Topic
Process Safety
Prevention and mitigation of major process-related events.
Newest 100 Documents
All 190 in search- 2026Sep
Shell Polymers Furnace Explosion and Fire — Furnace Explosion and Fire at Shell Polymers
Investigates the June 2025 furnace explosion and fire at Shell Polymers Monaca following coke-trap cleaning. Inadvertent opening of isolation valves allowed cracked gas to enter the firebox and ignite. The report examines reliance on administrative safeguards, safety instrumented system bypasses, alarm suppression and confusing valve interfaces, recommending engineered protection and improved interface design.
- 202619 Aug
Improvements Needed In Production Safety System Training
This alert reports offshore production safety training deficiencies identified through audits, written competency tests and fire drills. Findings include gaps in retained knowledge, certification, contractor training oversight and emergency preparedness. Operators and contractors are asked to consider reviewing training arrangements, verifying competence, improving lifesaving equipment familiarity and checking alarm audibility.
- 202610 Aug
United States Steel Corporation Clairton Plant Coke Oven Explosion
Investigates the fatal Clairton coke works explosion during high-pressure water washing of a cast-iron isolation valve. Overpressurisation caused valve failure and a coke oven gas release. The report examines maintenance procedures, hazard assessment, occupied-building siting and process safety governance, supported by valve examination and causal analysis.
- 202621 Jul
Bio-Lab Inc. Conyers Fire and Chemical Release
Investigation of the Conyers chemical-storage warehouse fire and release examines sprinkler corrosion, water-triggered decomposition and emergency response. It identifies sprinkler component failure as the most likely initiating water source, analyses storage and ventilation shortcomings, and recommends corporate safeguards and broader reactive-hazard coverage. Supporting work includes AcciMap analysis and chemical testing.
- 202627 May
Givaudan Sense Colour Explosion
Investigation of a fatal reactor explosion during caramel colouring manufacture in Louisville. A vent valve failed closed, accelerating sugar decomposition; cooling and emergency pressure relief capacity were inadequate. Calorimetry and component testing inform findings on reactive hazards, process safety implementation, operating limits, occupied-building siting and regulatory coverage gaps.
- 2026Apr
Emergency response systems save lives! — Process Safety Beacon, April 2026
This issue examines an ammonia release at a Virginia food processing facility where evacuees encountered the outdoor cloud and four employees were hospitalised. It highlights shortcomings in alarms, emergency shutdown use and release-specific planning, emphasising trained responders, regular drills, safe relief discharge locations and wind-dependent evacuation routes.
- 2026Mar
Production PINCs
Numbered regulatory inspection questions address production safety systems, well barriers and casing-pressure diagnostics. Checks cover shutdown valve operation, gas and fire detection calibration, firewater pumps, pressure relief and protective devices on process equipment. Conditional approval requirements and specified testing intervals support inspection of production facilities and subsea components.
- 202626 Feb
Dow Louisiana Operations Explosions
Investigation of the Dow Plaquemine explosion examines work lights left inside a reflux drum during turnaround. Degraded light debris punctured a rupture disc, admitting ethylene oxide into air-containing relief piping. The report analyses vessel closure practices, loss of nitrogen inerting, inadequate monitoring and relief routing that enabled propagation into the drum.
- 202623 Feb
PEMEX Deer Park Chemical Release
CSB investigation of a fatal hydrogen sulphide release during refinery maintenance in Deer Park, Texas. Workers opened the wrong flange on active piping. The report examines equipment identification, permit scope and hold points, interacting maintenance operations, contractor reassignment and operational discipline, recommending clearer marking and work authorisation arrangements.
- 2026Feb
Inherently Safer Principles — Process Safety Beacon, February 2026
Explains inherently safer design through an alkylation reactor sampling case. Consistent quality-control results supported reducing routine sampling from twice daily to weekly, with additional samples under specified changes or upsets. Introduces minimisation, substitution, moderation and simplification, and calls for management-of-change review before implementing identified options.
- 2026Jan
Near-misses predict future incidents — Process Safety Beacon, January 2026
This bulletin explains how near-misses can reveal weaknesses in process safety systems before serious incidents occur. It places them within Tier 3 process safety metrics and encourages personnel to recognise and report events, understand company definitions, and ask about learning. Collected reports should be analysed for potentially serious trends.
- 2025Dec
Health Safety Insight 2025
Annual review of UK offshore energy health and safety, centred on 2024 performance with historical comparisons. It examines hydrocarbon releases, maintenance backlogs, injury trends, medical assessment outcomes and evacuations, including mental health. Offshore aviation analysis covers fleet utilisation, helicopter safety indicators and the inclusion of wind operations.
- 2025Oct
Refinery Cooling Tower Explosion and Fire — Process Safety Beacon, October 2025
A refinery cooling tower incident in India illustrates how hydrocarbons leaking from a heat exchanger can accumulate in cooling water pipework and escape during commissioning. Ignition was likely associated with nearby hot work. The bulletin discusses exchanger vulnerability, start-up hazards and notifying nearby workers so they can suspend work.
