°C, however, due to a process upset in the de-ethaniser column, the stream feeding into the depropaniser drum was a liquid at about 0°C(or lower) with a high C2 content. This would flash within the drum resulting in a temperature which could be as low as -10°C. The feed drum material could normally be used at temperatures as low as -20°C, however the fracture occurred at a weld, which with ageing may fail at up to 0°C.

The raising of the alarm was also flawed. The first operator to enter the control room to report the gas release was distressed and shocked. A second operator left the room to investigate, leaving orders for the fire alarm to be sounded. This did not occur. Some witnesses stated that the alarm system failed, but the investigation found that the system was in good working order before the explosion, and that none of the button switches had been operated.

KEY ISSUES:
• DESIGN CODES – PLANT
• EMERGENCY RESPONSE / SPILL CONTROL

Image Credit: Nationaal Archief

At the premises of Corus UK Ltd, Port Talbot, No. 5 Blast Furnace exploded at approximately 17.13 pm on 8 November 2001. The entire furnace, which with its contents weighed approximately 5000 tonnes, lifted bodily at the lap joint, rising some 0.75 m from its supporting structures, leading to the explosive release of hot materials (an estimated 200 tonnes in total, comprising largely solids and semisolids, with a little molten metal) and gases into the cast house.

Three employees died: Andrew Hutin, Stephen Galsworthy and Len Radford. A further 12 employees and contractors sustained severe injuries. Many more suffered minor injuries and shock.

Report: https://www.icheme.org/media/10689/the-explosion-of-no-5-blast-furnace-corus-uk-ltd-port-talbot.pdf

Image Credit: HSE

A vapor cloud explosion occurred in the gas plant associated with the 29,700 bbl/d FCC unit on a 136,000 bbl/d refinery. The initial vapor cloud explosion and several subsequent lesser explosions could be heard in Marseille, approximately 18 miles from the refinery. An estimated 11,000 pounds of light hydrocarbons were involved in the initial explosion. A gas detection system in the FCC unit sounded an alarm indicating a major gas leak. While the unit operator was contacting the security service to warn of this situation, the initial explosion occurred. The initial gas release is believed to have resulted from a pipe rupture in the gas plant, which was used to recover butane and propane produced in the FCC unit. The explosions and subsequent fires devastated about two hectares of this refinery, which covers an area of about 250 hectares. The gas plant, FCC unit, and associated control building were completely destroyed by this incident. Two new process units, which were under construction and scheduled to come into operation in 1993, were seriously damaged. Outside of the refinery, roofs were damaged in the nearby town of Chateauneuf les Martigues and windows were broken within a radius of 3,000 feet. Some windows were broken up to six miles away.

The refinery fire brigade and more than 250 fire fighters from three neighboring industrial sites and four nearby towns were used for more than six hours to bring this incident under control. Approximately 37,000 US gallons of foam concentrate were used during the fire fighting effort. Some fires were intentionally left burning after the incident was under control to allow safe depressurizing of the process units since the flare system was partially damaged by the explosions.

[ Property Damage $225 Million. Estimated Current Value $474 Million ]

Image credit: Total

November 9, 2010 explosion at an E.I. duPont de Nemours and Co. Inc., Yerkes chemical plant in Buffalo, New York when a contract welder and foreman were repairing the agitator support atop an atmospheric storage tank containing flammable vinyl fluoride. The welder died instantly from blunt force trauma, and the foreman received first-degree burns and minor injuries. The explosion blew most of the top off the tank. The top and agitator assembly hung over the side of the tank supported only by a 2-foot section of the top (cover photo). The explosion caused minor overpressure damage in the tank farm area and the adjacent production building.

KEY ISSUES:
• FLAMMABLE GAS MONITORING
• TANK ISOLATION
• HOT WORK PERMITS, PROCEDURES & SIGN-OFFS

ROOT CAUSES:
1. All potential explosion hazards associated with hot work activities not identified and mitigated
2. All relevant forms required for permits not completed in accordance with corporate policies and industry standards (including NFPA 326 and NFPA 51B)
3. Appropriate DuPont personnel did not officially approve hot work permits, by signature or equivalent, consistent with DuPont policies

Image credit: CSB

On November 12, 2008, a 2-million-gallon liquid fertilizer tank (designated as Tank 201 by the owner) catastrophically failed at the Allied Terminals, Inc. (Allied) facility in Chesapeake, Virginia, seriously injuring two workers and partially flooding an adjacent residential neighborhood.

