Incident Videos

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

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

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

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, 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

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

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

On Sunday, November 29, 2015, an operator at the Delaware City Refining Company’s (DCRC) sulfuric acid alkylation unit suffered second-degree burns to the face and neck and third-degree burns to the wrist from a flash fire. The incident occurred when operations personnel were preparing equipment for maintenance work by de-inventorying and draining vessels located between two isolation points. A single block valve isolated the vessels being decontaminated from a pressurized and inventoried depropanizer column containing hydrocarbons; unknown to operations personnel, the valve leaked in the closed position, resulting in backflow of flammable material from the depropanizer. When an operator opened the vessel drain valve to empty what he assumed was condensate water from the vessel to the oil water sewer, the hydrocarbons from the depropanizer also released to the sewer and ignited, resulting in a flash fire.

Prior to maintenance work, operations personnel commonly prepare equipment by depressurizing, de-inventorying, washing, and draining. These activities often involve opening process equipment and piping and can result in a release of hazardous energy. Though equipment preparation activities can occur rather frequently in process plants, the tasks involved may vary among pieces of equipment and piping and combinations of equipment and, thus, may be non-routine and not be included in an existing procedure. Because of the non-routine nature of equipment preparation activities, process plants should develop a system to ensure that equipment preparation activities are carefully planned, which includes selecting proper isolation methods and identifying hazards through a risk assessment.

KEY ISSUES:
• OPERATING PROCEDURES
• MAINTENANCE PROCEDURES
• EQUIPMENT ISOLATION
• MANAGEMENT OF CHANGE
• DRAINING EQUIPMENT TO SAFE LOCATION

ROOT CAUSES:
1. Deficiencies in planning & executing non-routine equipment preparation activities

Image credit: CSB

A major fire broke out on a refinery processing unit designed to convert heavy oil residues into refined products, resulting in serious damage to the plant.

[ Property Damage $250 Million. Estimated Current Value $259 Million ]

Image credit: ENI

In the early hours of 3 December 1984 a relief valve on a storage tank containing highly toxic methyl isocyanate (MIC) lifted. A cloud of MIC gas was released which drifted onto nearby housing.

Prior to this, at 23.00 hrs on 2 December, an operator noticed the pressure inside the storage tank to be higher than normal but not outside the working pressure of the tank. At the same time a MIC leak was reported near the vent gas scrubber (VGS). At 00.15hrs a MIC release in the process area was reported. The pressure inside the storage tank was rising rapidly so the operator went outside to the tank. Rumbling sounds were heard from the tank and a screeching noise from the safety valve. Radiated heat could also be felt from the tank.
Attempts were made to switch on the VGS but this was not in operational mode.

Approximately 2,000 people died within a short period and tens of thousands were injured, overwhelming the emergency services. This was further compounded by the fact that the hospitals were unaware as to which gas was involved or what its effects were. The exact numbers of dead and injured are uncertain, as people have continued to die of the effects over a period of years.

The severity of this accident makes it the worst recorded within the chemical industry.

KEY ISSUES:
• PLANT MODIFICATION / CHANGE PROCEDURES
• REACTION / PRODUCT TESTING
• DESIGN CODES – PLANT
• MAINTENANCE PROCEDURES
• EMERGENCY RESPONSE / SPILL CONTROL

Image Credit: No credit

An explosion and fire that occurred in a polyethylene wax processing facility operated by Marcus Oil and Chemical on the southwest side of Houston, Texas. On Friday, December 3, 2004, at about 5:50 pm, employees heard a loud “pop” then saw light from a fire reflecting off a shiny tanker truck parked near the process equipment. About 45 seconds later, a violent explosion occurred and a fire fueled by molten wax erupted near the main warehouse. The warehouse and nearby equipment were quickly involved in the fire.

The Houston Fire Department arrived approximately five minutes after the explosion. Firefighters extinguished the three-alarm blaze by midnight, approximately seven hours after the explosion.

Three firefighters were slightly injured while fighting the fire, and local residents sustained minor injuries from flying glass. The explosion shattered windows in buildings and vehicles and caused structural damage as far as one-quarter mile away. Significant interior damage resulted when suspended ceilings and light fixtures were blown down in the onsite buildings, nearby businesses, and a church. Tank 7, a 12-foot diameter, 50-foot long, 50,000-pound pressure vessel was propelled 150 feet where it impacted a warehouse belonging to another business..

