INCIDENT Operators Running Without Training: The Bayer Crop Science Incident Prior to the 2008 incident, the methomyl unit at the Institute facility had been shut down for two major equipment upgrades: the DCS had been replaced and the old carbon steel residue treater vessel had been replaced with a new stainless steel pressure vessel. In this […]
INCIDENT Williams Olefins Incident: The Day Multiple Safety Errors Led to a Major Chemical Plant Blast Part 3: Identification of potential hazards When the new valves were integrated into the existing system, the company underwent a management of change (MOC) process, which should have led to a more involved Process Hazard Analysis (PHA). If the […]
Previous INCIDENT Maintenance activities at Carbide Industries couldn’t keep pace with equipment deterioration. The failure was ultimately catastrophic. While no single cause was pinpointed for the March 21, 2011 explosion at Carbide Industries, most fingers point back to the furnace lid. This was a complex structure of steel and ceramic construction, designed to take the […]
Operators didn’t see the tank overfilling. Part of the problem was mechanical, but part was inattention. How much can we expect from individual operators? The Buncefield fuel depot fire was somewhat akin to leaving the tub filling in the upstairs bathroom, going somewhere else in the house and forgetting the water is running. On one […]
INCIDENT Mechanical Failures and Misunderstandings On March 23, 2005, the raffinate splitter process was being restarted after a turndown. The unit had been shut down February 21 so that the tower could be drained, purged, and steam cleaned to remove residues. Apparently nothing had been done to check level sensors installed in the tower, and […]
When disasters like the Sayano–Shushenskaya hydroelectric power station collapse in Khakassia, Russia, occur, it is difficult to get past the overpowering tragedy of 75 people losing their lives and 40 other sustaining injuries. The only way to draw positives from such an incident is to learn from the experience so that the same mistakes never […]
INCIDENT A Process Hazard Analysis of the Human Factor: Piper Alpha Incident Operator and supervisor errors escalated a process safety incident into a disaster. Could people better trained in oil and gas safety procedures have prevented it, or stopped the process safety incident once the fire stated? On the night of July 6, 1988, five […]
INCIDENT When the lower layers of protection are effective, upper layers may not get much attention. But then something fails and other weaknesses exposed. The Buncefield oil storage depot fire on December 10, 2005 provides an interesting examination of a fire at a site that most people probably considered safe. It was simply a tank […]
INCIDENT T2 Laboratories: Why Hazard Recognition is Step 1 in Bolstering Plant Safety On December 19, 2007, an exothermic reaction at T2 Laboratories, a Jacksonville, Florida-based chemical manufacturer, led to a runaway condition resulting in a massive explosion that killed four workers, injured 32 others and destroyed neighboring businesses. That day, the workers were mixing […]
INCIDENT Assessing & Learning From The Tragedy To Build Better Safety Measures When Turbine 2 broke apart violently at the power station, death and injury were not the only tragic outcome. The flooding of the turbine hall and engine room, and a collapsed ceiling damaged or destroyed 9 of 10 turbines resulting in over a […]
INCIDENT Ignoring a problem doesn’t make it less of a problem. It can allow a situation to escalate until something breaks. When the EAF exploded at Carbide Industries, March 21, 2011, the two fatalities were operators working in the control room only 12 ft. from the lid of the furnace. The explosion was violent enough […]
Catastrophic situations often occur as a result of complacency. If, over time, warnings of abnormal conditions are ignored without any apparent consequence, those situations begin to slide into the realm of routine. Then, if the pattern of consistent oversight persists, stakeholders suddenly and unexpectedly find themselves in a crisis situation that endangers both life and property. […]
Looking at the 2005 Texas City refinery fire with the benefit of nearly 10 years of reflection and much discussion of what was going on at the facility, it is difficult to imagine how anybody working there could have had any sense of personal security. Those individuals who spend most of their waking hours surrounded […]