Accepted Manuscript

A web-based collection and analysis of process safety incidents

Pranav Kannan, Tatiana Flechas, Edna Mendez, Laura Angarita, Purvali Chaudhari,
Yizhi Hong, M. Sam. Mannan
PII:

S0950-4230(16)30228-5

DOI:

10.1016/j.jlp.2016.08.021

Reference:

JLPP 3309

To appear in:

Journal of Loss Prevention in the Process Industries

Received Date: 1 July 2016

Revised Date:

27 August 2016

Accepted Date: 29 August 2016

Please cite this article as: Kannan, P., Flechas, T., Mendez, E., Angarita, L., Chaudhari, P., Hong,
Y., Mannan, M.S., A web-based collection and analysis of process safety incidents, Journal of Loss
Prevention in the Process Industries (2016), doi: 10.1016/j.jlp.2016.08.021.
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A web-based collection and analysis of process safety incidents

Pranav Kannan, Tatiana Flechas, Edna Mendez, Laura Angarita, Purvali Chaudhari, Yizhi Hong
and M. Sam. Mannan

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Mary Kay OConnor Process Safety Center

Artie McFerrin Department of Chemical Engineering
Texas A&M University System
College Station, Texas 77843-3122, USA

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Corresponding author: M. Sam Mannan, Tel.: +1 979 862 3985; fax: +1 979 458 1493; e-mail
address: mannan@tamu.edu
Abstract

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Process safety incidents have large consequences on people, community and environment;
hence, it is important to have a learning organization to build on lessons learned from incidents
both within and outside the organization. In this study, a web-based collection of process safety
incidents is categorized and analyzed in a two-tiered manner to identify proximate causes.
Further, a risk-based framework is used to determine deficiencies in the safety management
systems. 96 incidents were collected and subjected to the analysis. Even though these incidents

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are from across the world, they are not statistically representative due to the lack of a universal
database of process safety incidents. During the analysis, it was observed that 60% of the
incidents resulted in explosions and 16% had equipment malfunction as a proximate cause. In

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addition, the analysis using the risk-based framework showed that incidents were influenced by a
deficiency of safe work practices, operating procedures and conduct of operations. Future work
in this area includes the development of tools for continuous monitoring of safety critical

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systems by leveraging lessons learned from previous incidents.

Key Words: Incident analysis; Learning organization; Risk-based

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1. Introduction
An organization which strives to be at the apex of performance for both production and safety
can be expected to have the attribute of best-in-class safety culture. This characteristic implies

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that the organization continually learns from other companies and itself (Mannan, Mentzer, &
Zhang, 2013). Learning lessons from within and outside the organization is a challenge due to
unavailability of information, insufficient analysis and, lack of delivering lessons in a usable
format. Additionally, there are barriers to incident information sharing because of intellectual

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property and legal implications. In order to learn from incidents, a combination of elements such
as trust in the incident investigation, assessment of consequences severity and people involved,
contribute to the effectiveness of the learning process. Organizational learning theory can be

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used to combine these elements (Drupsteen & Guldenmund, 2014). Another aspect is related to
information availability; incident databases are the core for building the data analysis tree;
however, a comprehensive worldwide or nationwide database is required to perform this
analysis. Current and past attempts include the Process Safety Incident Database (PSID) (Sepeda,
2006), eMARS (Major Accident Reporting System) of the European Union (EU Directive,
1997), IChemE accident database (Powell-Price, Bond, & Mellin, 1998) ARIA database

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(Analyse, 2016) MHIDAS database (Moreno & Cozzani, 2015) WOAD database (DNVGL,
2016) and others. However, these databases have several limitations including, restricted access
(members and stakeholders only), incident collection focused on specific regions and, limited
reporting and update process. This restricts the possibilities for addressing common issues in

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different industries through a common learning platform. Incident databases help to build safer
workplaces by helping organizations to learn and improve their safety management systems.

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Furthermore, databases provide guidance for academic research in order to aid solving industrial
safety issues.

The need for learning from incidents is exemplified by the economic impact that incidents have
on the company and the community. The property damage in the 100 largest losses of the
hydrocarbon industry from 1974 to 2013 was estimated to be more than 34 billion USD (Marsh,
2013). In the difficult economic climate being endured by the oil and gas sector after the oil price
crash in late 2015, the need to prevent incidents cannot be underestimated.

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In the literature, there are various definitions for incident such as the one from the National
Safety Council (NSC) which defines an incident as an unplanned or undesirable event that
adversely affects the completion of the task; specifically for the chemical industry, it is defined

plant, community or the environment (CCPS, 1993).