KEY ISSUES:
• PRESSURE VESSEL REPAIRS & ALTERATIONS
• NITROGEN INERTING SYSTEM DESIGN & OPERATION

ROOT CAUSES:
1. Poor welding severely weakened Tank 7 and led to its catastrophic failure.
2. The connection between the nitrogen and the compressed air systems increased the oxygen concentration in the inerting gas to an unsafe level.
3. Pressure vessels had operating pressures in excess of 100 psig, yet none was equipped with a pressure relief device.

Image Credit: CSB

The Halifax Explosion was a maritime disaster in Halifax, Nova Scotia, Canada, which happened on the morning of 6 December 1917. The Norwegian vessel SS Imo collided with SS Mont-Blanc, a French cargo ship laden with high explosives, in the Narrows, a strait connecting the upper Halifax Harbour to Bedford Basin, causing a large explosion on the French freighter, devastating the Richmond district of Halifax.

Approximately 2,000 people were killed by the blast, debris, fires or collapsed buildings, and an estimated 9,000 others were injured. The blast was the largest man-made explosion at the time, releasing the equivalent energy of roughly 2.9 kilotons of TNT (12,000 GJ).

Image Credit: Library of Congress

On December 7, 2009, at approximately 2:30 pm, State Special Vessel No. 2, under an operating pressure of 29,000 psig, suddenly and violently ruptured, 120 days into a 150-day operating cycle. A white cloud of steam and debris rapidly expanded outward from the facility, traveled onto the interstate, and dissipated within seconds.

The sudden release of superheated liquid caused an eight-foot tall by four-foot wide vessel fragment, weighing approximately 8,600 pounds, to travel through two concrete walls and finally land about 435 feet from the NDK building. The fragment skipped across a neighboring facility parking lot and slammed into the wall of an adjacent business office. The force of the impact pushed the wall inward causing furniture to shift and ceiling tiles to fall. One person working near the wall was injured.

The thrust from the escaping liquid caused the base of the vessel to violently shear away from its foundation and blew pieces of structural steel out of the building into the parking lot of a nearby rest stop gas station, known as the Illinois Tollway (I-90) Oasis. One piece of structural steel struck and killed a truck driver at the rest stop. After shearing from its base and throwing shrapnel out of the facility, the vessel swung from the building and landed on the ground outside.

KEY ISSUES:
• PRESSURE VESSEL DESIGN & MATERIAL SELECTION REQUIREMENTS
• LEARNING FROM PREVIOUS INCIDENTS
• INSPECTIONS

ROOT CAUSES:
1. Stress corrosion cracking.
2. Testing & inspection deficiencies.

Image credit: CSB

The International Biosynthetics (IBIS) plant was, at the time of the accident, a wholly owned subsidiary of Shell UK Ltd. and employed some 250 people in the manufacture of fine chemicals.

The release occurred on the phosgene plant at 11:27 hours on 7 December 1991. The batch reaction involved the phosgenation of dimethyl aniline (DMA) in a toluene solution. The process involved the addition of 1 tonne of recycled toluene to the reactor, then as no more recycled toluene was available fresh toluene was to be added. Attempts were made to fill the reactor with 2 tonnes of fresh toluene. The flow indicator showed that the required amount of toluene had been added to the reactor, however a control valve between the pump and the vessel was closed and none of the toluene had been added. A level measurement was available for the vessel but as the process appeared to be proceeding normally this was not checked.

The next stage was to add 20 kg of phosgene to check if any water was present in the reactor. This would have resulted in a temperature rise of the solution. Because there was insufficient toluene in the vessel, the temperature indicator was not in the solution and therefore showed no temperature rise. As there appeared to be no water in the reactor, 0.8 tonnes of phosgene were then added to the vessel. After a shift changeover the next steps in the process were carried out. These were to add 1.6 tonnes of DMA and heat to 65°C. The operating temperature was reached but the temperature continued to rise to well above 100°C. As the pressure increased the pressure control valve, pressure relief valve and bursting disc all operated as designed and relieved the vessel to a scrubbing column. The reaction was more violent than had been predicted and the relief system had insufficient capacity to deal with the pressure rise. This resulted in a connection on the condenser line failing and releasing the contents of the vessel to atmosphere. Fortunately the phosgene had been consumed in the reaction. However, the vapour cloud drifted for 4 km affecting about 60 people and staining some property blue.

