Setting
Onshore Facility
Physical location at a land-based industrial or operating facility.
Newest 100 Documents
All 184 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.
- 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.
- 202615 Apr
UK HSE: electrician seriously injured on onshore wind farm
An electrician sustained life-changing injuries during substation maintenance at an onshore wind farm. The investigation identified departure from a prepared switching programme and inadequate checking and change approval processes. The flash highlights safe work systems, management of change, coordination of parallel tasks, electrical-work review and supervision.
- 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.
- 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.
- 2025Nov
PPE only works when you wear it correctly! — Process Safety Beacon, November 2025
This Beacon examines a California refinery release during pressure-gauge replacement, where ineffective isolation and absent respiratory protection increased harm from hydrogen sulphide exposure. It explains limitations of personal protective equipment and stresses task-specific procedural requirements, correct use, pre-use inspection and regular checks of condition and respirator cartridge expiry.
- 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.
- 2025Sep
Several errors lead to a hydrogen leak & fire — Process Safety Beacon, September 2025
This bulletin examines a hydrogen filling incident in Santa Clara in which a trainee inadvertently restarted filling while piping was dismantled for repair. Escaping hydrogen ignited, producing a deflagration and jet fire. It emphasises isolation procedures, authorised repairs, understandable controls and clear instructions for newer employees.
- 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.
- 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.
- 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.
- 202416 Apr
Lone worker collapsed at onshore site
A lone worker at an onshore workshop collapsed because of a pre-existing, non-work-related medical condition and was discovered the following day. The flash examines delayed alarm raising and absent personnel tracking, highlighting lone-working risk assessment, medical screening, health surveillance and consideration of automatic fall alarms.
- 202326 Dec
Wendland 1H Well Fatal Explosion
CSB investigates a fatal blowout and fire during tubing-head replacement at a Texas oil and gas well. It analyses inadequate well-control planning, ineffective hydrostatic and valve barriers, and ignition-source management. Recommendations address workover methods for underpressured reservoirs, well-history review and gaps in industry guidance and federal regulation.
- 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.
- 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.
- 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.
- 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.
- 2023Jan
Hydrogen Sulfide Release
This fatality alert describes hydrogen sulphide poisoning that killed a worker responding to a pump alarm and, later, his spouse at an oil production facility. It examines defective gas detection, missing detector-use policies, inadequate isolation arrangements and visitor access, alongside recommendations for lockout/tagout, ventilation assessment and detection-system assurance.
- 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.
- 20221 Nov
Failure to plan properly: electrician sustains serious burns (UK HSE)
An electrician suffered serious burns at a supermarket warehouse when his metal spanner contacted a live busbar, causing an electrical explosion. Generator connection work alongside high-voltage maintenance lacked adequate planning and contractor coordination. The flash highlights failures to stop the circuit supply and appoint a competent person to organise the work.
- 202228 Sep
Sunoco Logistics Partners Flash Fire
Investigation of a flash fire and explosion during flange welding at Sunoco’s Nederland terminal, injuring seven contractors. The report examines residual crude oil, pipe isolation tools, atmospheric testing, permits and procedure implementation. It discusses similar incidents and stresses ensuring a non-flammable internal atmosphere before hot work; the specific causal scenario remains unresolved.
- 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.
- 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.
- 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.
- 202124 Sep
Evergreen Packaging Paper Mill - Fire During Hot Work
Investigation of a fatal fire during paper-mill tower maintenance in Canton, North Carolina. A heat gun fell into flammable resin, and fire spread between connected bleaching towers, killing two workers. The report examines hot-work recognition, confined-space permits, contractor coordination, combustible fibreglass construction and emergency response, with recommendations for procedures and training.
- 202121 May
Aghorn Operating Inc. Waterflood Station Hydrogen Sulfide Release
This investigation summary examines a fatal hydrogen sulphide release at an Odessa waterflood station that killed an employee and his spouse. It identifies a broken pump plunger, while leaving failure timing unresolved, and examines detector nonuse, missing lockout procedures, inadequate ventilation, detection and alarm failures, and deficient site security.
- 202122 Apr
EC175B Accessory Gearbox Bearing Failure During Post-Maintenance Ground Run
An AAIB investigation examines an EC175B accessory gearbox bearing failure during a post-maintenance ground run at Aberdeen Airport. Excess grease and trapped air imposed excessive axial loading during alternator installation. Manufacturer testing informed revised maintenance instructions covering grease removal and V-band clamping. A subsequent similar event is also discussed.