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as any occurrence, condition or action which did or could result in personal injury, damage to the

There have been several attempts to develop incident databases for applying tools to understand
risk and organizational performance; however, some are restricted to limited sectors such as

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biodiesel or ethanol industries, storage tanks, runaway reactions and others (Barton & Nolan,
1989; Chang & Lin, 2006; Olivares, Rivera, & Mc Leod, 2014, 2015). Incident investigation is a
consequence of the reporting of an incident. A study using the eMARS analyzed 121 incidents

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which were classified to identify parameters to improve safety issues (Drogaris, 1993). Olivares
et al. collected incidents of the biodiesel industry worldwide for the period of 2003 to 2013
(Olivares et al., 2014). They analyzed a total of 85 events which led to more than 17 fatalities
and further injuries. The authors found that there was an important gap in the dissemination of
lessons learned. A similar study was performed for the ethanol industry, covering a 16 year
period from 1998 to 2014 (Olivares et al., 2015). They found 125 events gathered from 93 data

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sources (newspaper articles, web resources, etc.) and observed that in 63% of the cases, the
incidents were fires at the facility. Additionally, 16% of the events were attributed to
maintenance related issues. Incident analysis are also performed by the nature of precursor
events such as runaway reactions in the chemical industry (Barton & Nolan, 1989). The analysis

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of incidents from 1962 to 1987 identified the causes contributing to over-heating and reaction
runaways. 189 incidents were analyzed and its causes were classified into process chemistry,

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plant design and operation. The main conclusion was the need for appropriate guidance for
thermal hazard assessment in small and medium-sized facilities. Different studies have also
covered specific process equipment, such as the incidents collection related to storage tanks by
Chang and Lin. The authors looked at 242 incidents with storage tanks over 40 years and
analyzed the incidents using a fishbone diagram (Chang & Lin, 2006). An important finding was
that one-third of the incidents were caused due to lightning and another third was caused by
human error. The technical causes were divided into failure, sabotage, crack and rupture, leak
and line rupture, and others. A more generalized approach towards equipment-based incidents
was carried out using an already existing database (Kidam & Hurme, 2013a). The study was
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restricted to the Japanese Failure Knowledge Database which is managed by academia. The
incident contributors were identified and it was determined that 78% of equipment-related
incidents had technically oriented factors, including design and human interface deficiencies.
Another study of the same database ranked 364 incidents according to its frequency and

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importance in incident prevention, this led to an observation that the most important contributors
were the human and organizational factors which were related to 19% of the incidents (Kidam &
Hurme, 2013b). A study covering 349 petrochemical incidents over a 10-year period in Taiwan
used the data mining classification and regression tree (CART) to examine the distribution and

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rules governing the factors of the incidents. It was observed that pipelines were a major
equipment-related source for incidents (C.-W. Cheng, Yao, & Wu, 2013). Another type of

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incidents are NaTech incidents (natural disaster which results in release of hazardous materials).
A study that focused on identifying and analyzing NaTech events found that quality of available
data is poor and, a specific database is needed for analysis, prevention and mitigation of this type
of incidents (Campedel, Cozzani, Krausmann, & Cruz, 2008).

Databases can be harnessed using a variety of techniques such as frequency exceedance curves,
which focuses on high impact consequences that include injuries and fatalities (Prem, Ng, &

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Mannan, 2010). Databases need to be analyzed keeping in mind the duration of the data
collected, the geographies the data are collected from, and the operational environments of the
facilities reporting the abnormal event. The interpretation of statistics from databases is highly
dependent on the context of the incident, which needs to be taken into account in order to avoid

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erroneous conclusions. In the absence of a comprehensive open access-worldwide database of

process safety incidents, it is imperative that academic institutions take leadership towards

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maintaining databases from available sources. In this sense, the objective of this work is to
provide a methodology for building databases and analyzing process safety incidents from open
source information.

2. Methodology
The approach used in this study is based on the 20 elements of Risk-based Process Safety
(RBPS) (CCPS, 2007). The previous methodology enables to rapidly identify deficiencies and
further implement lessons from incidents. The deficiencies may be related to some of the next
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four pillars in which the 20 RBPS elements are divided: risk management, commitment to
process safety, learning from experience and, understanding hazards and risk (CCPS, 2007). The
methodology uses guidelines for designing process safety management systems as a basis for
incidents analysis. This allows organizations to directly focus on possible areas of improvement,

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thus reducing the latency of learning from incidents. The salient feature of this work is the widescale applicability of the method even in poor information environments, which are very
common in incident databases. This method can be used internally by companies to identify
issues within their facilities or, on a larger scale for a systematic analysis of incidents within an

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industry sector.

The literature for this work was collected based on incidents reported from Googles web crawler

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(Google, 2016). The web crawlers are used to identify incident related news which are further
notified with the source of the news article. Incident refers to a broad range of upset conditions
relative to normal operations. The term incident has various applications such as human safety,
environmental impact, uncontrolled release of product and operation beyond design limit (Guy
Desjardins, 2012). Incidents may also be defined more specifically by a regulator in a particular
jurisdiction such as the environmental protection agency in the United States, which defines

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incident as a work related event where an injury, ill health (regardless of severity) or fatality
occurred or could have occurred (EPA, 2014). The incidents in this work broadly can be
categorized under the aforementioned definitions, with a focus on process safety related upsets.
The incidents were categorized according to their domain of operation (upstream, midstream,

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downstream). Upstream includes incidents from offshore and onshore production of oil and gas,
midstream includes incidents related to storage and transport of chemicals and petroleum

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products and downstream covers all aspects of process industry including chemicals production,
petrochemicals, refineries, and others. Furthermore, additional information was collected
including the type of incident (fire, explosion, and release), potential causes (Rootcauselive,
2016), and consequences to the environment and the community. In case of multiple
consequences (e.g., incident that led to fire and explosion), the most significant consequence was
used in the results and discussion sections; however, all the consequences were cataloged. An
effort was made to keep an extensive search by collecting information from diverse geographic
zones covering Asia, North America, South America, Europe, Australia and Africa. However, it
was noted that in the absence of a complete and thorough source of information, it would not be
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possible to perform a statistical analysis of the data found. The incidents were grouped into three
zones with zone 1 covering North America, zone 2 consisting of Europe, South America,
Australia and Africa, and zone 3 covering Asia. After data collection, the next step was the
classification of incidents based on industry type, incident category and substance involved.