KEY ISSUES:
• CONTROL SYSTEMS
• REACTION / PRODUCT TESTING
• RELIEF SYSTEMS / VENT SYSTEMS

Report: https://www.icheme.org/media/13702/release-of-chemicals-from-international-biosynthetics-ltd.pdf

Image Credit: HSE

An explosion ripped through the New Cumberland A.L. Solutions titanium plant in West Virginia on December 9, 2010, fatally injuring three workers. The workers were processing titanium powder, which is highly flammable, at the time of the explosion.

KEY ISSUES:
• FEDERAL COMBUSTIBLE DUST OVERSIGHT
• HAZARD RECOGNITION & TRAINING
• LEARNING FROM PREVIOUS INCIDENTS

ROOT CAUSES:
1. AL Solutions did not mitigate the hazards of metal dust explosions through engineering controls, such as a dust collection system. Specifically, AL Solutions did not adhere to the practices recommended in NFPA 484 for controlling combustible metal dust hazards.

Image credit: CSB

A release of hexane created a vapor cloud which was ignited on an electric motor, causing an explosion. This resulted in damage to a process unit and injured 20 people. The plant was eventually replaced.

[ Property Damage $200 Million. Estimated Current Value $280 Million ]

Image credit: Gaulke

In the early hours of Sunday 11th December 2005, a number of explosions occurred at Buncefield Oil Storage Depot, Hemel Hempstead, Hertfordshire. At least one of the initial explosions was of massive proportions and there was a large fire, which engulfed a high proportion of the site.

Over 40 people were injured; fortunately there were no fatalities. Significant damage occurred to both commercial and residential properties in the vicinity and a large area around the site was evacuated on emergency service advice. The fire burned for several days, destroying most of the site and emitting large clouds of black smoke into the atmosphere.

KEY ISSUES:
• SYSTEMATIC ASSESSMENT OF SAFETY INTEGRITY LEVEL REQUIREMENTS
• PROTECTING AGAINST LOSS OF PRIMARY CONTAINMENT
• ENGINEERING AGAINST ESCALATION OF LOSS OF PRIMARY CONTAINMENT
• ENGINEERING AGAINST THE LOSS OF SECONDARY AND TERTIARY CONTAINMENT
• OPERATING WITH HIGH RELIABILITY ORGANISATIONS
• DELIVERING HIGH PERFORMANCE THROUGH CULTURE AND LEADERSHIP

HSE Reports:
MIIB Final Report Vol 1: https://www.icheme.org/media/13707/buncefield-miib-final-report-volume-1.pdf
MIIB Final Report Vol 2a: https://www.icheme.org/media/13923/buncefield-miib-final-report-volume-2a.pdf
MIIB Final Report Vol 3a: https://www.icheme.org/media/13923/buncefield-miib-final-report-volume-2a.pdf
Land Use Planning – Recommendations: https://www.icheme.org/media/10694/recommendations-on-land-use-planning.pdf
Land Use Planning – Model: https://www.icheme.org/media/13709/illustrative-model-of-a-risk-based-lup-system_repaired.pdf
Explosion Mechanism: https://www.icheme.org/media/10696/buncefield-explosion-mechanism-advisory-group-report.pdf
BSTG Final Report: https://www.icheme.org/media/10697/safety-and-environmental-standards-for-fuel-storage-sites.pdf
Emergency Preparedness: https://www.icheme.org/media/10698/recommendations-on-emergency-preparedness.pdf
Design & Operation: https://www.icheme.org/media/10699/recommendations-on-the-design-and-operation-of-fuel-storage-sites.pdf
Initial Report: https://www.icheme.org/media/10700/buncefield-initial-report.pdf
Investigation – Progress Report: https://www.icheme.org/media/10705/buncefield-first-progress-report.pdf
Investigation – 2nd Progress Report: https://www.icheme.org/media/10703/buncefield-second-progress-report.pdf
Investigation – 3rd Progress Report: https://www.icheme.org/media/10702/buncefield-third-progress-report.pdf
Why did it happen?: https://www.icheme.org/media/10706/buncefield-report.pdf

Image Credit: Hertfordshire County Council

At approximately 2:00 pm on December 11, 2002, a maintenance employee entered the wastewater treatment (WWT) room at Environmental Enterprises, Inc. (EEI), in Cincinnati, Ohio, to retrieve a tool. His path brought him directly alongside the WWT clarifier, an open-top tank with a conical bottom for settling solids (Figure 1).

