Incident Videos

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”

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 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

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)

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

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

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

On August 12, 2016, seven workers were injured – three critically – when a flash fire occurred during hot work activities at Sunoco Logistics Partners, a terminal facility in Nederland, Texas.

KEY ISSUES:
• HOT WORK

Image credit: CSB

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

A short interruption in the supply of cooling water to a separation column downstream of a steam cracker resulted in the need to open relief valves from the column to flare. Subsequent manual choking back of the relief line to flare resulted in the pressure relief valves opening. These valves vibrated excessively, resulting in the failure of the bolted flanges and the release of the propylene-rich column overhead line into the atmosphere. The resultant explosion led to the failure of utility lines to the cracker requiring a crash shutdown. The lack of process steam due to the interruption to the utility supply resulted in the failure of furnace tubes and the release of quench oil. There was subsequently a pool fire from the released quench oil under the cracker, resulting in damage to four of the 10 cracker furnaces.

[ Property Damage $180 Million. Estimated Current Value $187 Million ]

Image credit: Unipetrol

There was a chlorine release at Pacific Steel recycling plant. The gas came from a cylinder that workers were crushing for scrap metal. Evacuation of 17 buildings inside an industrial park

Proximate causes:
• Lack of knowledge of hazards present
• Inadequate training effort
• Lack of policies/standards/procedures for the task

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

A series of explosions occurred in an oil field chemical supply company in Conroe

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: Brett Coomer

On the morning of August 14, 2002, 48,000 pounds of chlorine was released over a 3-hour period during a railroad tank car unloading operation at DPC Enterprises, L.P., near Festus, Missouri. The facility repackages bulk dry liquid chlorine into 1-ton containers and 150-pound cylinders for commercial, industrial, and municipal use in the St. Louis metropolitan area.

Chlorine is a toxic chemical. Concentrations as low as 10 parts per million are classified as “immediately dangerous to life or health” (NIOSH, 2003). Although the wind direction on the day of the release carried the majority of the chlorine plume away from neighboring residential areas, some areas were evacuated. Sixty-three people from the surrounding community sought medical evaluation at the local hospital for respiratory distress, and three were admitted for overnight observation. The release affected hundreds of other nearby residents and employees, and the community was advised to shelter-in-place for 4 hours. Traffic was halted on Interstate 55 for 1.5 hours. Three DPC workers received minor skin exposure to chlorine during cleanup activities.

This incident began with the failure of a chlorine transfer hose (CTH) connecting a tank car to the facility repackaging process. The U.S. Chemical Safety and Hazard Investigation Board (CSB) determined that the ruptured hose was constructed of stainless-steel braid rather than Hastelloy C, a metal alloy (CSB, 2002).

KEY ISSUES:
• MECHANICAL INTEGRITY
• EMERGENCY MANAGEMENT
• CHLORINE TRANSFER HOSE SUPPLY

ROOT CAUSES:
1. The DPC quality assurance (QA) management system did not have adequate provisions to ensure that chlorine transfer hoses met required specifications prior to installation and use.
2. Branham Corporation, the CTH fabricator/distributor, did not have a QA management system to ensure that fabricated hose complied with customer specifications or that its own certification of materials specifications were correct.
3. The DPC testing and inspection program did not include procedures to ensure that the process emergency shutdown system would operate as designed.

Image Credit: CSB

The 160,000 bbl-per-day capacity refinery was shut down due to a pool fire, as a result of a pipework release on the crude distillation unit. Three days later, the crude column suffered a structural failure due to an internal fire caused by air ingress from the previously ruptured pipework reacting with pyrophoric material and oil in the column. The crude distillation unit was shut down for 12 months. The cause of the initial pool fire was due to incorrect piping material specification in one elbow, which failed.

[ Property Damage $145 Million. Estimated Current Value $247 Million ]

Image credit: Citgo

At this gas processing plant, a series of electrical power interruptions caused several shutdowns of one or both of the identical 165,000 bbl-per-day gas fractionation process trains. The parallel trains were separated from one another by approximately 100 feet. At the time of the loss, the propane feed was approximately 100% of design capacity for Plant I and 25% of design capacity for Plant II. It is believed that there was a release of approximately 1,900 bbl of propane in Plant I over a 30-minute period. A large vapor cloud is believed to have been ignited by a security vehicle, which had stalled and was being restarted. The probable source of the propane was a flange in a four-inch-diameter relief valve line.