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Subsequently, the first tier of analysis focused on information from open sources towards the
incident description, potential causes, contributing factors, and consequences. The second tier of
analysis was performed by using the 20 elements of the risk-based process safety guidelines
(CCPS, 2007). These elements provide a framework to prioritize process safety improvements in

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any facility. Based on available information, each one of these 20 elements was analyzed in
order to know if it had or not influenced on the proximate causes of the incidents collected.

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Appendix A - Table 2 summarizes the method employed for analyzing the impact of these
elements on all the 96 incidents in this study. A Boolean scoring system (1 or 0) was employed
to evaluate which elements had the most influence on the incidents. A score of 1 was assigned
to indicate the lack of competency exhibited in that element, while the number 0 was assigned
to indicate either the fulfillment (i.e. the organization or the facility was competent) or absence
of adequate information to infer the competency. To illustrate this concept, when 1 has been

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attributed to the process safety culture risk-based element this indicates that there was a lack of
competency in relation to that element which eventually contributed towards the incident. In the
present paper, process safety incidents were collected for one-year period worldwide, extending
from October 2014 to October 2015. The risk-based methodology proposed in this study was

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applied to analyze and classify these incidents. This framework gives the opportunity to go
beyond compliance towards a continuously improving management system and also, allowing

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the lessons learned to be incorporated into business processes. Finally, some recommendations
were made in order to improve the safety performance in industrial facilities.
The methodology followed in this study is summarized in Fig. 1.

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Classification
Type of industry
Incident category
Substance involved

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Data collection
Media reports
Web crawlers
Internet search

Analysis (layer 1)
Incident description
Potential causes and
contributing factors
Consequences

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Analysis (layer 2)
CCPS's 20 elements for
risk-based process safety

Fig. 1. An overview of the four step methodology for database construction and analysis based
on process safety incidents reported in media.

Table 1

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The risk-based process safety guidelines provide 20 elements to implement or improve a process
safety management system. Detailed definitions can be found in the Guidelines for Risk-based
Process Safety (CCPS, 2007). Table 1 lists these elements which are used in the tier 2 analysis.

The 20 elements of risk-based process safety (CCPS, 2007).

Process safety culture

E-11

Contractor management

E-2

Compliance with standards

E-12

Training and performance assurance

E-3

Process safety competency

E-13

Management of change

E-4

Workforce involvement

E-14

Operational readiness

E-5

Stakeholder outreach

E-15

Conduct of operations

Process knowledge management

E-16

Emergency management

Hazard identification and risk analysis

E-17

Incident investigation

Operating procedures

E-18

Measurement and metrics

E-9

Safe work practices

E-19

Auditing

E-10

Asset integrity and reliability

E-20

E-7
E-8

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E-6

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E-1

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Management review and continuous

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3. Results and discussion

3.1 Incident collection and classification
A total of 96 incidents were collected worldwide for one calendar year (October 2014 to October

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2015) using Googles web crawlers, as described in the methodology section. The complete list
of incidents along with their description can be found in Appendix A - Table 1. The tiers of
analysis performed on this dataset allow examining the robustness and usefulness of the

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methodology. The distribution of incidents is given in Fig. 2.

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Zone 1 (North
America)

26%

49%

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25%

Zone 2 (Europe,
South America,
Australia, Africa)
Zone 3 (Asia)

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Fig. 2. Incident distribution by geographic zones.

Given the constraints in collecting the total number of incidents that happened during the one-

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year period around the world, the results presented in this paper should not be interpreted as
comparative analysis between regions. Nevertheless, according to Fig. 2, about half of the
incidents collected (49%) are attributed to zone 3 (Asia). One of the factors that may have
influenced this share is the proliferation of a large number of industrial facilities in this rapidly
developing region; which is also a major population center with an estimated 5 billion
inhabitants by the year 2050 (Bongaarts, 2015). Furthermore, it was observed that zone 2 which
covered the largest geographical area (Europe, Africa, Australia and South America), contributed
only ~25% of the incidents. This low percentage may be attributed to the reduced amount of
incident reporting in the open media, especially in areas such as Africa. However, it may also
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indicate that highly regulated regions such as Europe are exhibiting a higher level of process
safety performance. This may be attributed to the regulatory structure including the Seveso
directives and, better awareness of best practices (Mitchison & Clement, 1998). It is important
to highlight that the incidents reported in this study were found in online sources; hence, in

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countries where media reports of incidents are sparse or there is under reporting, it may
significantly affect the numbers obtained. The analysis here can be assumed to be an
underestimation as compared to the complete incidents dataset.

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The importance of official incident reports worldwide is critical since most of open information
is sourced by media, where there may be an element of speculation. As an example of mandatory
reporting, the Seveso I directive requires all member states to report all major industrial

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accidents involving dangerous substances to the European Commission, which resulted in the
Major Accident Reporting System (MARS), maintained by the Major Accidents Hazards Bureau
(MAHB) in Ispra, Italy (Jones, Kirchsteiger, & Bjerke, 1999). Another example that can be
mentioned is related to PHMSA (Pipeline and Hazardous Materials Safety Administration) in the
United States. This organization administers the national pipeline regulations and requires the
reporting of all loss of containment incidents that meet the pipeline safety regulation criteria (49

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CFR 191/195) (Girgin & Krausmann, 2016).