As the mechanic approached the clarifier, he noticed a “rotten egg” odor that became stronger as he moved forward. He suddenly felt pressure in his lungs and was unable to breathe. He attempted to flee the area but was overcome by hydrogen sulfide (H2S) gas and collapsed.

Fortunately, fellow employees found the victim a few moments later and pulled him to safety. He recovered, and there were no other injuries. .

KEY ISSUES:
• HAZARD COMMUNICATION
• OPERATING PROCEDURES
• MANAGEMENT OVERSIGHT
• MECHANICAL INTEGRITY

ROOT CAUSES:
1. The facility had no written procedures for operating the WWT area.
2. The operator responsible for the WWT area had no formal training in waste treatment or chemistry.
3. This incident may have been avoided if the operator had been aware of the possible reactions that can produce H2S gas.
4. EEI did not have a formal system for investigating incidents and communicating findings to employees.
5. The facility did not implement procedures or assign responsibilities for calibrating, inspecting, and maintaining the H2S detector.
6. Management oversight could have ensured that then proper treatment methods were used.

Image Credit: CSB

An explosion occurred in the ammonium nitrate process area of this plant. As a result of the explosion, the seven-story main process building was completely destroyed and a 30-foot-diameter crater was created. Metal fragments from the explosion punctured one of the plant’s two 15,000-metric-ton refrigerated ammonia storage tanks. The punctured tank released an estimated 5,700 metric tons of ammonia, causing the evacuation of approximately 2,500 people from the surrounding area. Metal fragments also punctured a nitric acid tank, resulting in the release of approximately 100 metric tons of this acid. The explosion tore metal siding from adjacent buildings, damaged three third-party electric generating stations, broke windows of buildings 16 miles away in Sioux City, and was felt more than 30 miles away.

[ Property Damage $203 Million. Estimated Current Value $404 Million ]

Image credit: EPA
Ref: https://en.wikipedia.org/wiki/Port_Neal_fertilizer_plant_explosion

A straight run of eight-inch-diameter line carrying hot oil from the high pressure separator to the low pressure stripper in a refinery hydrodesulfurizer fractured circumferentially in the parent metal in the heat zone about 1.5 inches from a weld. Hot oil at 700 psi and 650°F sprayed across the roadway into the hydrogen units where ignition occurred. An intense fire around the pipe rack in the hydrogen plant caused a 16-inch-diameter gas line to rupture, adding a second blow torch to the fire. More pipes ruptured with explosive force in adjacent areas. The fire resulted in a crash shutdown of the entire 600,000 bbl/d refinery. After six and a half hours, the fire was extinguished. Damage was extensive. The three hydrogen plants and the four hydrodesulphurization (HDS) units were heavily damaged or destroyed. Before the loss, the line which failed was judged as having excessive vibration. It is believed that the hot oil line failed due to fatigue, considered, in turn, to be largely due to hydrogen embrittlement.

[ Property Damage $75 Million. Estimated Current Value $180 Million ]

Image credit: PDVSA

On 14 December 1984 fire broke out in a furniture repository in Sheffield which formed part of a very large warehouse and transit shed building occupied by the National Freight Consortium plc. In two days the fire destroyed the whole warehouse, with the exception of one protection section. It involved the attendance of several hundred fireman over a total period of six days.

Among the wide variety of goods stored in the building was a relatively small tonnage of chemicals. Concern was expressed during and after the fire about the difficulty experienced by the Fire Brigade in identifying the possible risks from the materials stored, followed by allegations by the Fire Brigades’ Union that firemen had been unnecessarily exposed to harmful fumes without the benefit of breathing apparatus.

The fire also led to expressions of concern about a number of aspects, including the delay in summoning the Fire Brigade and possible exposure of member of the public to harmful fumes and asbestos material evolved in the fire.

Report: https://www.icheme.org/media/13698/the-brightside-lane-warehouse-fire.pdf

Image Credit: HSE

A huge boil-over occurred on a fuel oil tank, killing at least 160 people in a huge fire ball. The explosion occurred on the fuel oil tank while it was being gauged, blowing the roof off the tank and setting it on fire. Eight hours after the tank fire started a violent boil-over occurred. Burning oil flowed down the hill where the tank was located and surrounded a second tank.