[ Property Damage $65 Million. Estimated Current Value $156 Million ]

Image credit: Saudi Aramco

Erosion failure in a 10-inch-diameter slurry recycle oil line in an 82,000 bbl per day fluid bed coking unit released liquids close to their auto ignition temperature. A vapor cloud which covered a large area ignited almost immediately resulted in a ground fire covering a large area which resulted in the failure of six or seven additional lines. The fire eventually extended over a 150-feet-diameter area with damage up in the unit structure up to a height of more than 100 feet. Metallurgical examination revealed that a 1.8-inch-long piece of carbon steel pipe had inadvertently been inserted into the slurry recycle line made of 5-chrome during an earlier metals inspection. The reactor fractionator, light gasoil stripper, 15,000 hp air blower, pumps, and pipe racks were severely damaged or destroyed. About 2,700 barrels of hydrocarbon liquids were released from process equipment during the fire. Much of this was by gravity flow from ruptured lines, although pumps, which could not be shut down, contributed much of the flow. A 900 psig steam line, which supplied the turbine drivers of the compressors, ruptured, hampering fire fighting efforts.

[ Property Damage $75 Million. Estimated Current Value $190 Million ]

Image credit: Syncrude

A fire broke out in a crude unit of a 325,000 bbl/d refinery and burned for more than six hours. No injuries were reported. Company officials said a major portion of the refinery was able to continue to operate. The another crude unit at the refinery remained operational.

[ Property Damage $200 Million. Estimated Current Value $255 Million ]

Image credit: Chevron

An earthquake measuring 7.4 on the Richter scale caused a collapse of a 312-feet-high concrete chimney on one of the crude units, setting off fires at this 226,000 bbl-per-day refinery. Fires also broke out on several storage tanks on the site. The process teams successfully isolated and tackled the crude unit fire. Fires on the tank farm were allowed to burn themselves out after storage tanks were pumped out as much as possible. Due to broken water mains, firefighting efforts were limited to attempts by aircraft to drop chemicals on the fires. The US and several other countries sent foam supplies, personnel, and equipment to fight the fires. Damage to the refinery included total loss of six storage tanks, deformation of a further four storage tanks, and approximately 50% damage to other floating roof tanks. Damage to process units included the fire on the crude distillation unit, damage to a reformer, and damage to several connecting pipelines. All employees were evacuated. Airplanes were used to spray chemicals to extinguish the fire because of a shortage of water due to broken main.

[ Property Damage $200 Million. Estimated Current Value $362 Million ]

Image credit: Tupras

On August 19, 2004, an explosion at the Sterigenics International, Inc., ethylene oxide (EO) sterilization facility in Ontario, California, injured four workers and caused extensive damage to the 66,000 square-foot facility. Flying glass from the control room windows was responsible for all of the injuries, and both the facility structure and equipment sustained severe damage. The Sterigenics plant and neighboring facilities were evacuated, and plant operations were disrupted for 9 months.

Sterigenics is a contract medical sterilization services provider that specializes in various types of sterilization in the U.S. and around the world. Its EO facility in Ontario performs services for manufacturers of a variety of medical products such as disposable syringes, urinary tract catheters, and cardiovascular stints and valves.

KEY ISSUES:
• PROCESS HAZARD ANALYSIS
• PROCESS DESIGN
• EMPLOYEE TRAINING
• LESSONS LEARNED

ROOT CAUSES:
1. Engineering controls installed at the facility did not prevent an explosive concentration of ethylene oxide (EO) from reaching the oxidizer.
2. The maintenance supervisor did not fully understand the hazards associated with the process.

Image Credit: CSB

While a worker was welding on top of a tank that contained one million gallons of sodium hydrosulfide a massive explosion occurred.

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

Oil, condensate, and hydrogen sulphide leaked from a wellhead on platform being serviced by a jack-up rig in the Timor Sea. A total of 69 workers on the rig were evacuated. Oil and gas started spilling after a plug blocking one of the project’s 1,200-meter deep wells came free. The next day, a 12-kilometer-long, 30-meter-wide spill was reported. Attempts were made to plug the well over the next two months. It was estimated that the well was leaking 400 bbl-per-day of oil and gas. On November 1, 2009, it was reported that drillers had successfully intercepted the well and were beginning to put heavy mud into the shaft. However, a fire broke out on the drilling platform as deeper leak was being plugged. The fire was extinguished two days later. A total of about 4,140 tons of oil was estimated to have been lost. The incident affected both the platform and the drilling rig.