- 202525 Sep
Cuisine Solutions Ammonia Release
CSB investigates an ammonia refrigeration release at Cuisine Solutions in Sterling, Virginia, which injured workers during evacuation. Relief-valve testing and dispersion modelling examine overpressure, liquid aerosol and unsafe discharge. The initiating upset remains undetermined. Recommendations address relief-system assessment, process-data retention, ammonia alarms and emergency preparedness.
- 20253 Jun
TS USA Molten Salt Eruption
Investigates the fatal molten-salt eruption at TS USA’s Chattanooga facility on 30 May 2024. Retained water in a plugged roller generated pressure before entering the oxidising bath and producing a steam explosion. Examines drainage hazards, reprocessing procedures, training, protective barriers and failures to share learning from earlier incidents.
- 202527 May
Honeywell Geismar Chlorine and Hydrogen Fluoride Releases
Investigation of three releases at Honeywell Geismar’s HFC-245fa unit between 2021 and 2024, involving fatal HF exposure, a corrosion-driven reboiler explosion and serious injury during gasket replacement. The report examines mechanical integrity, startup procedures, protective equipment, organisational change and capital funding, recommending independent auditing and safer-technologies analysis.
- 2025Apr
Knowing ‘why’ makes tasks safer — Process Safety Beacon, April 2025
This bulletin compares valve actuator removal incidents in La Porte in 2021 and Baton Rouge in 2016. It highlights missing procedures and training, and stresses understanding why critical tasks follow specified steps. Recommendations include illustrated instructions, signed checklists, demonstrated competence and checking procedures against field conditions.
- 202513 Mar
Marathon Martinez Renewable Fuels Fire
Investigation of a renewable diesel startup fire at Martinez, California, following heater tube rupture. Low process flow and afterburning caused overheating, releasing diesel and hydrogen and seriously injuring an operator. The report examines valve alignment, instrumented safeguards, combustion monitoring, alarm responses, human factors and corporate oversight, with recommendations and comparisons to earlier incidents.
- 2025Feb
Process safety leadership findings of Energy Division inspection programme
HSE reports findings from inspections of UKCS production operators’ process safety leadership, using a consistent framework based on the COMAH leadership intervention tool. It examines leadership competence, contractor assurance, cumulative risk, performance indicators and incident learning, identifying weaknesses alongside good practice and recommendations for duty holders.
- 2024Oct
Some short-cuts may cut lives short — Process Safety Beacon, October 2024
This bulletin examines procedural shortcuts through a fatal polyethylene reactor incident in Pasadena, Texas. It describes inadequate isolation, unenforced permits and cross-connected valve air hoses. Guidance stresses operational discipline, functioning safeguards and authorised assessment of changes, warning against treating temporary safeguard bypasses as routine practice.
- 202424 Jun
BP - Husky Oregon Chemical Release and Fire
Investigates the fatal naphtha release and flash fire at the BP-Husky Toledo Refinery in Oregon, Ohio. Examines cascading process disturbances, vessel overflow, manual draining, misleading level indications and alarm overload. Recommendations address engineered overfill safeguards, abnormal-situation procedures, stop-work practice and alarm performance, alongside shortcomings in applying earlier incident lessons.
- 202321 Dec
KMCO LLC Fatal Fire and Explosion
Investigation of the fatal isobutylene explosion and fire at KMCO’s Crosby facility. Metallurgical testing established pressure-driven brittle fracture of a cast-iron y-strainer. The report examines thermal-expansion hazards, manual versus remote isolation, emergency-response roles and alarm use, identifying weaknesses in hazard evaluation and response that contributed to the incident and its severity.
- 202311 Dec
Foundation Food Group Fatal Chemical Release
Investigation of a fatal liquid nitrogen overflow at Foundation Food Group’s poultry plant. A deformed bubbler tube disabled freezer level control and overflow protection, producing an oxygen-deficient room atmosphere. The report examines design dependencies, missing monitoring and ventilation, emergency preparedness, process safety management and regulatory gaps.
- 20236 Dec
Didion Milling Company Explosion and Fire
CSB investigates fatal combustible corn dust explosions at Didion’s Cambria mill. It examines propagation through interconnected dust collectors and pneumatic conveying systems, secondary explosions and building collapses. Comparative mill teardown, dust testing and explosion modelling support analysis of deficient safeguards, change management, housekeeping, emergency preparedness and regulatory oversight.
- 2023Dec
Overfill of vapour recovery units
HSE warns that a gasoline overfill exposed dependence between a vapour recovery unit’s process controls and overfill protection, resulting in loss of containment. The notice calls for risk assessment, physical verification, inspection, maintenance and testing of safety functions, with independent safeguards and control-system modifications where required, managed through change procedures.