[ Property Damage $70 Million. Estimated Current Value $193 Million ]

Image credit: Radio Rescate

At 1:33 pm on December 19, 2007, a powerful explosion and subsequent chemical fire killed four employees and destroyed T2 Laboratories, Inc. (T2), a chemical manufacturer in Jacksonville, Florida. It injured 32, including four employees and 28 members of the public who were working in surrounding businesses. Debris from the reactor was found up to one mile away, and the explosion damaged buildings within one quarter mile of the facility.

On December 19, T2 was producing its 175th batch of methylcyclopentadienyl manganese tricarbonyl (MCMT). At 1:23 pm, the process operator had an outside operator call the owners to report a cooling problem and request they return to the site. Upon their return, one of the two owners went to the control room to assist. A few minutes later, at 1:33 pm, the reactor burst and its contents exploded, killing the owner and process operator who were in the control room and two outside operators who were exiting the reactor area.

KEY ISSUES:
• REACTIVE HAZARD RECOGNITION
• HAZARD EDUCATION
• EMERGENCY PREPAREDNESS
• PROCESS DESIGN & SCALE-UP

ROOT CAUSES:
• T2 did not recognize the runaway reaction hazard associated with the MCMT it was producing.

Image credit: CSB

The incident occurred as a two-train, ethylene cracker was being started up after its major six-year turnaround. A spanner was left in the pipework going to the medium pressure stage of a compressor. This resulted in the compressor tripping on high vibration. The trip caused an overpressure in the high pressure stage of the compressor and a loss of containment of hydrocarbon that was ignited.

[ Property Damage $250 Million. Estimated Current Value $273 Million ]

Image credit: Petroineos

An eight-inch-diameter pipeline operating at approximately 700-pounds-per-square-inch ruptured, releasing a mix of ethane and propane. The record low temperature of 10°F for the region is believed to have contributed to the rupture. After a few minutes, the resulting release was ignited, causing a vapor cloud explosion. The explosion shattered windows up to six miles away and could be felt as far as 15 miles away. Seventeen additional pipelines, in a pipe rack containing 70 lines, were ruptured by the explosion.

The resulting fire involved two large storage tanks holding 3.6 million gallons of diesel, 12 small tanks containing a total of 882,000 gallons of lube oil, and two separator units. The explosion resulted in the partial loss of electricity, steam, and fire water for the refinery, since two power lines, two steam lines and a 12-inch diameter fire water line were located in this pipe rack. Upon the initial explosion, the lines for the dock fire pumps were damaged. Therefore, the water for fire fighting had to be supplied with the remaining plant fire pumps and municipal fire trucks taking draught from alternate sources. Approximately 48,000 gallons of aqueous film-forming foam (AFFF) concentrate, 200 fire brigade members, and 13 pumper units were used during the fire fighting effort, which was successful in extinguishing the fire approximately 14 hours after the initial explosion. Because of this incident, the refinery was completely shut down for three days and operated at reduced capacity for an additional three weeks.

[ Property Damage $69 Million. Estimated Current Value $155 Million ]

Image credit: Sam Kittner

Failure of seabed components caused 210,000 metric tonnes of FSU to break free in bad weather. Three out of four latch plates fractured. About 210,000 bbl-per-day of crude was lost, equating to about 10% of UK production.

[ Property Damage $60 Million. Estimated Current Value $138 Million ]

Image credit: ShipSpotting.com

An explosion and fire occurred at a gas-to-liquids (GTL) plant in Bintulu, Sarawak. The fire was brought under control on the next day. The plant was one of only two commercially successful GTL plants in the world at the time, with a capacity to produce 12,500 bbl-per-day of middle distillates and waxes from natural gas feedstocks. The explosion occurred in the air separation unit (ASU) which supplied oxygen for the production of synthesis gas feedstock. The investigation into the incident pointed to an initial combustion event in the ASU as the most probable cause. This combustion event is thought to have initiated explosive burning of the aluminium heat exchanger elements in the presence of liquid oxygen, such that the elements ruptured explosively. Twelve people were injured, none seriously, and the plant was shut down for several months for repairs.

[ Property Damage $275 Million. Estimated Current Value $510 Million ]

Image credit: Shell

A benzoyl peroxide (BPO) explosion and fire that occurred at the Catalyst Systems, Inc., production facility in Gnadenhutten, Ohio. At 11:55 am on January 2, 2003, a vacuum dryer holding nearly 200 pounds of BPO exploded. Employees were drying granular 75 percent BPO to make 98 percent BPO when the material explosively decomposed. One employee was slightly injured, and the BPO processing building was significantly damaged.