- 202023 Oct
UK HSE: Employee's foot crushed by forklift at maritime freight logistics company
A worker suffered multiple foot fractures when a 15 tonne forklift ran over his foot while steel coils were being unloaded and stacked in a South Wales shed. The flash reports HSE prosecution of the maritime logistics company and findings of inadequate workplace transport risk control and assessment.
- 202025 Aug
Fire in welding fumes extraction system
A shore-based workshop was evacuated after filters in a welding fume extraction unit caught fire. Blocked filters allowed metal particles to accumulate, oxidise and heat up. Portable carbon dioxide extinguishers proved unsuccessful; emergency services used water and cooling. The flash recommends incorporating manufacturer-specified pressure-display checks into routine operation and maintenance.
- 202015 Apr
UK HSE: Worker fell into lift shaft – safety controls bypassed
A worker moving a loaded trolley in a hangar suffered life-changing injuries after falling into a lift shaft. Although the exact cause was not established, investigators found faulty lift doors and routine bypassing of safety devices using an emergency release key. The flash highlights withdrawal from service or alternative working arrangements and communication.
- 2020Mar
March, 2020 - Vacuum Trucks can Catch Fire and Explode! — Process Safety Beacon, March 2020
This bulletin describes a vacuum truck explosion at a Californian wastewater facility involving incompatible substances, followed by fires and evacuations. It explains flammable vapour and static electricity hazards during vacuum collection, and highlights permit completion, material compatibility checks, grounding and bonding, and separation of vent discharge from ignition sources.
- 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 Jul
High potential near miss – Storage box dropped from forklift
A high-potential near miss involved a storage box weighing approximately 770 kg falling 4 m from forklift forks at a supply base. Non-captive pockets were used after handling information was not passed to new personnel. Lessons include reviewing handling instructions and clearly marking lifting locations visible from ground level.
- 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.
- 201912 Jun
Pryor Trust Fatal Gas Well Blowout and Fire
Investigation of an Oklahoma gas-well blowout and fire that killed five workers in the driller’s cabin. It examines underbalanced drilling, tripping methods, missed influx indications, disabled alarms, procedural and change-management deficiencies, blocked escape routes and unsuccessful blowout-preventer closure. Recommendations address drilling regulation, barrier assurance, alarm design and operating practices.
- 201920 Mar
Near miss: Winch wire snagged and released suddenly
A land-based drilling near miss involved a winch-wire thimble snagging on the rig chassis while the mast was raised. Increasing tension bent the thimble, releasing the wire and hoist plug near the driller. Lessons address safe wire positioning, snagging checks, routine-task complacency and reviews of procedures and risk assessments.
- 201821 Dec
Unsafe backloading of equipment
Equipment returned from a demobilised vessel was found inadequately packed and secured while a half-height container was unloaded from a truck at a yard. Contents included a full propane cylinder. The flash identifies inadequate supervision and rushing, and calls for stop-work intervention and safe, secure backloading.
- 201812 Oct
2016.1 Preparedness for Response Exercise Program (PREP) Guidelines
Voluntary multi-agency guidelines describe exercises for oil pollution response plans covering vessels, facilities and pipelines. They distinguish notification drills, incident management tabletop exercises and equipment deployment, with agency-specific schedules and evaluation arrangements. Guidance addresses operator training, equipment maintenance, dispersant simulations, documentation and credit for actual responses.
- 201823 Aug
Near miss: unplanned release of 2″ blasting hose outlet from air receiver coupling clamp
A near miss during onshore blasting and painting involved a 2″ hose separating at an improperly tightened Chicago connector. Its restraint arrested the hose, but released energy overturned an air receiver standing unstably on sand. The flash recommends stable footings, connection inspections, restraints and assessment of safer connectors and protective barriers.
- 20189 Aug
Sikorsky S-92A Nose Landing Gear Failed to Extend During Approach
An S-92A approaching Scatsta could not extend its nose landing gear despite recycling and emergency blowdown attempts. Ground engineering staff realigned the nosewheels with a lever, enabling a safe landing. Examination did not establish why self-centring failed. The operator addressed servicing awareness and links between emergency landing procedures.
- 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.
