SafeChemE

SafeChemE Home Courses  Resources  About

Operator Error and Equipment Malfunction

Chemical Safety Board Videos

Arkema Inc. Chemical Plant Fire, Crosby, TX (8/29/2017)
  • Manufactures organic peroxides
  • Hurricane Harvey Flooding disabled the refrigeration
Video Exercise
Donaldson Enterprises Inc. Fatal Firework Disassembly and Explosion, Waipahu, HI (4/8/2013)
  • Change in procedures to disassemble and dispose of fireworks. An explosion resulted from not analyzing change with regard to PPA
  • No analysis of the hazards
  • Friction of the chairs
  • Hazard of the black powder
Video Incident Report Exercise
NDK Crystal Inc. Explosion with Offsite Fatality, Belvidere, IL (10/7/2009)
  • Recommended inspections not performed
  • Vessels corrosion
  • High pressures and temperatures and vessels did not meet code
Video Incident Report Exercise
Oil Site Safety, Weleetka, OK (4/14/2010)
  • Never really illustrated what happened. Suggests that an ignition source was provided by two high school students playing in a tank half filled with crude oil that exploded
  • Flammable vapor
  • Proximity of the location
Video Incident Report Exercise
Silver Eagle Refinery Flash Fire and Explosion and Catastrophic Pipe Explosion, Woods Cross, UT (1/12/2009)
  • Pipe corrosion
  • The component that failed had no record of ever being inspected for corrosion as it thinned over the years
  • Bad inspection strategies
Video Incident Report Exercise
Caribbean Petroleum Refining Tank & Explosion, San Juan, PR (10/23/2009)
  • Gasoline overflowed in storage tanks
  • Malfunction of tank level measurement
Video Incident Report Exercise
Buncefield Terminal, United Kingdom (12/11/2005)
  • Gasoline overflow
  • Liquid level measurement failed
Exercise
Chevron Refinery Fire, Bayamón, PR (10/23/2009)
  • The refinery used obsolete equipment rather than the safest modern designs
  • Analysis of the effectiveness of safeguards inteded to control hazards was missing
Video Incident Report Exercise


Hot Work

Bethune Point Wastewater Explosion, Daytona Beach, FL (1/11/2006)
  • Hydrocarbon heated by sun and vaporize and flow through line. Find spark from welding
Video Exercise
Partridge Raleigh Oilfield Explosions, Raleigh, MS (6/5/2006)
  • Welding accident
  • The lessons to avoid not work accidents
  • Conduct Hazard Evaluation. THINK! KTPPA
  • 3000 gallons of methanol
  • Shows effects of accident on victim's family
  • Delaware River
  • <ul><li>Water sulfuric acid and hydrocarbons</li><li>Heating up hydrocarbons during day</li><li>Con Agra loads</li></ul>
  • Did not repeat flammable gas testing
  • What hazard assessment should be performed?
Video Incident Report Exercise
BP Texas City Refinery Accident, Texas City, TX (03/23/2005)
  • Flammable liquids fed to isomerization unit
  • Malfunctions cause the unit to over flow with flammable liquid
  • What is the TNT equivalent of 1.5 meters diameter by 3 meters high plume and a 42 meter high tank explodes
  • Need to translate Spanish
Video Incident Report Exercise
Motiva Enterprises Sulfuric Acid Tank Explosion, Delaware City, DE (7/17/2001)
  • Hot Work used acetylene touch on crude oil line
  • Same as one of others
  • Issued 7 lessons to prevent Hot work accident volume at gas vs. heating of vessels by sum to produce flammable gas
Video Incident Report Exercise
E. I. DuPont De Nemours Co. Fatal Hotwork Equipment, Buffalo, NY (11/9/2010)
  • Good description of process
  • February 2010 Issued Bulletin Seven Key Lessoned to Prevent Deaths in Hot Works. Also the need in and around tanks to monitor for flammable gasses in tanks vinyl fluoride gas was present in flowed into tank 1. What was pressure drop to cause flow?
  • Flammable gas contained in the tank
  • No testing of the flammability of the gas inside the tank
  • Deficiencies in the safety management hot work
Video Incident Report Exercise


Miscellaneous

Fire from Ice, *** (***)
Video Exercise
Incident Animation of DuPont La Porte Gas Leak That Killed Four Workers, *** (***)
Video Exercise
Oil Tank Explosion Animation, *** (***)
Video Exercise
Oil tanker explosion: Fuel tanker truck bursts into flames on Detroit highway, *** (***)
Video Exercise
Animation of Bayer CropScience Pesticide Waste Tank Explosion, *** (***)
Video Exercise
Drum Explodes During Welding, Killing Worker, *** (***)
Video Exercise