KEY ISSUES:
• HAZARDS OF BENZOYL PEROXIDE
• REACTIVE CHEMICAL HAZARDS
• PROCESS SAFETY MANAGEMENT SYSTEMS

ROOT CAUSES:
1. Industry standards and guidance documents not reviewed and followed.
2. Good engineering practices to manage the hazards not implemented.

Image Credit: CSB

A hydrogen leak on a reactor ignited causing a fire in the hydrocracking distillation unit 87, causing extensive damage to the main reactor. No fatalities were declared.

A fire broke out at the oil sands refinery in Upgrader 2, an area of the plant that converts bitumen into crude oil products. Approximately 250 people were evacuated from the plant, but no injuries were reported. The fire burned for nine hours before being extinguished. Witnesses reported two explosions minutes apart which sent a fireball six stories high into the air. The plant also suffered ice damage from water used to fight the fire as temperatures in the area fell below -35 C. On February 3, 2005, the company announced that a ruptured cycle line was the most likely cause of the fire. Oil production was reduced from 225,000 bbl-per-day to about 110,000 bbl-per-day for about nine months.

[ Property Damage $120 Million. Estimated Current Value $168 Million ]

Image credit: Suncor

On 4 January 1977, a serious fire and explosion occurred at the Braehead Container Clearance Depot at Renfrew in Scotland.

The fire and explosion, which originated at a warehouse occupied by James Kelman Transport and Storage, completely wrecked that warehouse and the adjacent whisky bonded warehouse occupied by Clyde Container Services Ltd and also caused widespread window and roof damage to domestic, commercial, industrial and public property within a radius of a mile of the premises. The cost of the damage is estimated at some £6 000 000.

It was fortunate that, despite the extent of the damage, only twelve members of the public and one watchman were treated for shock and minor injuries. After investigation had eliminated one cause of fire after another it was discovered that it had accidently been started by three boys who had lit a fire to warm themselves at a den which they had made, during the New Year holiday, from cardboard cartons stacked beside the warehouse.

Subsequent experimental work tended to suggest that explosions of this nature and severity can be caused by the involvement of commercially pure sodium chlorate under the intense heat conditions of an industrial fire.

Report: https://www.icheme.org/media/13693/the-fire-and-explosion-at-braehead-container-depot-renfrew.pdf

Image Credit: HSE

On 4th January 1966, an operation to drain off an aqueous layer from a propane storage sphere was attempted. Two valves were opened in series on the bottom of the sphere. When the operation was nearly complete, the upper valve was closed and then cracked open again. No flow came out of the cracked valve, so it was opened further. The blockage, assumed to be ice or hydrate, cleared and propane gushed out. The operator was unable to close the upper valve and by the time he attempted to close the lower valve this was also frozen open. The alarm was raised and traffic on the nearby motorway was stopped. The resulting vapour cloud is thought to have found its source of ignition from a car about 160 m away. The storage sphere was enveloped in a fierce fire and upon lifting of the relief valve a stream of escaping vapour was ignited.

The LPG tank farm where the sphere was located consisted of four 1200 m3 propane and four 2000 m3 butane spheres. The fire brigade arrived on site, but were not experienced in dealing in refinery fires, and it appears they did not attempt to cool the burning sphere. They concentrated their hoses on cooling the remaining spheres. About 90 minutes after the initial leakage, the sphere ruptured, killing the men nearby. A wave of liquid propane flowed over the compound wall and fragments of the ruptured sphere cut through the legs of the next sphere which toppled over. The relief valve on this tank began to emit liquid.

The fire killed 18 people and injured 81 others. Five of the storage spheres were destroyed.

KEY ISSUES:
• DESIGN CODES – PIPEWORK
• SECONDARY CONTAINMENT
• OPERATING PROCEDURES
• EMERGENCY RESPONSE / SPILL CONTROL
• DESIGN CODES – PLANT

Image Credit: Fonds Georges Vermard

This incident occurred at an oil sands facility, specifically with minor explosions occurring in the froth treatment plant. Damage appeared to be mainly limited to electrical cables in the solvent recovery area. The cause of the fire appears to have been a hydrocarbon leak in piping. The plant’s emergency response team was assisted by the local fire brigade and the fire was extinguished in two hours. Only one minor injury was reported. The incident occurred eight days after the new facility began operating.