The 96 incidents collected worldwide for this paper resulted in 398 fatalities and more than 2000
injuries. It should be noted that in many of these incidents there were also evacuations and

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shelters in place, which would magnify the total number of people affected. Fig. 3 provides the
distribution of fatalities and injuries for each one of the zones. According to this figure, the

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incidents collected in zone 1 led to 8 fatalities, zone 2 evidenced 112 fatalities and, incidents in
zone 3 resulted in 278 fatalities. Although this is not a comparative analysis, based on the
collected incidents it was observed that the majority of fatalities were in Asia (zone 3). The
skewness of the data towards zone 3 is expected, given some high consequence incidents that
occurred in this region during the past year. As an example, the Tianjin warehouse explosion in
August 2015 resulted in 165 fatalities and several hundred injuries (Huang & Zhang, 2015).

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1600

1457

1200

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1000
Fatalities

800

Injuries

600
353

400
190

200

112

8
0
Zone 2

Zone 3

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Zone 1

278

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Number of fatalities/injuries

1400

Fig. 3. Number of fatalities and injuries by geographic zones.

Fig. 4 shows the classification of incidents per region according to the categories: upstream,
downstream and midstream. For all three geographic zones, the majority of incidents collected
are associated with downstream facilities. This was an unexpected result specially for zone 1

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(North America), since the fatality rate in the United States for the oil and gas upstream sector
(offshore and onshore), is seven times higher than for all U.S. workers (Gunter et al, 2013).
50
45

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35
30

Upstream

25

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Number of incidents

40

Midstream

20

Downstream

15
10
5
0

Zone 1

Zone 2

Zone 3

Fig. 4. Distribution of incidents between upstream, midstream and downstream facilities.

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An extrapolation of the previous statistic to other regions would indicate that the number of
incidents in the upstream domain is much higher than what is found in the open media, showing
the need for maintaining comprehensive databases based on information sharing. This can be
extended to cover other sectors such as petrochemicals, refining, pharmaceuticals, bulk

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chemicals, fertilizers and can be maintained by industry organizations, which can then be used to
develop recommendations to improve safety performance. The lack of adequate incident
reporting of upstream incidents, especially in offshore locations, may be the reason of the
skewness of the data set towards the downstream sector. Also, the relative low number of

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midstream incidents found may be due to a lack of media coverage and/or incident reporting
related to pipelines, warehouses and other transportation infrastructure. This needs further

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analysis especially for zone 1 (North America), since much of the midstream infrastructure in the
United States (pipeline network and railroad system) is ageing (Leis, 2015) and can be a leading
indicator for future incidents.

According to Fig. 5, the highest percentage of incidents worldwide comes from the downstream
sector (84%), followed by midstream (14%) and upstream (2%). Downstream incidents cover a
wide range of facilities including refineries, petrochemical plants, chemical process facilities and

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others, which typically form one of the last manufacturing steps in the chemical supply chain.
The significant incident reporting in the downstream sector may be attributed to the relative
proximity of the facilities to population centers. However, this provides a contrasting view, since
midstream infrastructure typically possesses the largest exposure to the general population,

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primarily serving as carriers or distribution channels passing by populated areas. The

downstream incidents reflect the need for robust learn from incidents rubrics, since some of

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the most significant process safety incidents historically have been attributed to the downstream
sector. These include the Bhopal gas disaster (Yang, Khan, & Amyotte, 2015), the Flixborough
disaster (Kerin, 2015), the Texas City refinery explosion (Hopkins, 2008) and others. The
downstream incidents reveal a need to renew the process safety management programs to
identify areas of lapses and loopholes to stem the number of incidents. An important tool is the
use of the RBPS elements which is discussed in the analysis tier 2.

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2%

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14%

84%

Midstream

Upstream

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Downstream

Fig. 5. Incident distribution based on industry type

Another aspect that was looked at during the data classification stage was the type of incident.
This is important in order to analyze the consequences of the events, which were categorized as
fire (F), explosion (E) and release of chemicals (R). Fig. 6 shows the distribution of incident

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consequences collected worldwide. It is observed that 60% of the incidents resulted in

explosions, 21% resulted in fires and 19% were mentioned to have chemical releases. In some
incidents a combination of consequences was evidenced, for example fire and explosion or fire

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and release. In those cases, the highest impact consequence was used in this section. A complete
list of the consequences can be accessed in the Appendix A. Since the source of the incidents
was on-line media, explosions usually have the highest amount of attention due to their nature of

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large sound and shock wave. This may have resulted in additional coverage by the local
population and media. In contrast, chemical releases may have less attention given that
substances may be released into the atmosphere with high rates of dilution.

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Fire

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21%

60%

Release

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19%

Explosion

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Fig. 6. Incident distribution based on consequence type.