On the day of the incident, Allied was filling Tank 201 with liquid fertilizer to check for leaks prior to painting the tank. During the filling, a welder and his helper sealed leaking rivets on the tank.

At a fill level about 3.5 inches below the calculated maximum liquid level, the tank split apart vertically, beginning at a defective weld located midway up the tank. Within seconds, the liquid fertilizer overtopped the secondary containment, partially flooding the site and adjacent neighborhood. The collapsing tank wall injured the welder and his helper, who were working on the tank. Employees of a neighboring business responded and extricated them. At least 200,000 gallons of the liquid fertilizer were not recovered; some entered the southern branch of the Elizabeth River.

KEY ISSUES:
• LIQUID FERTILIZER STORAGE TANK STANDARDS
• TANK MODIFICATION FOR CHANGE-IN-SERVICE
• TANK INSPECTION

ROOT CAUSES:
1. Allied did not ensure that welds on the plates to replace the vertical riveted joints met generally accepted industry quality standards for tank fabrication.
2. Allied had not performed post-welding inspection (spot radiography) required for the calculated maximum liquid level for the tank.
3. Allied had no safety procedures or policies for work on or around tanks that were being filled for the first time following major modifications and directed contractors to seal leaking rivets while Tank 201 was being filled to the calculated maximum liquid level for the first time.

Image credit: CSB

An explosion occurred in an air line in a reactor used for the liquid phase oxidation of butane as it was being started up. The explosion ruptured the external portion of the air line to the reactor, allowing the reactor contents to vaporize and form a cloud. The vapor cloud drifted and ignited about 25 to 30 seconds after the initial release. There was extensive property damage in the immediate area as a result of the vapor cloud explosion and significant damage throughout the site. Windows were broken seven miles away. The immediate cause was believed to be insufficient purging of the reactor when it had previously been down.

[ Property Damage $215 Million. Estimated Current Value $516 Million ]

Image credit: The Center For Land Use Interpretation

On November 15, 2014, approximately 24,000 pounds of highly toxic methyl mercaptan was released from an insecticide production unit (Lannate® Unit) at the E. I. du Pont de Nemours and Company (DuPont) chemical manufacturing facility in La Porte, Texas. The release killed three operators and a shift supervisor inside a manufacturing building. They died from a combination of asphyxia and acute exposure (by inhalation) to methyl mercaptan.

KEY ISSUES:
• EMERGENCY PLANNING & RESPONSE (PREPAREDNESS)
• IMPLEMENTATION OF PROCESS SAFETY MANAGEMENT SYSTEMS
• ASSESSMENT OF PROCESS SAFETY CULTURE

ROOT CAUSES:
1. DuPont’s corporate process safety management system did not ensure that DuPont La Porte implemented and maintained an effective process safety management system; and
2. DuPont La Porte did not assess its culture for process safety in the site’s Safety Perception Surveys or any other formal assessment program, allowing serious process safety deficiencies to exist at the site.

Image credit: CSB

Chemical leak at a metal recycling plant. Firefighters sealed the valve and dispersed the vapor cloud. Two workers were treated at the scene as a precautionary measure

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

At about 11:30 a.m. on November 17, 2003, an uncontrolled decomposition reaction in a batch scrubber released chlorine gas into the air at the DPC Enterprises, L.P. (DPC) chlorine repackaging facility in Glendale, Arizona. Hazardous emissions continued for about six hours. Residents and workers in a 1.5 square mile zone were told to evacuate, and 11 police officers and five members of the community sought medical treatment for exposure to chlorine.

KEY ISSUES:
• MATCHING SAFEGUARDS TO RISK
• OPERATING PROCEDURES
• REACTIVE HAZARDS
• EMERGENCY RESPONSE

ROOT CAUSES:
1. Corporate standards relied solely on procedural safeguards against scrubber over-chlorination.
2. Corporate hazard assessment process did not identify or address the consequences of failure to follow the bleach manufacturing SOP, including potential off-site consequences.
3. Internal PSM/RMP audit program did not detect deficiencies in operating procedures, training, operating practice, process safety information, and hazard assessment.

Image Credit: CSB

A gas explosion that occurred inside a coal mine in northern China has claimed the lives of 15 miners and left another nine injured, according to authorities. The blast took place at a mine operated by the Feng Yan Group in Pingyao County, Shanxi province.