- 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.
- 2018
Manganese Exposures During Welding and Hot Work Tasks Presentation
Presentation examining manganese exposure during welding and hot work, neurological health effects and the basis for occupational exposure limits. It compares inhalable and respirable sampling results across working conditions, discusses local exhaust ventilation and worker positioning, and presents respiratory protection choices alongside welder engagement and implementation strategies.
- 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.
- 20177 Nov
Two yard-based fatal road traffic accidents (UK HSE)
This safety flash describes two fatal yard vehicle incidents: uncontrolled forward movement during HGV coupling and a pedestrian struck by a reversing telehandler. HSE findings address coupling systems, trailer parking brakes, driver training and pedestrian segregation. IMCA highlights traffic management and safety culture within subcontracted haulage.
- 201718 Sep
ExxonMobil Baton Rouge Refinery Chemical Release and Fire
This safety bulletin examines an isobutane release and fire at ExxonMobil’s Baton Rouge refinery that seriously injured four workers. It analyses plug valve gearbox removal, pressure-retaining bolt arrangements, design ambiguity and organisational practices. Lessons address safer valve designs, human-factors hazard analysis, written removal procedures and operator training.
- 20171 Sep
Worker trapped and injured by reversing vehicle
A spotter at a land-based seismic survey camp injured his right wrist when trapped between a reversing mobile crane’s extended outrigger and a well house. He lost balance in snow, while the operator continued after losing visual contact. The flash recommends clear communication protocols and stopping when visual or verbal contact is lost.
- 201711 May
Freedom Industries Chemical Release
Investigates the Freedom Industries chemical spill in Charleston, West Virginia, where internal tank-floor pitting corrosion released a mixture into the Elk River and public water supply. Examines deteriorated secondary containment, inspection deficiencies, treatment limitations, water testing, emergency communication and regulatory gaps, with recommendations for source-water protection and contamination response.
- 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.
- 201727 Feb
Crewman struck and injured by forklift truck
A crewman was struck by an unloaded forklift while walking through a shipyard, subsequently developing shoulder and hip pain and being placed on restricted work. The flash examines cab blind spots, pedestrian awareness and absent traffic management. Actions include reviewing traffic-management standards, limiting vehicle speeds and recommending workforce consultation.
- 201727 Feb
Two falls – one from a telehandler in a shipyard – failure to think through risks
Two prosecution cases concern falls during elevated work. A contractor died after a telehandler basket jerked following release from fencing in a shipyard. Another worker fell nearly two metres while cleaning a mixing machine. The cases highlight inadequate risk assessment, supervision and training for work at height.
- 201613 Sep
High potential near-miss: Dropped object
A 5.6 kg metal panel fell 7–10 metres from an automatic rolling-door hood in an ashore workshop. Rusted brackets, absent secondary retention and a hood excluded from inspection were identified. Actions included examining remaining panels, fitting self-tapping screws as secondary retention, conducting a dropped-object survey and introducing annual hood checks.
- 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.
- 201615 Jan
Worker killed when struck by a load on a moving crane
A foundry worker suffered fatal head injuries when a crucible suspended from an overhead crane swung forward after the crane stopped. The flash reports investigation findings of longstanding failures to review risk assessments and safe systems of work, absent crane-operator refresher training and inadequate training for new employees.
- 201522 Oct
Everyday activity, unwanted outcome: Poor manual handling leads to back strain
A shore worker strained his back while removing a box containing an approximately 20 kg turbocharger from a 2 m shelf. Working alone, he had not anticipated its weight and held on as it fell to waist height. The flash highlights checking labels and storing heavy items at waist height where possible.
- 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.
- 20152 Oct
Confined space fatality in shipyard
A rope access worker died after entering a riser guide tube to retrieve foam at a fabrication site. The flash identifies missing job safety analysis, pre-entry gas testing, rescue equipment and written procedures. Recommendations include eliminating entry, approving JSA before permits, detector training and mechanical extraction arrangements.
- 20152 Oct
Electrician fatally electrocuted
An electrician at a land-based oil installation was fatally electrocuted by an arc-blast after climbing onto a pole-mounted substation platform, and also fell from height. The flash identifies deficient risk assessment, permit review, maintenance and weekend safety culture, with corrective measures addressing equipment, supervision, lone working and documentation.