[ Property Damage $250 Million. Estimated Current Value $303 Million ]

Image credit: Chris Twomey

A warehouse in Zibo city exploded, triggering a fire. Huge flames were visible

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

On August 23, 2010, at the Millard Refrigerated Services facility in Theodore, Alabama, hydraulic shock caused a roof-mounted 12-inch suction pipe to catastrophically fail leading to the release of more than 32,000 pounds of anhydrous ammonia. The hydraulic shock was enabled during the restart of the plant’s ammonia refrigeration system following a 7-hour power outage. In addition to the catastrophic failure of roof-mounted piping, the pressure developed by the hydraulic shock event also caused an evaporator coil inside the facility to rupture.

The ammonia cloud released from the roofmounted pipe and travelled 0.25 miles across the river adjacent to the plant. Downwind of the ammonia release were crew members on the ships docked at Millard and over 800 contractors working outdoors at a clean-up site for the Deepwater Horizon oil spill. One Millard employee sustained injuries after briefly losing consciousness from ammonia inhalation. Nine ship crew members and 143 of the offsite contractors downwind reported exposure. Of the exposed victims, 32 required hospitalization, and 4 were placed in intensive care.

KEY ISSUES:
• REFRIGERATION SYSTEM DESIGN
• REFRIGERATION SYSTEM OPERATION
• RESPONDING TO AN AMMONIA RELEASE

ROOT CAUSES:
• Likely a result of condensation-induced shock, vapor-propelled liquid, or a combination of both.

Image credit: CSB

A very powerful explosion occurred in an area of pressured propane and butane storage at the refinery. At least 48 people were killed and more than 80 injured. The explosion hit an area of storage tanks, damaging nine tanks. It was reported that there had been several leaks at the refinery in the previous year.

[ Property Damage $320 Million. Estimated Current Value $349 Million ]

Image credit: PDVSA

Truck carrying anhydrous ammonia began leaking chemicals on the highway. The highway was closed and a 1 km exclusion zone was put in place when the truck began leaking

Proximate causes:
• Inadequate assessment of potential failure (reports suggest a pressure relief valve on the truck had failed)
• Inadequate work planning

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

A 16 inch natural gas pipeline, located in California (USA), which conveys gas entrained with oil containing polychlorinated biphenyl (PCB) was damaged by third party activity.

An excavation subcontractor using a drill punctured the gas pipeline. The hole allowed the gas to escape in an upward direction, which was then carried towards nearby buildings. The gas did not ignite and was naturally dispersed. However, there was a fall out of the PCB-oil as a mist, which contaminated an eight square block area of the city’s financial district. This initiated the evacuation of approximately 30,000 individuals

Image Credit: NTSB

A heating unit at a Petrobras depot used to treat fuel for ocean-going ships exploded. The blast and resulting fire broke out while workers were doing planned maintenance on the heating unit.

Proximate causes:
• Inadequate work planning

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

A semi-submersible barge ran aground near Ulsan during a typhoon.

[ Property Damage $75 Million. Estimated Current Value $185 Million ]

Image credit: Marsh

On August 28, 2008, at about 10:35 p.m., a runaway chemical reaction occurred inside a 4,500 gallon pressure vessel known as a residue treater, causing the vessel to explode violently in the methomyl unit at the Bayer CropScience facility in Institute, West Virginia. Highly flammable solvent sprayed from the vessel and immediately ignited, causing an intense fire that burned for more than 4 hours. The fire was contained inside the Methomyl-Larvin insecticide unit by the Bayer CropScience fire brigade with mutual aid assistance from local volunteer and municipal fire departments.

The incident occurred during the restart of the methomyl unit after an extended outage to upgrade the control system and replace the original residue treater vessel. Two company employees who had been dispatched by the control room personnel to investigate why the residue treater pressure was increasing were near the residue treater when it ruptured. One died from blunt force trauma and burn injuries sustained at the scene; the second died 41 days later at the Western Pennsylvania Burn Center in Pittsburgh, Pennsylvania. Six volunteer firefighters who assisted in the unit fire suppression activities and two contractors working at the facility were treated for possible toxic chemical exposure.

