Sector
Downstream and Process Industries
Refining, chemical processing and associated industrial operations.
Newest 100 Documents
All 182 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.
- 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.
- 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.
- 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.
- 2025Aug
Thermal Expansion runs hot and cold! — Process Safety Beacon, August 2025
This bulletin explains how heating trapped liquids and freezing accumulated water can rupture process pipework. Two chemical-processing incidents illustrate releases, fires and injuries involving a burst strainer and cracked propane piping. It highlights pressure relief, established isolation and depressurisation procedures, accommodation of thermal movement and temperature-dependent freezeproofing.
- 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.
- 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.
- 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.
- 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.
- 202315 Jun
Wacker Polysilicon Chemical Release
This investigation examines a hydrogen chloride release during heat-exchanger maintenance at Wacker Polysilicon. Excessive bolt torque fractured a graphite nozzle; three workers fell while escaping, with one fatality. The report analyses maintenance instructions, hazardous-energy control, simultaneous insulation work and restricted egress, recommending clearer procedures, coordinated operations and additional escape routes.
- 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.
- 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.
- 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.
- 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.
- 202113 Sep
Failed lifting equipment: fatality during pipe erection activities
This safety flash describes a fatal incident at an oil refinery during pipe erection using two wire rope pulling hoists and pulleys. A pulley broke while the pipe was being lifted, allowing the rope and pipe to fall. The rope struck a worker on scaffolding, who later died in hospital.
- 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.
- 202015 Sep
UK HSE: Two workers suffer multiple burn injuries
Two workers, including an apprentice, suffered life-changing burns during reassembly of high-pressure steam pipework following maintenance of a steam turbine driven pump. Steam was released uncontrollably at around 250°C. The investigation identified safe-system-of-work failures, including incomplete checks and verifications required by the steam isolation procedure.
- 202010 Sep
Failure to detect dangerous gas/vapour due to incorrect specification of sample tube
This safety alert examines misleading readings from pumped gas detectors caused by vapour adsorption inside unsuitable sampling tubes. A fatal explosion followed hot work based on a false reading. It recommends checking detector–tube combinations with the substance of interest where practicable and assessing sampling-system response times.
- 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.
- 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.
- 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.
- 201920 Aug
Catastrophic rupture of dead-leg pipe-work
This safety alert examines refinery pipework ruptures associated with highly localised internal corrosion in dead-legs. It explains how routine thickness checks missed deterioration and outlines inspection expectations, including risk assessment, wider wall-thickness testing and timely replacement. Operators should consider removing non-essential dead-legs and account for thermal gradients, liquid interfaces and condensation.
- 20192 Aug
Use of ICAR Capacitors in uninterruptable power supply (UPS) systems
This alert addresses two industrial UPS fires involving overheating ICAR self-healing polypropylene capacitors in 2011 and 2018. It advises dutyholders to consider prompt replacement of affected models and review cooling requirements. Capacitance testing and visible bulging or discolouration may not reliably indicate these capacitors’ remaining service life.
- 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.
- 2018Dec
High Temperature Hydrogen Attack: Safe use of carbon steel
HSE alerts operators to carbon steel degradation through high temperature hydrogen attack. It distinguishes safer metallurgy for new or replacement equipment from cautious use of Nelson curves for existing plant. Recommendations address operating histories, temperature and hydrogen partial pressure limits, validated complementary non-destructive testing, examination intervals and specialist inspector competence.
- 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.
- 2018Jun
Safe Work Permits – Understand the Scope of Work — Process Safety Beacon, June 2018
This bulletin examines two nitrogen-asphyxiation deaths during refinery maintenance after workers attempted to retrieve tape from a vessel outside the permitted job scope. It emphasises recognising scope changes, reassessing confined-space entry requirements, communicating hazards and stopping work to consult the permit issuer before undertaking unapproved tasks.
- 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.
- 2018Apr
Measurements & Site Security
Inspection questions address liquid hydrocarbon and gas production measurement, royalty and allocation meters, sampling arrangements, proving and calibration. They cover run tickets, production commingling approvals, record retention and tank requirements. Site-security checks address theft, tamper-evident seals and meter bypasses, with regulatory authorities and enforcement actions listed alongside individual checks.
- 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.