- 202330 Nov
Yenkin-Majestic Resin Plant Vapor Cloud Explosion and Fire
Investigation of a fatal resin-plant explosion and fire following solvent vaporisation and release through an altered reactor manway. The report examines pressure-containment design, inadequate alteration assurance, agitator-dependent safeguards, alarm deficiencies and evacuation preparedness. Recommendations address low-pressure vessel guidance, safer process design and flame-resistant clothing.
- 20236 Jul
Intercontinental Terminals Company (ITC) Tank Fire
Investigation of the March 2019 tank-farm fire at ITC’s Deer Park terminal, following a circulation-pump seal failure and butane-enriched naphtha release. The report examines pump maintenance, gas detection, emergency isolation, fire spread, containment failure and regulatory exemptions, with recommendations addressing mechanical integrity, tank-farm design and process safety management.
- 20236 Jul
Optima Belle Explosion and Fire
An interim CSB investigation update describes a fatal dryer explosion during trial dehydration of sodium dichloroisocyanurate dihydrate at Optima Belle in West Virginia. It outlines vacuum drying, steam heating, sampling and temperature changes, alongside decomposition hazards. Explosion debris caused a neighbouring methanol pipeline fire; the initiating conditions remain under investigation.
- 202329 Jun
Watson Grinding Fatal Explosion and Fire
Investigation of the Houston propylene explosion that killed two employees and a nearby resident. It examines a degraded, poorly crimped hose, inconsistent supply isolation and non-functional automated safeguards. Findings address process safety management, change assessment, emergency preparedness and regulatory exclusions; lighting activation is identified as the likely ignition event.
- 202325 May
LyondellBasell La Porte Fatal Chemical Release
This investigation examines the fatal chemical release during plug-valve actuator removal at LyondellBasell’s La Porte complex. Two workers died following exposure to acetic acid and methyl iodide. It compares similar incidents and examines valve design, pressure-retaining components, work procedures, training, isolation and pre-authorisation risk assessment.
- 202312 May
Process Explosion Causes Medical Evacuation
Two offshore workers installing a skillet in pipework suffered smoke inhalation and burning sensations after opening a flange. The investigation identified absent purging or flushing and unrecognised potential pyrophoric materials. BSEE recommends considering fire and explosion management plans and procedures addressing ignition sources, oxygen ingress and fuel.
- 202324 Apr
Bio Lab Conyers Chemical Release
Investigation of Hurricane Laura damage, chemical decomposition, chlorine release and fire at Bio-Lab’s Louisiana facility. It examines hurricane preparedness, process hazard analysis, structural damage, fire-water reliability and regulatory coverage of reactive chemicals. Appendices analyse separate Conyers decomposition events and provide structural and fire-protection consultant reviews.
- 202324 Apr
Bio-Lab Lake Charles Chemical Fire and Release
Investigation of hurricane-related chemical decomposition, fire and chlorine release at Bio-Lab’s Louisiana manufacturing facility. It examines building resilience, process hazard analysis follow-through, deficient fire protection and emergency equipment readiness, alongside gaps in reactive-hazard regulation. Appendices include structural and fire-code assessments and separate Conyers decomposition incidents.
- 202229 Dec
Husky Energy Superior Refinery Explosion and Fire
Investigation of the Superior refinery explosion during fluid catalytic cracking shutdown. It examines air entering hydrocarbon equipment, missing steam-barrier and purge safeguards, eroded slide valves, procedural and training deficiencies, and brittle vessel fragmentation. Debris punctured an asphalt tank, escalating the event into fire; recommendations address transient-operation safeguards and emergency preparedness.
- 202221 Dec
Kuraray Pasadena Release and Fire
Investigation of an ethylene release and fire during reactor startup at Kuraray’s Pasadena plant, injuring 23 workers. It examines unsafe atmospheric pressure-relief discharge, disabled interlocks, alarm flooding, conflicting operating instructions and restricted flare use. Recommendations address safe discharge design, worker exclusion, operating limits, training and independent process safety assessment.
- 202219 Dec
TPC Port Neches Explosions and Fire
An investigation using AcciMap examines dead-leg management in high-purity butadiene service. Its causal analysis identifies an unimplemented process hazard analysis recommendation and a flushing procedure that was not carried out. It also records gaps in requirements for remotely operated emergency block valves on existing equipment.
- 202211 Oct
Philadelphia Energy Solutions (PES) Refinery Fire and Explosions
Investigates the PES refinery fire and explosions following corrosion-induced rupture of an elbow in its hydrofluoric acid alkylation unit. Examines material composition, inspection coverage, vessel failure, unavailable remote isolation and impaired water-spray mitigation. Contrasts successful rapid acid deinventory with failed safeguards and assesses alternative alkylation technologies and regulatory recommendations.