KEY ISSUES:
• PROCESS HAZARDS ANALYSIS
• PRE-STARTUP SAFETY REVIEW
• PROCESS SAFETY INFORMATION & TRAINING
• EMERGENCY PLANNING & RESPONSE

ROOT CAUSES:
1. Bayer did not apply standard Pre-startup Safety Review (PSSR) and turnover practices to the methomyl control system redesign project. The equipment was not tested and calibrated before the unit was restarted.
2. Operations personnel were inadequately trained to operate the methomyl unit with the new distributed control system (DCS).
3. Malfunctioning equipment and the inadequate DCS checkout prevented the operators from achieving correct operating conditions in the crystallizers and solvent recovery equipment.
4. The out-of-specification methomyl-solvent mixture was fed to the residue treater before the residue treater was pre-filled with solvent and heated to the minimum safe operating temperature.
5. The incoming process stream normally generated an exothermic decomposition reaction, but methomyl that had not crystallized due to equipment problems greatly increased the methomyl concentration in the residue treater, which led to a runaway reaction that overwhelmed the relief system and over-pressurized the residue treater.

Image credit: CSB

On Sunday, August 28, 2016, at approximately 12:10 pm, a nitrous oxide trailer truck exploded at the Airgas manufacturing facility in Cantonment, Florida. The explosion killed the only Airgas employee present and heavily damaged the facility, halting nitrous oxide manufacturing at Cantonment indefinitely.

KEY ISSUES:
• PROCESS SAFETY MANAGEMENT SYSTEM
• INHERENTLY SAFER DESIGN
• REACTIVE HAZARDS
• HAZARD ANALYSIS
• INEFFECTIVE SAFEGUARDS

ROOT CAUSES:
1. Airgas did not evaluate inherently safer design options that could have eliminated the need for the pump;
2. Airgas never evaluated its process to identify and control process safety hazards;
3. Airgas did not effectively apply the hierarchy of controls to the safeguards that the company used to prevent a possible nitrous oxide explosion;
4. Airgas installed equipment that increased the likelihood of an explosion without performing a management of change safety review;
5. Airgas did not apply an essential industry safety instrumentation standard, or key elements of a voluntary safe storage and handling standard, both of which are intended to prevent nitrous oxide explosions;
6. Airgas safeguards that failed to prevent the explosion include an automatic shutdown safety control and an explosion prevention device;
7. Airgas failed to apply lessons from previous nitrous oxide explosions; and
8. Airgas did not provide its Cantonment facility with an appropriate level of technical staffing support.

Image credit: CSB

The Arkema Crosby facility is located within the 100-year and 500-year flood plain. Extensive flooding caused by heavy rainfall from Hurricane Harvey exceeded the equipment design elevations and caused the plant to lose power, backup power, and critical organic peroxide refrigeration systems. Consequently, Arkema used its standby refrigerated trailers to keep the organic peroxide products cool. This flooding also eventually forced all Arkema’s employees to evacuate from the facility. A Unified Command established a 1.5-mile evacuation zone around the Arkema facility and helped transport residents out of this zone for their safety.

On August 31, 2017, organic peroxide products stored inside a refrigerated trailer decomposed, causing the peroxides and the trailer to burn. Twenty-one people sought medical attention from exposure to fumes generated by the decomposing products when the vapor travelled across a public highway adjacent to the plant. Emergency response officials initially decided to keep this highway open, despite the fact that it ran through the established evacuation zone around the Arkema facility, because this road served as an important route for hurricane recovery efforts. Over the next several days, a second fire and a controlled burn conducted by the Unified Command consumed eight more trailers holding Arkema’s remaining organic peroxide products that required low-temperature storage. Over the course of the three fires, in excess of 350,000 pounds of organic peroxide combusted. As a result, more than 200 residents living within 1.5 miles of the facility who had evacuated the area could not return home for a week.