- 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.
- 201725 Oct
Safety features of the Siemens Maxum Edition II gas chromatograph
This flash describes an explosion causing life-changing injuries to a technician when a Siemens Maxum Edition II gas chromatograph returned to service. Hydrogen had accumulated during hold status, and the automatic purge was not re-engaged. Users should review purge controls against the maintenance manual and discuss operating arrangements with manufacturers.
- 20171 Oct
Siemens - Maxum II Edition Gas Chromatograph - Safety Features
HSE alerts gas chromatograph users to an explosion that caused life-changing injuries during return to service of a Siemens Maxum II. Hydrogen had accumulated while the unit was on hold, and automatic purging was not re-engaged. Users should review purge controls and discuss operating arrangements with manufacturers.
- 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.
- 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.
- 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.
- 20173 May
Near-miss: Gas release from subsea pipeline
A gas release occurred during subsea spool connection while divers were in the bell for shift changeover. The vessel moved clear and an ROV released the crane hook safely. Findings highlight missing refinery communication about valve opening; recommendations address permit understanding, inter-site communication, H2S preparedness, drills and equipment testing.
- 2017May
Corroded Tanks — Process Safety Beacon, May 2017
This bulletin describes two fatal refinery incidents involving corroded tanks: a hot-work ignition of flammable vapours and an operator falling through a weakened hot-oil tank roof during manual measurement. It highlights uncorrected defects, reporting and escalation of corrosion concerns, and avoiding access onto unsuitable or badly corroded equipment.
- 201724 Apr
Catastrophic failure of silo – bolted conical bottom section
This alert examines catastrophic separation of a silo’s bolted conical bottom, releasing approximately 600 tonnes of wheat grain. It links failure to manufacturing-induced micro-cracks at sharp cold-formed folds and subsequent fatigue cracking. Recommended measures include penetrant inspection of both fold surfaces, repeated inspections, attention to warning signs and exclusion zones.
- 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.
- 2016Dec
Ignition Sources – Once More — Process Safety Beacon, December 2016
This bulletin explains obvious and less visible ignition sources, including delayed fires after hot work, unstable or incompatible chemicals, enhanced oxidation and pyrophoric materials. It emphasises hazardous-area procedures, combustible spill containment, checking insulation for leaks, chemical storage requirements and management of change when introducing new materials.
- 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.
- 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.
- 201512 Aug
'Norfolk Range' large wheeled dry powder fire extinguishers manufactured before 2009 by UK Fire International Ltd
This alert examines failed Norfolk Range wheeled dry powder extinguishers with bottom-mounted discharge hoses. Suspected water ingress at elbow joints caused powder caking that could obstruct discharge and escape routine servicing checks. It recommends targeted inspection and consideration of extended servicing and storage protected from rain or damp conditions.
- 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.
- 201514 Apr
External chloride stress corrosion cracking of stainless steel lokring pipe connectors
This alert examines chloride stress corrosion cracking in stainless steel Lokring connector driver rings and the resulting containment risk. It explains limitations of surface inspection, contrasts radiographic detection of internal cracks, and advises identifying affected connectors and removing those whose failure could pose safety risks, with removal prioritised by consequence, service time and corrosive conditions.
- 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
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.
- 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.
- 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.
- 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.
- 201426 Feb
Liquid metal embrittlement by mercury in the refining and allied process industries
HSE warns refining and allied process operators about mercury-induced liquid metal embrittlement and failures of primary containment. It discusses susceptible alloys and potentially unknown material couples, recommending risk-based precautions that could include mercury removal from process streams and suitable construction materials. Occupational exposure hazards are explicitly outside its scope.
- 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.
- 201413 Jan
Failure of a foot valve actuator on an LPG road tanker
An HSE alert describes an LPG tanker foot-valve actuator failing to close during a propane release. Low-temperature tests identified frozen moisture and shattered neoprene bellows as separate failure mechanisms. It recommends checking bellows material compatibility and regularly inspecting their condition, rather than relying on successful operation under normal conditions.
- 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.