Following the explosion, 11 miners managed to escape without injury.

The mine, which is proportionally small, was in the news last year due to its failure in providing adequate training for workers. Xinhua quoted the Shanxi Administration of Coal Mine Safety as saying that 35 miners were working underground at that time.

Shanxi Administration of Coal Mine Safety accident investigation division director Shen Xuping said: “It is a production safety accident caused by production activity that broke the law and regulations, which reveals the problems of the involved company, such as lack of awareness of the rule of law and chaotic management.”

Authorities are currently carrying out an investigation to determine the cause of the explosion.

Image Credit: AFP / Getty

On Friday 19 November 2010 at 3:45pm there was an underground explosion at the Pike River coal mine. Twenty-nine men lost their lives, and their bodies have not been recovered.

Two men survived the explosion. They were in the stone access tunnel (drift), a distance from the pit bottom area where the main workplaces were located. Although initially overcome, Daniel Rockhouse rescued himself and his colleague Russell Smith.

The New Zealand Police led the emergency response that involved emergency services, and mines rescue crews from New Zealand, New South Wales and Queensland. Despite strenuous efforts by everyone involved, a lack of information concerning the conditions underground prevented a rescue attempt.

A second explosion on Wednesday 24 November extinguished any hope of the mens survival. The emergency focus changed to recovery of the bodies.

Image Credit: AFP

At approximately 05:35 hours on 19 November 1984 a major fire and a series of catastrophic explosions occurred at the government owned and operated PEMEX LPG Terminal at San Juan Ixhuatepec, Mexico City. As a consequence of these events some 500 individuals were killed and the terminal destroyed.

Three refineries supplied the facility with LPG on a daily basis. The plant was being filled from a refinery 400 km away, as on the previous day it had become almost empty. Two large spheres and 48 cylindrical vessels were filled to 90% and 4 smaller spheres to 50% full.

A drop in pressure was noticed in the control room and also at a pipeline pumping station. An 8-inch pipe between a sphere and a series of cylinders had ruptured. Unfortunately the operators could not identify the cause of the pressure drop. The release of LPG continued for about 5-10 minutes when the gas cloud, estimated at 200 m x 150 m x 2 m high, drifted to a flare stack. It ignited, causing violent ground shock. A number of ground fires occurred. Workers on the plant now tried to deal with the escape taking various action. At a late stage somebody pressed the emergency shut down button.

About fifteen minutes after the initial release the first BLEVE occurred. For the next hour and a half there followed a series of BLEVEs as the LPG vessels violently exploded. LPG was said to rain down and surfaces covered in the liquid were set alight. The explosions were recorded on a seismograph at the University of Mexico.

KEY ISSUES:
• PLANT LAYOUT
• ISOLATION
• ACTIVE / PASSIVE FIRE PROTECTION
• LEAK / GAS DETECTION
• EMERGENCY RESPONSE / SPILL CONTROL

Image Credit: Mexico News Daily

On November 22, 2016, an isobutane release and fire seriously injured four workers in the sulfuric acid alkylation unit at the ExxonMobil Refinery in Baton Rouge, Louisiana (‘Baton Rouge refinery’). During removal of an inoperable gearbox on a plug valve, the operator performing this activity removed critical bolts securing the pressure-retaining component of the valve known as the top-cap. When the operator then attempted to open the plug valve with a pipe wrench, the valve came apart and released isobutane into the unit, forming a flammable vapor cloud. The isobutane reached an ignition source within 30 seconds of the release, causing a fire and severely burning four workers who were unable to exit the vapor cloud before it ignited.

KEY ISSUES:
• HUMAN FACTORS
• EQUIPMENT DESIGN
• HIERARCHY OF CONTROLS
• OPERATING PROCEDURES & TRAINING

ROOT CAUSES:
1. Human factors associated with operational difficulties that exist in machinery and other equipment.
2. Deficient procedures for workers performing potentially hazardous work.
3. Inadequate training to ensure workers can perform all anticipated job tasks safely.

Image credit: CSB

On November 22, 2006, at about 2:45 am, a violent explosion at the CAI/Arnel manufacturing facility rocked the town of Danvers, MA. The explosion and subsequent fire destroyed the facility, heavily damaged dozens of nearby homes and businesses, and shattered windows as far away as two miles. At least 10 residents required hospital treatment for cuts and bruises. Twenty-four homes and six businesses were damaged beyond repair. Dozens of boats at the nearby marina were heavily damaged by blast overpressure and debris strikes.