- 201510 Aug
Uncontrolled exposure to hand-arm vibration (HAVS)
This safety flash summarises an HSE prosecution concerning uncontrolled hand-arm vibration exposure in motor vehicle repair workshops. Up to 25 staff faced unrestricted handheld power-tool use. The account identifies absent tool replacement arrangements, inadequate maintenance, missing vibration-risk instruction and no health surveillance for early signs of HAVS.
- 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.
- 201511 Mar
Horsehead Holding Company Fatal Explosion and Fire
An independent desk study examines the fatal Monaca zinc-refinery incident using CSB evidence and the author’s records. It proposes sump restriction, liquid-zinc backfilling and explosive decompression as the sequence, while acknowledging disputed analysis. Discussion covers distillation-column design, temperature trends, operating procedures, human factors and predictive warnings.
- 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
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.
- 201410 Dec
Super Puma Rejected Takeoff Following Rotor Spindle Fatigue Failure
Investigation of a Super Puma takeoff rejection at Aberdeen Airport following rotor spindle fatigue failure. Metallurgical examination, finite element modelling, fatigue tests and flight-load measurements examined assembly preload, wear and interference-fit stresses. The report describes revised spindle assembly arrangements and recommends reviewing options to extend helicopter health and usage monitoring into rotating systems.
- 201425 Nov
Injuries sustained whilst trying to stop moving objects
Two incidents describe injuries sustained while attempting to regain control of moving objects: a rolling pipe at an onshore yard and a travelling chain block during vessel maintenance. The flash examines instinctive intervention rather than differing root causes, recommending that job safety assessments address potential loss of control and mitigations.
- 2014Oct
guide to the health and safety regulatory regime
Guidance for planners explains HSE’s regulation of shale gas wells and its relationship with planning authorities and environmental regulators. It describes lifecycle well integrity, steel casing and cement, abandonment plugs, advance notifications, weekly reporting and independent well examination, alongside hydraulic fracturing consent requirements and routes for raising site concerns.
- 201416 Jul
AL Solutions Fatal Dust Explosion
Investigates the fatal December 2010 metal dust explosion at AL Solutions in West Virginia, probably originating in defective zirconium blending equipment. Examines dust testing, earlier incidents, ignition hazards, water-based cleaning and suppression, and regulatory oversight. Recommendations address combustible-metal safeguards, process hazard analysis and employee and contractor training.
- 201414 Apr
Silver Eagle Refinery Flash Fire and Explosion and Catastrophic Pipe Explosion
Metallurgical investigation of a refinery discharge-pipe rupture during hot hydrogen catalyst regeneration in Woods Cross, Utah. Ultrasonic thickness measurements, chemical analysis, metallography and fracture alignment document internal wall thinning. The findings are consistent with sulfidation corrosion as the primary cause; gas-release calculations and security-video analysis examine the subsequent explosion.
- 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.
- 201320 Dec
Serious working at height incidents
Six incidents resulted in one fatality and five lost-time injuries, involving elevated and same-level falls. Cases include an unsecured walkway, a ladder, exposed ROV-system hoses and unattached harness lanyards during roof work. Recommendations address permit conditions, concurrent operations, competence, supervision, suitable equipment, toolbox talks and stopping doubtful work for reassessment.
- 201314 Nov
NDK Crystal Inc. Explosion with Offsite Fatality
This investigation examines a crystal-production pressure-vessel rupture in Belvidere, Illinois, which killed a truck driver off site. It identifies stress corrosion cracking as the likely failure mechanism and considers possible embrittlement. The report analyses coating protection, missed internal inspections, vessel design, regulatory oversight and facility siting.
- 20139 May
Near-miss: Failure of gas quad fitting
A gas-bank equalisation transfer in an ashore yard suffered a cracked, incorrectly specified low-pressure fitting failure. A fragment struck a nearby workshop wall, and inadequate whip checks allowed hose damage. No injuries occurred. Lessons address pressure ratings, thread awareness, training, risk assessment, hose restraint, restricted access and real-time pressure measurement.
- 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.
- 201330 Jan
Fatal wind farm accident
This safety flash reports the death of a crane operator during turbine installation at an onshore wind farm in Europe. A turbine blade fell onto the crane cab. The manufacturer stated that further updates would follow completion of the root cause analysis.
- 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.