The type of substances involved in the incidents are highly varied, indicating that there is no
specific chemical which can be singled out as the main source of upset events. Although, the
most common substances involved in the incidents collected are crude oil and other
hydrocarbons contributing to ~22% of the incidents, followed by ammonia or anhydrous

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ammonia contributing to ~10% of the events. These observations are in agreement with the fact
that continuous improvement in process safety is required in different areas of the oil and gas
industry, as well as in mature technologies such as ammonia production. In addition, it was
observed that 14 incidents involved organic substances such as cyclohexanol, acrylonitrile,

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methyl mercaptan, acetone and acetal. The hazards represented by organics can be extended into
long term toxicological implications. Since they are easily dispersed into the natural ecosystems

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and enter the food chain, damaging the flora and fauna even long after the incident has occurred.
Hence specific focus needs to be placed on containing incidents which may result in a release of
organics into the environment.
3.2 Analysis tier 1

The classification of incidents was followed by the first tier of analysis, which consisted of
evaluating its potential causes. Since the incidents are relatively recent with limited information
accessible in the public domain, the causes are listed as proximate or potential causes. These
provide an initial insight into the possible reasons for the incident but may not be the ultimate
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root causes, which can only be determined after systematic investigation into the incident. This
analysis was based on a comprehensive potential causes list divided into possible immediate
causes and possible system causes (Rootcauselive, 2016). The results from this tier of analysis

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are presented in Fig. 7.

As expected, it is observed that 33% of the reports mention that the incidents are under
investigation. Although complete investigations of industrial disasters to determine root causes
can take quite a lot of time and in some cases several years, it is imperative that there is a system

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to report and distribute learnings as they are identified through the course of the investigation.
Many of the incident reports do not mention any on-going investigation or the proximate causes
of the event; 27% of the incidents collected had this attribute and they are listed as having

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unknown causes. This is an important concern since without investigating proximate causes,
the root causes cannot be discovered, which would ultimately result in a lack of learning from
incidents. The lack of adequate equipment, tools or vehicles was the proximate cause for 15% of
the incidents collected. It was also found that 14% of the incidents evidenced lack of procedures
for the task, policies or standards. An adequate set of procedures is a paramount element for the
safe operation of any process facility. They form the interface between the operators and the

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personnel with the control systems of the facility. Other identified proximate causes are
inadequate work planning (14%), lack of training effort (9%), failure in following procedures
(5%) and, inadequate assessment of needs and risk (4%). It should be noted that the percentages
in Fig. 7 do not sum 100% because some incidents evidenced more than one proximate cause,

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and for others there was not enough information about proximate causes since either they were

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not reported or reported as under investigation.

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Inadequate assessment of needs and risk

Failure in following procedures
Inadequate training effort
Inadequate work planning
Lack of work policies/standards/procedures
Inadequate tools equipment and vehicles
Unknown
Under investigation

4
5
9

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14
14
15

27

10
15
20
25
30
Percentage of incidents (%)

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33

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Fig. 7. Proximate causes of incidents expressed as a percentage of total incidents.

3.3 Analysis tier 2

The 20 elements of the Risk Based Process Safety (RBPS) shown in Table 1 were used as the
highest level of analysis. An important outcome from incident investigation and database
learning is a pathway towards implementing changes to existing management systems. To

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increase the ease of learnings from incidents and improving the consistency of the analysis, the
20 elements framework was used for scoring the competence of the management system related
to the collected incidents. The previous analysis was performed in the context of the information
available. A Boolean form of scoring was used, assigning a value of 1 to those elements for

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which a lack of competence was observed during the incident and, a score of 0 in case of
evidencing competence or absence of information. The objective of the analysis tier 2 was to

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determine a rapid method of learning from incidents, identifying low competence areas in
process safety management systems. The 20 elements are divided into four categories (Frank,
2007): commit to process safety, understand hazard and risk, manage risk and, learn from
experience. These 20 elements were analyzed for each of the 96 incidents collected worldwide,
yielding to 1920 points of information. Fig. 8 shows the percentage of points attributed to each of
the categories. The percentages indicate lacking of competence during the incident in the
respective category. It should be noted that some incidents had proximate causes related to lack
of competency in multiple areas. According to Fig. 8, it was observed that 43% of the
information points were related to lack of risk management, 30% to commit to process safety,
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15% to understanding hazard and risk and, 12% failure to learn from experience. This supports
the reasoning that risk management is an important aspect for preventing incidents. Also, it
provides a direction towards improving the state-of-the-art in risk management processes in
industry. Despite the fact that of risk management turns out to be a recurring theme uncovered

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during investigation, the lack of robust systems to manage risk is observed in the incidents
collected. Furthermore, it was found that the lack of commitment to process safety contributed to
30% of the overall deficiencies in the safety management systems. This represents an alarming
need in order to improve process safety awareness and also, to promote safety culture in every

Learn from
experience
12%

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industrial facility.

Commit to
process
safety
30%

Understand
hazard and
risk
15%

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Manage
risk
43%

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Fig. 8. Distribution of CCPS pillar elements.