KEY ISSUES:
• UNDERSTAND SITE FLOOD VULNERABILITY
• CONDUCT A FLOOD RISK ASSESSMENT
• STRENGTHEN FLOOD RESILIENCY
• IMPROVE EMERGENCY RESPONSE

ROOT CAUSES:
1. No PHA or facility siting requirement to consider flood risk
2. Organic peroxides not covered by EPA RMP
3. Trailers without telemetry

Image credit: CSB

An explosion occurred in a chemical plant, and the fire was controlled after 5 h.

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
See also: https://en.wikipedia.org/wiki/2015_Dongying_explosion
Image Credit: RT

A tank car was leaking Anhydrous ammonia and the cap from the tanker was missing, which created a vapor cloud.

Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
Image Credit: Fox 23 News

A truck carrying 50 tons of ammonium nitrate crashed and caught fire following an explosion. Firefighters trucks and bridge were destroyed. Debris found up to 1.5 km away

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

A chemical release and fire took place at the BASF’s Freeport site. The fire started when a mixture of cyclohexanone and cyclohexanol escaped from a vent stack due to a failure in the reactor tube.

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

Chemstar Limited was a small chemical company specialising in solvent recovery. The site was based in Stalybridge on the outskirts of Manchester. The explosion and subsequent fires occurred at approximately 23.30 hours on the night of 6 September 1981 resulting in one fatality.

At the time of the accident the main water supply to the Chemstar site had been cut, due to draining of the local reservoir, and the plant was running on a temporary water supply which was pumped from a nearby stream. For several days prior to the explosion, difficulties had been experienced with the temporary water supply, both with the diesel pump and another undiagnosed problem.

The cause of the explosion was due to an interruption in the water supply to the condenser of a hexane still. The still contained 6000 litres of hexane, which was being distilled to remove contaminants.

An employee initially noticed a strong vapour smell coming from the distillation room and after reducing the supply of steam to the still noticed that the water supply to the condenser had ceased. The employee and a delivery truck driver (on site to load his truck) started to investigate the loss of water. It is thought that the oil-fired boiler, which was supplying the steam, ignited the hexane vapours and caused the subsequent explosion.

The explosion killed the truck driver who was in the building at the time and the employee suffered severe burns. The fire spread to the rest of the site and at the height of the fire 37 fire appliances were in attendance.

KEY ISSUES:
• RELIABILITY OF UTILITIES
• RELIEF SYSTEMS / VENT SYSTEMS
• TRAINING

Report: https://www.icheme.org/media/13696/the-explosion-and-fire-at-chemstar-limited_repaired.pdf

Image Credit: Greater Manchester Fire & Rescue Service

A massive explosion occurred in a chemical plant. The fire was reported to be “very fierce”.

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

Ammonia gas and highly concentrated ammonia liquids spurted out from a flare piping in the southeast corner of the plant after the flare was extinguished.

Proximate causes:
• Inadequate tools, equipment & vehicles (Mal-function of Ammonia compressor);
• Inadequate training/knowledge transfer
• Lack of communication (hazards identification and communication)
• Lack of work rules/policies/ standards/procedures

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

On September 9, 2010, about 6:11 p.m. Pacific daylight time, a 30-inch-diameter segment of an intrastate natural gas transmission pipeline known as Line 132, owned and operated by the Pacific Gas and Electric Company, ruptured in a residential area in San Bruno, California. The rupture occurred at mile point 39.28 of Line 132, at the intersection of Earl Avenue and Glenview Drive.

The rupture produced a crater about 72 feet long by 26 feet wide. The section of pipe that ruptured, which was about 28 feet long and weighed about 3,000 pounds, was found 100 feet south of the crater. The Pacific Gas and Electric Company estimated that 47.6 million standard cubic feet of natural gas was released. The released natural gas ignited, resulting in a fire that destroyed 38 homes and damaged 70. Eight people were killed, many were injured, and many more were evacuated from the area.

Image Credit: NTSB

Explosion in a plant that produces industrial coatings. Around 30 to 40 houses damaged

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

The 365,000 bbl/d refinery sustained severe damage as Hurricane Ike passed through the Houston area, with related flooding due to storm surge as far away as Louisiana.

Hurricane Ike had an unusually large storm surge, which inundated the refinery.

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

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

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

A fire started in the oxidization plant. Some 130 firemen using 25 appliances controlled the blaze after four hours. The local railway line, ship canal, and roads were closed and 200 people evacuated. The plant was rebuilt with larger spacing to obtain authorities approval.