- 20125 Jan
Hoeganaes Corporation Fatal Flash Fires
This case study investigates three incidents involving combustible iron dust and hydrogen at Hoeganaes in Gallatin, Tennessee. It examines dust testing, accumulation and collection failures, hydrogen piping integrity, electrical classification and flame-resistant clothing. Recommendations address combustible dust standards, plant-specific training, gas-system maintenance and near-miss investigation.
- 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.
- 2011Sep
Oil Tank Safety Study
This investigative study examines public exposure to explosions at oil and gas production storage sites, drawing on three investigations, a wider incident compilation and a community survey. It reviews regulatory and industry-standard gaps, unauthorised access, hazard signage and safer tank designs, including floating roofs, pressure-vacuum relief valves, flame arrestors and vapour recovery.
- 2011Aug
Flammable Vapor Release Hazards in Congested Areas — Process Safety Beacon, August 2011
This bulletin examines a fatal natural gas explosion during pipe cleaning at a Connecticut power plant under construction. It explains how congestion can intensify vapour cloud explosions, including outdoors, and recommends hazard analysis, ignition control and safe venting arrangements when flammable releases are unavoidable.
- 201114 Jul
Confined space – multiple fatalities
An onshore oil-well incident involved four workers collapsing after entering a water tank containing water mixed with nitrogen, including attempted rescuers. Three subsequently died. The flash identifies failures in procedural compliance, confined-space permitting, pre-entry multi-gas testing, appropriate protective equipment and rescue planning.
- 201120 Jan
Bayer CropScience Pesticide Waste Tank Explosion
Investigation of a fatal residue-treater explosion during restart of Bayer’s methomyl unit at Institute, West Virginia. It examines runaway decomposition, bypassed interlocks, deficient startup preparation, operator training and emergency coordination. Detailed modelling assesses the adjacent methyl isocyanate tank’s blast shield, distinguishing actual damage from hypothetical release scenarios.
- 201024 Sep
Welding on a Truck Tire Rim Results in a Serious Injury
An alert describes welding repairs to a cracked truck wheel rim in a transport maintenance workshop. A newly mounted tyre was pressurised to 20–40 psi for weld testing, then leaking hub welds were repaired with pressure still inside. Minutes later, an explosion propelled the tyre to the roof, killing two people and injuring two.
- 201021 Jul
Veolia Environmental Services Flammable Vapor Explosion and Fire
This CSB case study examines a solvent-recovery explosion and fire at Veolia’s West Carrollton facility that injured four workers and damaged neighbouring properties. It analyses atmospheric relief arrangements, occupied-building siting and emergency response. The initiating overpressure cause remained uncertain; recommendations address closed relief systems, hazard analysis and safer building separation.
- 201028 Jun
Kleen Energy Natural Gas Explosion
CSB urgent recommendations examine the Kleen Energy explosion during commissioning-stage fuel gas pipe cleaning, alongside other fuel gas incidents. The document compares natural gas blowing with air, nitrogen and pigging alternatives, reviews gaps in standards and regulation, and proposes prohibitions on atmospheric flammable-gas releases for pipe cleaning.
- 2010Mar
Facility Siting — Process Safety Beacon, March 2010
Using the Texas City refinery explosion, this bulletin explains the importance of siting occupied permanent and temporary buildings away from process hazards. It discusses checking actual occupancy against siting studies, evaluating changes through management of change, avoiding unsuitable buildings as blast refuges, evacuating personnel and restricting access during high-hazard operations.
- 2010Feb
Packaging Corporation Storage Tank Explosion — Seven Key Lessons to Prevent Worker Deaths During Hot Work In and Around Tanks
This safety bulletin examines eleven hot-work accidents involving tanks across several industries. Seven lessons address alternatives to hot work, hazard assessment, atmospheric monitoring, adjacent spaces, written permits, training and contractor supervision. Cases distinguish absent gas testing from ineffective testing, emphasising detector calibration, sampling locations and monitoring before and during work.
- 2009Dec
The Bhopal Tragedy – 25 Years Ago — Process Safety Beacon, December 2009
This anniversary bulletin revisits the Bhopal methyl isocyanate release, with an accompanying 2004 Beacon. It describes water contamination, an exothermic reaction and inadequate safety systems, while retaining uncertainty over the water source. Lessons address reactive hazards, safe relief discharge, maintenance, change evaluation and emergency procedures.