The fire department ordered the evacuation of more than 300 residents within a half-mile radius of the facility. Numerous residents could not return for many months while they waited for their houses to be rebuilt or repaired. Seventeen months after the explosion, six homes had yet to be reoccupied as repairs were not complete..

KEY ISSUES:
• SAFE HANDLING OF FLAMMABLE LIQUIDS
• FIRE CODE COMPLIANCE & ENFORCEMENT
• STATE & LOCAL GOVERNMENT HAZARDOUS FACILITY LICENSING

ROOT CAUSES:
1. CAI management did not conduct a process hazards analysis or similar systematic review of processes involving hazardous materials.
2. CAI management did not use written procedures or checklists to facilitate safe process operations.

Image credit: CSB

Following torrential rain, rising floodwater allowed waste oil floating on the surface to be brought into contact with hot equipment on the refinery causing explosions and a fire. A second blaze broke out and several storage tanks reportedly caught fire and exploded. Damage to the refinery was extensive, two were killed, and a further three reported missing. Later reports said that two to three production units had been affected by the fire. The processing units affected were the crude unit, the 20,000 bbl-per-day vacuum distillation unit, the 24,000 bbl-per-day catalytic reformer unit, and the 24,000 bbl-per-day distillate hydrotreater. At the time, it was stated that the units not affected by the fire would restart within 15 days, although the other units would not be operational for a further eight to 12 months.

[ Property Damage $130 Million. Estimated Current Value $213 Million ]

Image credit: Samir

An explosion and fire occurred at the TPC Group chemical plant in Port Neches, Texas, on November 27, 2019.

An explosion occurred that shattered windows and ripped doors of nearby homes.
A second blast followed 13 hours later, and it took several days to extinguish the resulting fires. Three out of the 30 workers on site at the time of the initial explosion were injured.

Around 60,000 people within a four-mile radius of the chemical plant were asked to
evacuate due to concerns over air quality. Elevated levels of butadiene were registered
as well as other volatile organic compounds, exposure to which can cause irritation,
shortness of breath, headaches, and nausea.

The explosion’s cause has not been determined yet, but is said to have occurred in the south processing unit at a tank with finished butadiene.

Image credit: CSB

On November 28, 2003, two cases of Legionnaire’s Disease were recorded, the first symptoms of which dated back to the beginning of November. The dates of outbreak of the pathology, which were then staggered over time, revealed two distinct waves of contamination with a total of 86 individuals contaminated, aged between 32 and 92 (of whom 18 died).

These cases all broke out within a radius of slightly over 10 km around the city of Lens. The DDASS (local Sanitary and Social Affairs Office) conducted environmental investigations at the homes of patients and within several facilities open to the public. At the request of the DRIRE (Regional Agency for the Environment, Research and Industry), all facilities operating cooling towers within the designated zone were asked to adopt measures to identify the eventual presence of legionella and clean their circuits. On October 15, the operator of a chemical installation specialised in alcohols and fatty acids extracted samples whose results revealed a concentration of legionella at a level of 730,000 CFU units/litre. Following a shock treatment using biocides, analyses 15 days later yielded a concentration of less than 100 CFU/litre. On November 20, another inspection announced that the level of 600,000 CFU/litre had been reached.

In light of these results, the chemical plant’s cooling towers were ordered to be shut down on November 29. As of December 3, the tower circuits were drained and cleaned. Operations resumed on December 22, and a prefectural decree was issued January 2, 2004 mandating the operator to halt all plant activity once again due to the appearance of a second epidemic wave. High pressure cleaning work could have induced the dispersion of a contaminated aerosol. At the same time, the Prefect commissioned the DRIRE Agency to extend its investigations, notably by inventorying all cooling towers within the neighbouring 53 towns and imposed the shutdown of several installations (automobile washing stations, food processing activities, refrigerated warehousing, etc.), causing layoffs to hundreds of workers for several days. Even though a similarity was detected between the strains extracted from 23 of the patients and those present in the suspected cooling tower at the petrochemical plant, other sources of contamination could not be ruled out. High legionella counts in the lagoons of this same plant necessitated turning off aerators on January 20. This site’s revenue loss would amount to several millions of Euros, corresponding to a production downtime of 14 weeks. A prefectural order authorising reactivation of the towers was issued on March 19, 2004, yet the plant would never operate again.

Image credit: TF1