- 2022Oct
Communication – the heart of safe operations — Process Safety Beacon, October 2022
A solvent-transfer incident illustrates how unclear maintenance status and informal lockout arrangements can undermine safe restart. An operator was sprayed with solvent from an improperly tightened flange but was not injured. The bulletin emphasises work permits, communication between groups, participation in hazard reviews and following restart plans.
- 202229 Jul
Loy Lange Box Company Pressure Vessel Explosion
Investigation of a fatal steam-system pressure vessel explosion in St. Louis examines oxygen corrosion, incomplete repairs, water treatment and inspection failures. Metallurgical examination and thickness measurements underpin the findings. The report analyses regulatory oversight and process safety management, while noting that the pressure at rupture could not be determined.
- 202212 May
Process Safety Fundamentals – IOGP / Step Change
This safety flash summarises IOGP’s Process Safety Fundamentals through a Step Change in Safety learning pack suitable for safety meetings and toolbox talks. It highlights recognising change, stopping when work departs from expectations and investigating weak signals, alongside procedures, barriers, operating limits, isolation and ignition control.
- 2022May
“ What happens if ?” An important question for hazard reviews — Process Safety Beacon, May 2022
A fatal batch-mixing explosion and an earlier near-miss illustrate the importance of considering material misidentification and unintended reactions during hazard reviews. The bulletin recommends examining human error traps, using reactivity compatibility matrices, rigorously checking materials and keeping operating tanks closed, sealed and vented to a safe location.
- 2022Apr
Process Safety lessons from a ship fire — Process Safety Beacon, April 2022
This bulletin draws process-industry lessons from the USS Bonhomme Richard fire and a Navy review of earlier ship fires. It highlights improper storage of combustible and hazardous materials, ineffective inspections, deficient hot-work oversight and emergency preparedness, recommending adherence to permit procedures, designated storage and participation in emergency drills.
- 202228 Feb
UK HSE: Liquid petroleum gas (LPG) leak
This safety flash describes a release of around 15 tonnes of LPG at Fawley refinery, undetected for around four hours. HSE identified excessive pressure for the valve and absent flow-discrepancy detection. Emergency personnel reset the valve. The account stresses maintaining protective layers against major incidents; no fire or injury occurred.
- 2022Feb
Maintenance of industrial uninterruptible power supply (UPS) systems
This safety notice examines industrial UPS failures at onshore major hazard establishments, including disrupted emergency power, localised fires and plant shutdowns. It identifies inadequate maintenance information, shorter component lifetimes and outdated firmware, and calls for suppliers to review information and users to update maintenance arrangements using current manufacturer revisions.
- 202124 Sep
AB Specialty Silicones, LLC
Investigation of a fatal hydrogen explosion during silicone-emulsion batch manufacture in Waukegan, Illinois. Reactivity experiments linked unintended potassium hydroxide addition to hydrogen generation. The report examines similar chemical drums, atmospheric batch tanks, ventilation, failed detector trials, evacuation preparedness and procedural checks, alongside process safety culture and regulatory gaps for reactive chemicals.
- 202111 Aug
UK HSE: Oil company fined for hydrocarbon release – lack of written procedures
This safety flash describes prosecution following a release of more than 1000 kg of hydrocarbon gas at Beryl Alpha during well depressurisation. Missing risk assessment and written procedures left a technician relying on memory. Inadvertent defeat of emergency shutdown prolonged the release, while workers remained at muster for more than six hours.
- 202120 Jul
Cargo tank explosion and fire on chemical tanker Stolt Groenland
Investigation of the Stolt Groenland explosion and fire at Ulsan examines runaway styrene polymerisation following heat transfer through an intermediate cargo tank. It analyses inhibitor depletion, stowage planning, unused temperature monitoring and alarms, and onboard remedial limitations. Fire response and missed learning from the separate Stolt Focus incident are also considered.
- 202113 Jun
Industry safety improvement initiatives
This interim research report summarises an online survey of Australian offshore oil and gas operators’ safety improvement initiatives. It examines safety indicators, personal and process safety training, leadership coaching, culture perception surveys and improvement strategies. Findings are presented descriptively, with open responses summarised by word frequency and further qualitative research planned.
- 202113 Jun
Safety improvement initiatives in the Australian offshore petroleum industry
Descriptive results from a 2017 duty-holder survey examine personal and process safety indicators, training, leadership, culture and error risk management initiatives. Analysis includes 32 responses, with selected comparisons against 2012 findings. The report presents anonymised aggregate data and verbatim free-text responses without interpretive commentary.
- 2020Oct
Process Safety Fundamentals (IOGP Report 638)
Guidance introduces ten Process Safety Fundamentals for upstream operations, with downstream applicability also proposed. It addresses procedures, barriers, operating limits, isolation, ignition sources, change and unexpected conditions. Implementation guidance emphasises organisational engagement and coaching, supported by analysis of fatal and non-fatal process safety events and discussion of performance indicators.