[ Property Damage $120 Million. Estimated Current Value $189 Million ]

Image credit: Jason Woodhead

An explosion occurred on this oil sands upgrader site north of Fort McMurray, Alberta. Five workers were injured in the blast, including one who received third-degree burns. A subsequent fire occurred at the top of one of the site’s four coke drums and burned for nearly four hours. As a result, two of the coke drums were disabled. Workers returned to normal shifts the following morning. The majority of the damage was sustained above the cutting deck and derrick infrastructure of the coke drum. At the time of the incident, the plant was operating on bypass conditions due to process upsets. An internal investigation team determined that the fire resulted from the opening of the top unheading valve on an active low-pressure coke drum. This allowed hot hydrocarbons to be released within the coker cutting deck building and was followed by ignition, leading to the explosion and fire. Exceptionally cold weather following the incident hampered efforts to gain access to the coker unit’s cutting deck, due to the deluge protection in this area. Firefighting in freezing conditions caused additional damage.

[ Property Damage $385 Million. Estimated Current Value $425 Million ]

Image credit: CBC

One worker died after hazardous chemical vapors released from an over-pressurized reactor burned his respiratory system. The worker charged chemicals inside a reactor vessel and a reaction started before he could close it.

OSHA’s proposed penalties total $87,780

Proximate causes:
• 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: Google Maps

On January 7, 1998, two explosions in rapid succession destroyed the Sierra Chemical Company Kean Canyon plant near Mustang, Nevada, killing four workers and injuring six others.

The Kean Canyon plant manufactured explosive boosters for the mining industry. When initiated by a blasting cap or detonation cord, boosters provide the added energy necessary to detonate less sensitive blasting agents or other high explosives. The boosters manufactured at the Kean Canyon plant consisted of a base mix and a second explosive mix, called Pentolite, both of which were poured into cardboard cylinders. The primary explosives used in the base mix were TNT (2,4,6-trinitrotoluene), PETN (pentaerythritol tetranitrate), and Comp-B, a mixture of TNT and RDX (hexahydro-1,3,5-trinitro-1,3,5-triazine). The Pentolite is a mix of TNT and PETN.

KEY ISSUES:
• PROCESS SAFETY MANAGEMENT
• WORKER TRAINING
• PROCESS HAZARD ANALYSIS
• LANGUAGE BARRIERS

ROOT CAUSES:
1. Process hazard analysis (PHA) conducted by the facility was inadequate.
2. Training programs for facility personnel were inadequate.
3. Written operating procedures were inadequate or not available to workers.
4. The facility was built with insufficient separation distances between different operations and the design and construction of buildings was inadequate.
5. There was no systematic safety inspection or auditing program.
6. The employee participation program was inadequate.

Image Credit: CSB

An explosion severely injured a graduate student at Texas Tech University in Lubbock, Texas, in the chemistry department during the handling of a high-energy metal compound, which suddenly detonated. Texas Tech had entered into an agreement with Northeastern University, which holds a contract from the U.S. Department of Homeland Security to study the high-energy materials.

KEY ISSUES:
• LABORATORY SAFETY MANAGEMENT FOR PHYSICAL HAZARDS
• HAZARD EVALUATION OF EXPERIMENTAL WORK IN RESEARCH LABORATORIES
• ORGANIZATIONAL ACCOUNTABILITY & OVERSIGHT OF SAFETY

Image & AcciMap Credit: CSB

Image credit: CSB

An 11-year-old, 121,000-deadweight-ton tanker had completed unloading its first parcel of Arabian heavy crude when a small fire was noticed on deck. About 10 minutes later, fire spread to both sides of the ship. Later, a massive explosion occurred. The initiating event of the disaster was likely the buckling of the ship’s structure at deck level. Explosions in the ballast tanks and the breaking of the ship’s back followed. These events were produced by the conjunction of two separate factors: a seriously weakened hull due to inadequate maintenance and an excessive stress due to incorrect ballasting at the time of the disaster. In addition to the total loss of the ship, 1,130 feet of the concrete and steel jetty were damaged or destroyed.

[ Property Damage $70 Million. Estimated Current Value $248 Million ]

Image credit: Irish Times

In a chemical plant that produces fertilizer, carbon dioxide and dry ice, a pipeline explosion occurred.

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