- 20138 Oct
Chloride induced stress corrosion cracking of stainless steel thermowells
This safety alert describes internal chloride stress corrosion cracking in stainless steel thermowells identified during refinery maintenance. Heating and cooling can draw halide-containing atmospheric moisture through non-gas-tight instrument connections. Cracking could permit hazardous substance release if it penetrates the tube wall. Operators should register relevant thermowells and establish appropriate maintenance and inspection programmes.
- 20138 Oct
Corrosion in trunnion supports of pipework containing hazardous substances
This safety alert examines an LPG release at a UK refinery caused by hidden corrosion inside capped tubular pipe supports. Moisture accumulated through a weep hole positioned on support steelwork. It calls for suitable support examinations and cautions against permanently removing end caps without further design work.
- 2013Mar
Are your signs and labels confusing? — Process Safety Beacon, March 2013
This bulletin examines how missing or confusing equipment labels and signs can undermine safe plant work. It recommends repairing unreadable labels, matching identification to plant procedures and using consistent chemical names. Label corrections should use proper replacements, with consideration of a management of change review.
- 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.
- 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.
- 2011Dec
Caps and Plugs - One Day You Will Miss Them! — Process Safety Beacon, December 2011
Falling scaffolding debris opened a quarter-turn vent valve, releasing flammable material that ignited, killing one worker and seriously burning two others. The bulletin explains the importance of caps, plugs and additional containment barriers, checking missing closures, considering valve design and handle placement, and reviewing modifications through management of change.
- 2011Nov
One Incident – Three Beacons! — Process Safety Beacon, November 2011
Using a refinery fire near Sunray, Texas, this bulletin explains how one incident can yield several distinct safety lessons. It encourages reporting incidents and near misses, thorough investigation of root and contributing causes, and applying lessons to other plants. It also marks the Beacon’s tenth anniversary.
- 2011Oct
Hose Hazards! — Process Safety Beacon, October 2011
This bulletin examines process hose hazards through chlorine and phosgene release cases and discussion of contamination and blockage. It explains material selection, permeation and concealed corrosion, then recommends pre-use inspection, scheduled replacement, correct pressure ratings, secure connections, cleaning, storage and protection from vehicle damage.
- 2011Oct
Managing contractors - A guide for employers
Employer guidance aimed particularly at smaller chemical companies explains a five-step approach to managing contractor safety. Exercises, checklists and incident examples support planning, contractor selection, site induction, monitoring and review. It discusses legal responsibilities, coordinated risk assessments, safety method statements and permit-to-work arrangements.
- 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
Hazards from Abandoned Equipment — Process Safety Beacon, September 2011
Four examples illustrate hazards from abandoned equipment, including propane leakage, product contamination, an electrical ground fault and a toxic cloud from residual phosphorus trichloride. The bulletin recommends management of change, isolation, lockout and tagout, removal of abandoned assets, management awareness and periodic inspection of equipment remaining out of service.
- 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.
- 2011Jul
Shift Work — Process Safety Beacon, July 2011
This bulletin explains how rotating shifts and disrupted sleep can impair alertness in continuous process operations. Aviation events and major night-time process incidents illustrate the importance of vigilance. It discusses management’s scheduling role and practical fatigue-reduction measures, including quality daytime sleep, pre-shift naps, activity and avoiding demanding tasks when most tired.
- 2011Jun
Are you prepared for a natural disaster? — Process Safety Beacon, June 2011
This bulletin examines natural-disaster preparedness at hazardous-material storage and processing plants. Drawing on FM Global findings, it highlights underestimated risks and overconfidence in readiness. It recommends reviewing feasible emergency plans, understanding utility interruptions, ensuring response equipment is ready, and participating seriously in disaster drills.
- 2011Apr
Don 't let a small leak become a big leak! — Process Safety Beacon, April 2011
This bulletin uses photographs of a construction-site water leak escalating within minutes to highlight the dangers of apparently minor releases. It emphasises prompt reporting, timely repair, identifying the material, following plant procedures and monitoring from a safe location while maintenance preparations are completed.
- 2011Mar
Bad things can come in small packages! — Process Safety Beacon, March 2011
A bulletin describes an operator injured when sodium-bearing waste spilled from a pail and reacted with rainwater after methanol treatment. Solids had prevented complete reaction, and the procedure omitted mixing. It highlights hazards in small waste containers and recommends labelling, identifying unknown materials and safe disposal instructions.