- 2020Jul
Process interruptions: a threat to process safety — Process Safety Beacon, July 2020
This bulletin examines an explosion involving mononitrotoluene left in a shut-down vacuum distillation column. Leaking steam valves heated the material, leading to decomposition and a runaway reaction. It highlights shutdown isolation, detailed procedures, continued monitoring of process parameters and alarms, and repair or replacement of leaking block valves.
- 2020Jun
Can a “fail open” valve fail closed? — Process Safety Beacon, June 2020
A batch reactor incident illustrates how a valve designated fail open can remain closed when its mechanical linkage fails. The bulletin distinguishes utility-loss positions from other failure modes, discusses field observation of valve operation, and asks participants in hazard identification and change reviews to consider unintended valve positions.
- 202030 Jan
Explosion and fire on-board the chemical tanker Stolt Groenland
This safety flash summarises preliminary MAIB findings on explosions and fire aboard Stolt Groenland during ship-to-ship styrene monomer transfer at Ulsan. Investigators considered deck rupture from over-pressurisation followed by vapour ignition the probable explosion mechanism. The incident caused extensive vessel damage and injuries to crew and firefighters.
- 201917 Dec
Midland Resource Recovery Explosion
This investigation examines two fatal explosions during draining of chemically treated gas odorizers at Midland Resource Recovery in West Virginia. It identifies failures to characterise vessel contents and manage reactive chemistry hazards, while leaving the exact reactions unresolved. The report discusses operating procedures, overpressure protection and gaps in regulatory coverage.
- 201916 Dec
Explosion and fire on chemical tanker Stolt Groenland
This interim investigation examines explosions and fire aboard Stolt Groenland at Ulsan. Initial findings link probable tank rupture and vapour ignition to over-pressurisation during styrene monomer polymerisation. It describes inhibitor dosing, cargo conditions, firefighting and evacuation, alongside a separate Stolt Focus incident and reminders on monitoring and carriage instructions.
- 201930 Sep
UK HSE prosecution following 2011 fatal explosion in oil refinery
This safety flash reports HSE prosecution following a fatal refinery explosion in Pembrokeshire during tank emptying with a vacuum tanker. Four workers died and another was seriously injured. Investigators considered ignition of a highly flammable tank atmosphere the most likely initiator and identified longstanding safety-management failures.
- 2019Aug
Hidden Hazards! — Process Safety Beacon, August 2019
This manufacturing safety bulletin addresses hidden chemical and energy hazards before opening process equipment. An employee injury involving undocumented piping containing sulphuric acid illustrates the problem. It recommends understanding equipment contents, verifying labels, reviewing service changes, following line-breaking and lockout procedures, and resolving uncertainties before proceeding.
- 201925 Jun
DuPont La Porte Facility Toxic Chemical Release
Investigation of a fatal methyl mercaptan release at DuPont’s La Porte insecticide unit. Four workers died inside the manufacturing building. The report examines hydrate-blocked pipework, drain valves, inadequate safeguards, alarm communication and emergency response, alongside management of change, audit effectiveness, process safety culture and misleading reliance on occupational injury metrics.
- 201913 Feb
Enterprise Pascagoula Gas Plant Explosion and Fire
This case study examines the Pascagoula gas plant fires and explosions, identifying thermal fatigue in a brazed aluminium heat exchanger as the probable cause. It analyses repair history, blocked-layer venting, temperature monitoring and process safety management deficiencies, alongside emergency response and community notification. Two night-shift workers were uninjured.
- 201827 Sep
PSSR Rule Fact Sheet
This fact sheet outlines revisions to offshore oil and gas production safety regulations following review of the 2016 rule. It summarises updated standards, removal of third-party device certification, gas-lift shutdown valve classification, failure reporting, design documentation, atmospheric vessels, fire-tube inspection methods and approval before commencing production.
- 2018Aug
What if your agitator fails? — Process Safety Beacon, August 2018
This bulletin examines a German batch-reactor incident in which restarting agitation mixed accumulated reactants, rapidly raising temperature and releasing contents through a relief valve. It explains mixing and heat-transfer hazards, including in non-reacting vessels, and recommends obtaining technical assistance and reviewing operating history before restarting an agitator after loss of agitation.
- 2018Jul
Can overcooling a reactor cause a runaway reaction? — Process Safety Beacon, July 2018
This bulletin examines a British dye-factory reactor explosion following overheating, cooling below the required range and resumed reactant addition. It explains how low temperatures can allow reactants to accumulate, increasing vulnerability to runaway reactions. Laboratory studies and simulations suggested another heat source might also have been necessary in this incident.
- 201824 May
Arkema Inc. Chemical Plant Fire
Investigates organic peroxide fires at Arkema’s Crosby facility following Hurricane Harvey flooding. Examines loss of refrigeration and backup cooling, common-mode safeguard failures, flood-risk omissions in process hazard analysis, and evacuation decisions. Reviews extreme-weather guidance and recommends independent protection layers and improved emergency planning.