[ Property Damage $62 Million. Estimated Current Value $158 Million ]

Image credit: No credit

Tanker crash followed by a blast took place on a road close to the town of Maridi. The leaking tanker along with pilferage attempts led to an explosion.

Proximate causes:
• Lack of knowledge of hazard present
• Inadequate tools/equipment or vehicle
• Inadequate work planning

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

A synthetic ammonia leak at a chemical plant in Central China’s Henan province poisoned 20 residents in a nearby village It was reported that there were 300 kg of synthesized ammonia leaked from a cracked pipe.

Proximate causes:
• Inadequate tools, equipment & vehicles (Pipe crack)

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

Hurricane Hugo struck this refinery, causing extensive damage to 14 of the 500,000 – 600,000 bbl storage tanks in the tank farm area, the administration building, and the company housing. The damage to process units, which were idled in preparation for the hurricane, was limited to the asbestos insulation on process columns and piping. A maximum wind speed of 192 miles per hour was reported for this hurricane, before the wind speed measuring device at the St. Croix airport was damaged. Because of the damaged asbestos insulation, approximately 1,500 company employees and contractors worked seven days a week for 15 weeks to remove the asbestos debris from the refinery at a substantial extra expense. A contractor specializing in the construction of atmospheric storage tanks worked for more than one year rebuilding the 14 storage tanks damaged in the tank farm area.

[ Property Damage $167 Million. Estimated Current Value $375 Million ]

Image credit: Virgin Islands Free Press

On 21 September in 1921, two consecutive explosions occurred in a silo in the BASF plant in Oppau, Germany, creating a 20m deep, 90x125m large crater. The entire area was covered by dark green smoke and there were several additional fires and small explosions. At the time of the event 4500 tonnes of ammonium sulphate nitrate compound fertilizer (ASN) were stored in the silo.

The explosion killed 507 people and injured 1917. The plant and approximately 700 houses nearby were destroyed

Ref: https://en.wikipedia.org/wiki/Oppau_explosion

Between 20 and 120 tons of ammonium nitrate residue (equivalent to 20 to 40 tons of TNT) detonated on September 21, 2001 in the AZote Fertilisant (AZF) fertilizer plant in Toulouse, causing devastating effects at the site and far beyond.

At 10.17 am, a severe explosion (detonation) occurred in shed 221. The detonation, felt several kilometres away, corresponded to a magnitude of 3.4 on the Richter scale. Significant dust fallout from the installations and a crater were observed outside the plant.

An explosion at this fertilizer plant killed 31 people and hospitalized more than 600. The blast shattered windows and ripped doors from their hinges in the center of the city three kilometres away. Two chimneys and several buildings at the factory were flattened and damage was caused to more than 3000 homes, 500 of which are reported uninhabitable. There was a secondary blast at a nearby explosives factory, said to be caused from sparks created by the first explosion. The thick red and yellow flumes that spread over the city were first thought to be toxic and the public were advised to remain indoors. The blast left a crater 50 meters in diameter and 15 meters deep.

[ Property Damage $430 Million. Estimated Current Value $732 Million ]

Image credit: Thierry Bordas

On September 21, 2003, a violent explosion destroyed an underground distillation tower at the Isotec chemical manufacturing plant in Miami Township, Ohio, injuring one worker. The explosion ruptured a carbon monoxide gas pipe and led to a precautionary evacuation of about 2000 residents. The Isotec facility manufactures rare forms of oxygen and nitrogen, known as stable isotopes, which are used in research and medicine.

KEY ISSUES:
• PROCESS HAZARDS ANALYSIS
• INCIDENT INVESTIGATION
• LAND USE MANAGEMENT
• EMERGENCY RESPONSE

ROOT CAUSES:
1. Although Isotec and Sigma-Aldrich PHA records acknowledged the explosive potential of the NO system, there was no written documentation that action had been taken to minimize this potential.
2. Although Isotec experienced two previous NO distillation unit failures involving the detonation of liquid nitric oxide, the investigation records were incomplete. There was no record of the cause of the incidents and no documentation of corrective actions to prevent recurrence.
3. Neither the township zoning process nor the township and city permit approval processes adequately considered the hazards of preexisting industrial chemicals. Likewise, neither authority prescribed steps for addressing potential public consequences from the accidental release of chemicals.
4. A number of residents were not informed of the evacuation in a timely manner; others received no notification. Information was sometimes inconsistent or incomplete, causing confusion among evacuees

Image Credit: CSB

A clean out operation of a batch still, known as ’60 still base’, was organised in order to remove residues. This vessel had never been cleaned since it was installed in the nitrotoluenes area in 1961.