Further analysis of each of the four pillars provides insight into the contributing factors resulting
in their deficiency. The lack in the management of risk pillar was related to the majority of
incidents collected. The management of risk is a complex pillar with 9 factors contributing to the
overall risk control; these elements are shown in Fig. 9. The incident analysis showed major
deficiency in three factors, safe work practices (44 out of 96 incidents), and operating procedures
(43 out of 96) and, conduct of operations (41 out of 96). These factors have been highlighted in
incident investigations from past events, such as the lack of adequate operating procedures in the

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Texas City disaster of 2005. It was expected that the safe work practices element had such a
significant impact on the proximate causes of the collected incidents, given that non-routine
work exposes the employees to situations that they are not used to deal with. It was also observed
that that there is a lack of emergency management in 23% of the incidents analyzed. This is

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especially alarming since emergency management and response have a direct impact on the
community around the facilities. Examples of poor emergency response are the West Fertilizer
disaster in 2013 (Pittman et al., 2014) and Tianjin warehouse explosion in 2015 (Huang &
Zhang, 2015), both of which resulted in significant first responder casualties. The training and

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performance assurance element is used to keep employees informed regarding the current state
of the process and procedures and it also keeps them updated with the protocols in case of any

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abnormal event or process upset. Around 24% of the incidents collected showed improper
training and assurance, indicating the lack of awareness in the industry regarding the importance
of training.

Emergency management

22

Conduct of operations

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Operational readiness

35

Management of change

11

Training and performance assurance

Contractor management
Asset integrity and reliability

41

23
8

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14
44

Operating procedures

43

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Safe work practices

10
20
30
40
Number of incidents

50

Fig. 9. Elements contributing to the deficiency of the management of risk pillar.

Fig. 10 shows the number of incidents (out of 96) that evidenced a deficiency in each of the
elements related to the commitment to process safety pillar. This pillar provides the basis for
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excellence in process safety by exemplifying the commitment to a strong culture and, the
reflection of process safety as a value and not just as a priority. It was observed that 43 out of the
96 incidents studied exhibited a lack of good process safety culture. A good process safety
culture is demonstrated by the actual performance of management systems in the operating

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facilities and is not limited to the presence of the procedures, audits and documents (Hendershot,
2007). Hence, the operational performance of the safety systems is an important leading
indicator towards a good safety culture. Olive et al. (2006) have further elaborated on the
difference between safety culture and safety climate by illustrating the Challenger and Columbia

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space shuttle disasters. Following the Challenger disaster there was a strong orientation towards
safety in NASA; however, the underlying culture did not promote safety, resulting in another

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disaster (Columbia) almost two decades after the first incident. The steps to build a good safety
culture include the need for basic programs to maintain physical safety of the facility,
management level programs which include leaders participation and finally, employee focused
programs such as training and communication of safety requirements (Olive, OConnor, &
Mannan, 2006).

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Stakeholder outreach

Workforce involvement

12
28

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Process safety competency

Compliance with standards

47
37

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Process safety culture

43
0

10
20
30
Number of incidents

40

50

Fig. 10. Elements contributing to the deficiency of the commitment to process safety pillar.

Fig. 11 shows the deficiencies observed in the understanding hazards and risk pillar of the
safety management system. Almost half of the incidents (47 out of 96) evidenced a poor hazard
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identification and risk analysis as a causal factor. Hazards identification is used to determine
incident scenarios which can lead to possible abnormal events; since a process goes through
many stages in its lifecycle, safety reviews can be carried out at various stages in order to check
the scenarios relevance when time passes. In spite of the extensive development in the state of art

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in risk analysis, for example, a study (Tixier, Dusserre, Salvi, & Gaston, 2002) reviewed more
than 62 methodologies for assessing risk in industrial plants; improper hazard identification and
risk analysis continues to be one of the most relevant proximate causes of industrial incidents
(Tixier et al., 2002). The lack of proper hazards identification has also been attributed to several

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major efforts to improve its implementation in industry.

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major industrial disasters and the deficiency in this key element even today indicates the need for

Hazard identification and risk

analysis

Process knowledge management

47

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40

38

40

42

44

46

48

Number of incidents

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36

Fig. 11. Elements contributing to the deficiency of the understanding hazards and risk pillar.

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The last pillar of a robust safety management system is the requirement of having a learning
organization. Normal accident theory suggests that disasters are the result of complex socioeconomic systems and factors; to prevent these disasters, organizations need to possess certain
characteristics of response systems (Cooke & Rohleder, 2006). The incident learning system is
built on many factors including but not limited to incident reporting, quality of the reporting
system and management commitment to safety. According to Fig. 12, 20% of the incidents
collected (19 out of 96) showed a lack of robust audit systems in the facilities. This is an
important observation since audits provide a platform for improving the functioning of the
system. Auditing is mandatory by several regulatory agencies, such as under OSHA PSM
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standard which mandates compliance audits, and EPAs risk management plan (RMP) (Chemical
accident prevention provisions, 2016).
Performing adequate incident investigations is another important aspect of any continuous

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learning organizations. A complete and in-depth incident investigation of not only major
abnormal events but also near-misses, allows the organization to improve the system based on
lessons to learn. Incident investigation programs also focused on near-misses help to improve the
safety performance through its identification and analysis, taking these as warning signals of

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possible disasters. These programs may be based on frameworks such that individual sites can
analyze their own weak signals and implement system wide improvements (Phimister, Oktem,

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Kleindorfer, & Kunreuther, 2003).