- 201824 Apr
Packaging Corporation of America Hot Work Explosion
Investigation of a foul condensate tank explosion at PCA’s DeRidder mill that killed three contractors and injured seven. Air ingress created an explosive atmosphere; nearby hot work was the probable ignition source. The report examines turpentine recovery, outage conditions, permit limitations, process safety boundaries and explosion safeguards, with comparisons to earlier incidents.
- 20182 Mar
Loss of Containment (LoC) - Version 2 March 2018
Inspection guidance for assessing offshore oil and gas duty holders’ containment safeguards. It covers design, commissioning, operating limits, instrumented protection, relief, isolation, reinstatement and change management. Specialist sections address process hazards, FPSOs, tubing and hoses, alongside investigation, performance indicators, assurance and leadership.
- 2018Feb
Runaway Reactions Caused by Contamination — Process Safety Beacon, February 2018
This bulletin examines two explosions involving contaminated process materials: heated organic residue in pipework and crude methacrylic acid in a rail tank car. It explains reduced decomposition temperature, corrosion-related contamination and insufficient inhibitor, and recommends material identification, suitable construction materials, cleanliness and adherence to contamination-prevention procedures.
- 20185 Jan
Safety Alert 328 - Gas Release Hazards Identified by BSEE
BSEE summarises targeted Gulf of Mexico gas-release inspections following a review of incident and compliance data. Findings include oil or gas accumulation, deficient detector assurance, limited area-classification signage and gaps in work practices and training. Recommendations address inspection protocols, detector documentation, accessible procedures, job safety analyses and contractor training.
- 20183 Jan
MGPI Processing, Inc. Toxic Chemical Release
This case study investigates an incorrect sulfuric acid delivery connection to a sodium hypochlorite tank at MGPI in Atchison, Kansas, producing a chlorine-containing cloud. It examines unloading equipment design, pipe identification, procedure compliance, training, remote shutdown, control-room ventilation and escape respirator access, alongside community emergency planning and subsequent preventive changes.
- 20178 Dec
Safety Alert 327 - Failure to Properly Purge Compressors Leads to Explosions
This alert describes two compressor start-up explosions involving inadequate purging. One injured a mechanic with flying debris; the other damaged a cooler and piping. Preliminary findings discuss panel logic, purging knowledge and job safety analysis. Recommendations address procedures, training, start-up permissives and manufacturer-directed maintenance.
- 201715 Nov
Changes from dry gas to wet gas operation: guidance for HSE inspectors
Inspector guidance examines offshore installations converting from dry to wet gas operation. It addresses corrosion inhibition and monitoring, pipeline pigging and inspection, altered liquid flow, valve performance, detection and blowdown arrangements. It also covers maintenance, staffing, training, health hazards and management of change, including implications for onshore processing.
- 201718 May
Delaware City Refining Company
CSB safety bulletin examines a flash fire during maintenance preparation at Delaware City Refining Company. Hydrocarbons backflowed through a leaking closed valve while vessels were being emptied. It discusses isolation integrity, informal preparation instructions and management of change, with lessons on more protective isolation and an appendix reviewing other maintenance-related incidents.
- 20173 May
ExxonMobil Torrance Refinery Explosion
CSB investigates the Torrance refinery electrostatic precipitator explosion during FCC Safe Park operation and expander isolation. It examines failed catalyst and steam barriers, slide-valve erosion, hydrocarbon backflow, inadequate procedures and detection, and ignition within the energised precipitator. Recommendations address isolation, safeguard assurance, maintenance, operating modes and equipment siting.
- 201720 Apr
AirGas Facility Fatal Explosion
CSB investigates the fatal nitrous oxide explosion at Airgas in Cantonment, Florida, on 28 August 2016. Probable initiation involved transfer-pump heating during trailer loading, although the initiating event remains uncertain. Analysis examines flame arrestors, interlock design, pump changes and process safety management, alongside earlier explosions and recommendations for inherently safer design.
- 201619 Oct
Williams Olefins Plant Explosion and Fire
CSB case study examines the fatal Williams Geismar reboiler rupture, BLEVE and fire. It analyses likely liquid thermal expansion in standby equipment lacking effective pressure relief, alongside shortcomings in change management, hazard analysis and operating procedures. Metallurgical testing, finite element analysis and process modelling inform the failure assessment and recommendations.
- 20162 Aug
Tesoro Martinez Sulfuric Acid Spill
CSB case study examines two sulfuric acid releases at the Martinez refinery in February and March 2014, injuring four workers. It analyses sampling-system integrity, protective equipment, pipe preparation and isolation, alongside process safety culture and missed incident learning. Comparisons with other refineries inform discussion of safer sampling arrangements.