An operator dipped the sludge to examine it and reported the sludge as gritty with the consistency of soft butter to management. No sample was sent for analysis nor was the atmosphere inside the vessel checked for a flammable vapour. It was mistakenly thought that the material was a thermally stable tar.

In order to soften the sludge, which was estimated to have a depth of 34 cm (14 in), steam was applied to the bottom battery. Advice was given not to exceed 90°C. Employees started the clean out operation using a metal rake. The material was tar-like and had liquid entrained in it. Approximately one hour into the cleaning process a longer rake was used to reach further into the still.

The vessel’s temperature gauge in the control room was reported to be reading 48°C, instructions were given to isolate the steam.

At approximately 13:20 hrs a number of employees involved in the raking left the still base to get on with other tasks. One person left on the scaffold had stopped raking and noticed a blue light, which turned instantly to an orange flame. As he leapt from the scaffold an incandescent conical jet erupted from the manhole. This projected horizontally towards the Meissner control building. A vertical jet of burning vapours shot out of the top rear vent to the height of the distillation column nearby.

The jet fire lasted for approximately one minute before subsiding to localised fires around the manlid and buildings nearby. The force of the jet destroyed the scaffold, in the process, propelling the manhole cover into the centre of the Meissner control building. The jet severely damaged this building and then impacted on the north face of the main office block causing a number of fires to start inside the building.

A total of 22 fire appliances and over 100 fire fighters attended the incident.

KEY ISSUES:
• MAINTENANCE PROCEDURES
• REACTION / PRODUCT TESTING
• RAW MATERIALS CONTROL / SAMPLING
• CONTROL SYSTEMS
• PERMIT TO WORK SYSTEMS
• HAZARDOUS AREA CLASSIFICATION / FLAMEPROOFING
• PLANT LAYOUT

Report: https://www.icheme.org/media/13704/the-fire-at-hickson-and-welch-ltd.pdf

Image Credit: HSE

The wall of the kiln collapsed when 3 workers were inspecting the kiln furnace

Proximate causes:
• Inadequate tools, equipment & vehicles
• Inadequate training/knowledge transfer (Lack of understanding the process of the calcination of limestone);
• Lack of work rules/policies/ standards/procedures (lack of standard procedures for inspections);
• Inadequate work rules plan (lack of the pre-start safety review before inspection).

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

An explosion occurred in a chemical plant dealing with waste aluminum melting. The explosion occurred when the operator was melting the aluminum.

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

A fire on one of the Royal Navy’s latest guided missile destroyers has killed eight men. The £23m HMS Glasgow was being fitted out at a shipyard near Newcastle-upon-Tyne, north-east England, and was due to start sea trials shortly.

It is thought the fire at Swan Hunter’s Neptune yard was started by a welder’s torch after gas had been leaking from an oxygen cylinder. Six other shipyard workers were also injured in the blaze. Survivors reported hearing an explosion before the fire took hold and spread rapidly to three decks of the ship.

A Health and Safety Executive investigation confirmed oxygen, which had been leaking all night from a supply line, helped cause a fire to be ignited by a welder’s torch and burn more fiercely than normal. The HSE blamed Swan Hunter Shipbuilders for not ensuring the oxygen pipes had been disconnected the previous evening. But it also said ship workers failed to notice signs of leaking oxygen espite references in safety manuals and a film shown three times at the yard. The report also recommended designers consider providing alternative methods of escape from ships during their construction.

HMS Glasgow was commissioned three years later and is on active naval service.

An explosion occurred during the maintenance of the mill in Luxiang company

Proximate causes:
• Inadequate training/knowledge transfer (Lack of understanding the process);
• Lack of work rules/policies/ standards/procedures (wrong procedures for inspections);
• Inadequate work rules plan (lack of the pre-start safety review before inspection).

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

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 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

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

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.