Management review and

continuous improvement

18

Auditing

19

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Measurement and metrics

Incident investigation

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16
14

5
10
15
Number of incidents

20

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Fig. 12. Elements contributing to the deficiency of the learning from experience pillar.
4. Conclusions

A web-based strategy for collection and analysis of process safety incidents has been presented.
The method follows collection of incidents primarily using web crawlers (Google, 2016) and
classifying them using metrics, including incident type, consequences, and geographic zones. A
two-tiered approach was implemented to analyze the proximate causes of the incidents,
combining the available information with a rating system based on the CCPSs Risk Based
Process Safety (RBPS) elements. This strategy has been applied to build a database of incidents
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from October 2014 to October 2015, representing a total of 96 incidents worldwide; which have
been mined to identify important indicators of poor safety management systems.
From this specific sample, it was found that 33% of the incidents were under investigation and

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27% did not mention any on-going investigation or did not have enough information in order to
deduct the proximate causes of the event. This reveals that the sharing of lessons learned from
process safety incidents is a challenge due to unavailability of information in the public domain.
The previous concern highlights the importance of creating a worldwide database as a learning

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platform for sharing the main findings behind the root causes and contributing factors of process
safety incidents.

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In this paper, the 20 elements of a risk based approach to safety were used as the foundation for
the proposed methodology. The contribution of each one of the elements in the factors that led to
the 96 incidents was analyzed, yielding to 1920 points of information. At the same time, the
elements were divided into four categories (Frank, 2007): commit to process safety, understand
hazard and risk, manage risk and, learn from experience. It was observed that 43% of the
information points were related to lack of risk management and 30% to commit to process safety.

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This enables to conclude that risk management is a factor that plays a crucial role on the
prevention of incidents. Furthermore, there is an alarming need to improve process safety
awareness in order to promote safety culture as a priority. Failure to learn from experience was
also a relevant category (12%), which emphasizes the importance of a common learning

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platform.

Given the constraints in collecting the total number of incidents that happened during the one-

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year period around the world, the results presented in this paper should not be interpreted as the
complete incident statistics for this period of time.
Future work in the area of incident collection and analysis can be related to:
(1) Implementation of web crawlers to automatically identify possible incidents from open
sources and, develop systems (automated or manual) to classify incidents both within the
organization and externally.
(2) Encourage information sharing between academia, industry and government to build
robust incident databases to promote data mining and learning.
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(3) Disseminate incident investigation and risk analysis frameworks in usable formats across
specific industry domains. The usability includes appropriate classification, easy
accessibility (web-based, open to public) and, enough details to extract lessons to learn.
(4) Develop systems to continuously monitor the state of the safety management systems in

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the organization.
5. Acknowledgements

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We acknowledge the contribution of Ms. Jeimy Martinez in the collection of the incidents and
Ms. Valerie Green for providing resources for gathering incidents. This research was sponsored
by the Mary Kay OConnor Process Safety Center, Artie McFerrin Department of Chemical
Engineering at Texas A&M University.

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6. Appendix

The appendix Table 1 gives the list of incidents for the period of analysis in a concise format
giving details such as date, location, proximate causes, consequences and references.

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Table 2 gives the analysis of the incidents using the risk-based process safety elements.

7. References

AFP. (2014). Italy refinery fire causes panic in Sicily. The Malay Mail Online. Retrieved from

EP

http://www.themalaymailonline.com/world/article/italy-refinery-fire-causes-panic-insicily. Accessed on August 25 2015.

AC
C

Africa, e. (2015). Gallery: Fire engulfs Durban south oil factory. eNews Africa. Retrieved from
https://www.enca.com/south-africa/fire-engulfs-south-coast-oil-factory. Accessed on
June 20 2016.

Analyse, A. (2016). Recherche et Information sur les Accidents, French Ministry of Ecology and
Sustainable Development. Retrieved from http://www.aria.developpement-

durable.gouv.fr/?lang=en. Accessed on August 22 2016.

AP. (2014). 1 Killed, 11 injured in German Gas pipe explosion. Daily Mail. Retrieved from
http://www.dailymail.co.uk/wires/ap/article-2805084/1-killed-11-injured-German-gaspipe-explosion.html. Accessed on August 21 2015.
22 | P a g e

ACCEPTED MANUSCRIPT

AP. (2015a). Brazil oil ship explosion death toll rises to five. The Guardian. Retrieved from
http://www.theguardian.com/world/2015/feb/12/petrobras-oil-ship-explosion-brazil-fivedead. Accessed on August 28 2015.
AP. (2015b). Dozens killed in South Sudan fuel tanker explosion. The New York times. Retrieved

explosion.html?_r=1. Accessed on September 17 2015.

RI
PT

from http://www.nytimes.com/2015/09/18/world/africa/south-sudan-fuel-tanker-

AP. (2015c). Explosion, building collapse at chemical plant in western Germany leaves 13
injured, 5 missing. Fox News. Retrieved from

SC

http://www.foxnews.com/world/2015/08/05/explosion-building-collapse-at-chemicalplant-in-western-germany-leaves-13/. Accessed on August 24 2015.

M
AN
U

AP. (2015d). Fire hits chemical factory in northwestern Czech Republic. Daily star. Retrieved
from http://www.dailystar.com.lb/News/World/2015/Aug-13/310976-fire-hits-chemicalfactory-in-northwestern-czech-republic.ashx. Accessed on August 21 2015.
AP. (2015e). Large explosion rocks southeast Missouri aluminum plant. Fox News. Retrieved
from http://www.foxnews.com/us/2015/08/04/large-explosion-rocks-southeast-missourialuminum-plant/ Accessed on August 25 2015.