- 2016Mar
Safety Device or Control Device? — Process Safety Beacon, March 2016
This bulletin distinguishes routine process control from independent safety protection through a steam-locomotive example and a tank-overflow incident. It explains how reassigned operator duties turned a backup shutdown into primary control, and recommends clear procedures, training, calibration and scheduled testing of safety devices.
- 201628 Jan
West Fertilizer Explosion and Fire
Investigation of the West, Texas fertiliser facility fire and explosion, which killed 15 people and injured more than 260. The report examines ammonium nitrate detonation scenarios, storage construction, emergency planning, firefighter training, regulatory gaps and community siting. Laboratory analysis, damage surveys and seismic evidence inform findings while the precise detonation sequence remains uncertain.
- 2016Jan
Hydrate Hazards — Process Safety Beacon, January 2016
This bulletin explains hydrate formation in water-containing process systems and the temperature and pressure conditions involved. It describes blockage, trapped pressure and possible pipe rupture during removal, citing a fatal methyl mercaptan release. It emphasises understanding plant prevention and removal procedures and evaluating hazards before non-routine clearance work.
- 201521 Oct
Caribbean Petroleum Corporation (CAPECO) Refinery Tank Explosion and Fire
Investigation of gasoline tank overfill at CAPECO’s petroleum terminal, followed by vapour-cloud ignition and multiple tank fires. It examines unreliable float-and-tape gauging, absent independent overfill safeguards, drainage valves, filling procedures and emergency preparedness. Comparisons with earlier incidents inform recommendations addressing regulatory gaps and automatic overfill protection.
- 2015Oct
Water, water, everywhere... — Process Safety Beacon, October 2015
This manufacturing safety bulletin explains how misplaced water can trigger chemical reactions, catalyse decomposition or generate steam pressure. Examples include Bhopal, a ruptured residue pipe and a molten-iron furnace incident. It emphasises following operating procedures and reviewing exceptional water use through job safety analysis or management of change where appropriate.
- 2015Jul
Know when to leave! — Process Safety Beacon, July 2015
Three chemical-process incidents contrast fatal attempts to manage abnormal reactions or releases with prompt evacuation during a cylinder fire. The bulletin stresses recognising when to leave danger, understanding site emergency arrangements and practising drills, including knowing when evacuation or sheltering in a safe place is appropriate.
- 201512 Jun
Safety Alert 317 - Catastrophic Incident Avoided
A mezzanine deck shifted during installation on a floating offshore facility, damaging pressurised gas piping and a valve. The crew subsequently cut a brace without a change request or work permits before the installation manager stopped work. The alert examines shortcomings in lift planning, hazard communication and supervision, and recommends reinforcing effective stop-work arrangements.
- 2015Feb
Who are all these people? — Process Safety Beacon, February 2015
This bulletin uses three serious process incidents to discuss unnecessary personnel near hazardous operations. It explains how crowding can distract operators and increase exposure during startup, shutdown and abnormal conditions. Recommendations address access arrangements in operating procedures, emergency instructions for non-essential personnel and consideration of postponing other tasks.
- 201528 Jan
Chevron Richmond Refinery Fire
Final investigation of the Richmond refinery pipe rupture and fire examines sulfidation corrosion in low-silicon carbon steel, incomplete component inspection and rejected material upgrades. It analyses leak response, shutdown decisions, stop-work authority and safety culture, recommending stronger inspection requirements, corrosion-resistant materials and site-specific leak response protocols.
- 201515 Jan
Millard Refrigerated Services Ammonia Release
This safety bulletin examines an ammonia release at Millard’s refrigerated export facility. It discusses hydraulic shock likely associated with omitted defrost bleeding, shared evaporator valve controls and continued refrigerant supply to ruptured pipework. Prevention lessons address individual valve groups, protected controls and emergency shutdown when releases cannot be promptly isolated.
- 201515 Jan
US Ink Fire
CSB examines the US Ink explosion and flash fires that burned seven workers in East Rutherford, New Jersey. The investigation analyses combustible deposits, dust collection design, commissioning and hose failures, alongside deficiencies in organisational change, training and alarms. Laboratory testing and engineering analysis underpin findings and recommendations.
- 2014Sep
What is your role in Hazard Identification and Risk Analysis? — Process Safety Beacon, September 2014
This bulletin explains how front-line workers contribute to hazard identification and risk analysis through practical operating knowledge. It outlines what-if analysis, checklists and HAZOP, encourages discussion of procedural differences and equipment reliability, and stresses checking operator safeguards. The Longford fire illustrates the importance of completing planned studies.
- 2014Aug
Ignition Sources — Process Safety Beacon, August 2014
This bulletin explains why preventing flammable mixtures must be complemented by ignition-source control when equipment or procedures fail. It emphasises work permits, emergency actions during releases, hazardous-area classification and restrictions on portable electronics. It also highlights hot surfaces as potential ignition sources, particularly for materials with low autoignition temperatures.
- 2014Jul
Persistence – Good or Bad? — Process Safety Beacon, July 2014
Uses five process incidents to examine persistence when operations behave unexpectedly. Examples involve reactive blending, flammable releases, misleading vessel levels and phosgene feed hoses. Emphasises stopping for help, respecting operating limits, considering instrument readings and establishing criteria for emergency procedures or evacuation rather than attempting hazardous corrective action.
- 20145 Jun
Macondo Investigation Overview
Overview of the CSB investigation into the Macondo blowout during temporary well abandonment on Deepwater Horizon. It outlines the multi-volume report’s technical, organisational and regulatory scope, highlighting blowout preventer limitations, safety culture and international regulatory comparisons. It also describes evidence gathering, public hearings and obstacles to the investigation.
- 20141 May
Tesoro Anacortes Refinery Fatal Explosion and Fire
Investigation of the Tesoro Anacortes refinery heat-exchanger rupture that killed seven employees. Metallurgical analysis identified high temperature hydrogen attack in carbon steel. Process modelling, inspection limitations and Nelson curves are examined alongside hazardous startup practices, ineffective safeguards, safety culture and regulatory gaps. Recommendations emphasise inherently safer materials and verified operating conditions.
- 2014May
Key Programme 4 (KP4) Report
HSE reports findings from its 2011–2013 ageing and life-extension inspection programme for offshore installations. It examines structural, process, marine and pipeline integrity, equipment obsolescence and organisational arrangements. Recommendations emphasise forward planning, performance-data trending and assurance, supported by dutyholder case studies covering structural monitoring, gap analysis and hydrocarbon leak reduction.
- 2014Feb
Are we reliving past incidents? — Process Safety Beacon, February 2014
This bulletin compares recurring storage-tank fires involving carbon adsorbers in Norway and Georgia, USA. Adsorption heat and the absence of flame arresters were shared design problems. It advocates retaining and sharing incident knowledge, reviewing events elsewhere, and evaluating new hazards introduced by environmental protection equipment through process hazard analysis and management of change.
- 201325 Nov
Safety Alert 305 - Explosion, Fire and Fatalities West Delta Block 32 Platform E
This alert describes fatal explosions and fires during piping installation on West Delta 32 E platform. Welding ignited hydrocarbon vapours from a wet oil tank, followed by explosions in three tanks. It identifies failures in hot-work authorisation, isolation, fire watching and supervision, and recommends improved contractor coordination, pre-work meetings and stop-work arrangements.
- 20137 Feb
Carbide Industries Fire and Explosion
CSB case study examines a fatal electric arc furnace explosion at Carbide Industries in Louisville. It discusses cooling-water leaks, furnace-cover deterioration, control-room vulnerability and normalisation of recurring overpressure events. The exact cause remained undetermined. Recommendations address mechanical integrity, preventive maintenance and furnace-cover replacement, alongside identified gaps in furnace standards.
- 201317 Jan
Donaldson Enterprises, Inc. Fatal Fireworks Disassembly Explosion and Fire
This investigation examines a fatal fireworks-disposal explosion and fire in Waipahu, Hawaii. Disassembly accumulated explosive components, increasing the hazard and obstructing escape. The report analyses diesel soaking, possible ignition sources, deficient hazard analysis, process changes, contractor oversight and regulatory gaps. The ignition source was not definitively identified.
- 201219 Apr
E. I. DuPont De Nemours Co. Fatal Hotwork Explosion
Investigation of a fatal hot-work explosion at DuPont’s Buffalo facility during repairs to slurry-tank agitator supports. Vinyl fluoride vapour reached the tank through interconnected pipework. The report examines missing isolation, omitted internal atmospheric testing, inadequate process knowledge in permit review and undocumented process changes, with comparisons to earlier tank-welding incidents.
- 2012Apr
What if you unload the wrong material into a tank? — Process Safety Beacon, April 2012
This bulletin describes a chemical delivery connected to the wrong storage tank, producing toxic gases and prompting evacuation and sheltering. It examines similar labels, identical connections, procedural changes and missing checks, and recommends clearer identification, connection verification, qualified workers and management of procedural changes.
- 2012Jan
What happens when the lights go out? — Process Safety Beacon, January 2012
A mistaken circuit-breaker operation briefly interrupted PLC power, leaving a process running with partial controls and overloading a vent scrubber with toxic material. The bulletin emphasises assessing combined utility-failure effects, understanding device failure states, clearly labelling electrical controls, verifying operation and practising emergency procedures.
- 201120 Sep
DuPont Belle Toxic Chemical Releases
Final investigation of methyl chloride, oleum and phosgene releases at DuPont’s Belle plant in January 2010, including a fatal phosgene exposure. It examines rupture-disc alarms, sample-line corrosion, PTFE transfer-hose failure and maintenance scheduling, supported by metallurgical testing and dispersion modelling. Recommendations address change management, hazard assessment and phosgene safeguards.