TE
D

Arellano, P. (2015). White Deer gas explosion injures 4. Amarillo Globe News. Retrieved from
http://amarillo.com/news/local-news/2015-06-26/gas-explosion-white-deer-injures-4.
Accessed on August 25 2015.

Bainbridge, P. (2015). East Manchester Fire: Dramatic pictures show how flames tore through

EP

chemical plant near Etihad campus. Manchester evening news. Retrieved from
http://www.manchestereveningnews.co.uk/news/greater-manchester-news/east-

AC
C

manchester-fire-dramatic-pictures-8986995. Accessed on August 28 2015.

Barton, J., & Nolan, P. (1989). Incidents in the chemical industry due to thermal runaway
chemical reactions. Hazards X: Process Safety in Fine and Speciality Chemical Plants
(115), 3-18.

BBCNews. (2014). Men in hospital after chemical leak at Ireland Alloys in Blantyre. BBC News.
Retrieved from http://www.bbc.com/news/uk-scotland-glasgow-west-30080304.
Accessed on August 21 2015.
BBCNews. (2015a). China blast hits Shandong chemical plant. BBC News. Retrieved from
http://www.bbc.com/news/world-asia-china-34029202. Accessed on September 8 2015.
23 | P a g e

ACCEPTED MANUSCRIPT

BBCNews. (2015b). China explosions: What we know about what happened in Tianjin. BBC
News. Retrieved from http://www.bbc.com/news/world-asia-china-33844084. Accessed
on September 12 2015.
BBCNews. (2015c). China paraxylene chemical plant hit by explosion. BBC News. Retrieved

RI
PT

from http://www.bbc.com/news/world-asia-china-32196103. Accessed on August 29

2015.

BBCNews. (2015d). St Leonards 'Chemical Incident' leaves 13 needing treatment. BBC.

Retrieved from http://www.bbc.com/news/uk-england-sussex-32733986. Accessed on

SC

August 25 2015.

Blount, J. (2015). UPDATE 5- Petrobras Brazil refinery blast injures 3, workers protest. Reuters.

M
AN
U

Retrieved from http://www.reuters.com/article/2015/01/19/brazil-petrobras-refineryidUSL1N0UY0K720150119. Accessed on August 25 2015.

Bongaarts, J. (2015). Global fertility and population trends. Paper presented at the Seminars in
reproductive medicine.

Callahan, E. A contractor is in the hospital following a fire and chemical release cyclohexanone
in the 700 block of the BASF Freeport facility in Texas after a reactor tube failed.

TE
D

Retrieved, from http://metroforensics.blogspot.com/2015/09/a-contractor-is-in-hospitalfollowing.html. Accessed on September 17 2015.

Campedel, M., Cozzani, V., Krausmann, E., & Cruz, A. M. (2008). Analysis of Natech accidents
recorded in major accident databases. Paper presented at the Proceedings PSAM.

EP

CCPS. (1993). Guidelines for auditing process safety management systems: Center for chemical
process safety/AIChE.

AC
C

CCPS. (2007). Guidelines for Risk Based Process Safety: Wiley, Center for Chemical Process
Safety/AIChE.

CCPS. (2011). Process Safety leading and Lagging metrics. You Don't improve What you Don't
Measure. http://www.aiche.org/sites/default/files/docs/embedded-

pdf/CCPS_ProcessSafety2011_2-24-web.pdf. Accessed in March 2016.

Chang, J. I., & Lin, C.-C. (2006). A study of storage tank accidents. Journal of Loss Prevention
in the Process Industries, 19(1), 51-59.
Chemicals-technology (2015). Blast kills one and injures 11 at chemical factory in Gujarat,
India. chemicals-technology.com. Retrieved from http://www.chemicals24 | P a g e

ACCEPTED MANUSCRIPT

technology.com/news/newsblast-kills-one-and-injures-11-at-chemical-factory-in-gujaratindia-4493692/. Accessed on August 25 2015.

Chemical accident prevention provisions, 40 C.F.R. 68 (2016).

RI
PT

Cheng, C.-W., Yao, H.-Q., & Wu, T.-C. (2013). Applying data mining techniques to analyze the
causes of major occupational accidents in the petrochemical industry. Journal of Loss
Prevention in the Process Industries, 26(6), 1269-1278.

Cheng, N. (2015). Explosion rocks Bukit Jalil as chemical factory burns. THESTAR News.

Retrieved from http://www.thestar.com.my/News/Nation/2015/05/12/Accident-Fire-

SC

explosion-Bukit-Jalil/. Accessed on August 25 2015.

Chemical accident prevention provisions, 40 C.F.R 69 (1994).

M
AN
U

CHINADAILYNews. (2015). Chemical plant leak poisons 20 in central China. CHINADAILY

News. Retrieved from http://www.chinadaily.com.cn/china/201509/18/content_21915895.htm. Accessed on September 25 2015.
Chinasafety.(2015) Shandong Linyi gas explosion accident. The China State Administration of
Work Safety. Retrieved, from

http://www.chinasafety.gov.cn/newpage/Contents/Channel_21102/2015/0202/246093/co

TE
D

ntent_246093.htm. Accessed on September 14 2015.

Chinasafety.(2015) Hubei Fusheng Chemical Company deflagration accident. The China State
Administration of Work Safety. Retrieved, from
http://www.chinasafety.gov.cn/newpage/Contents/Channel_21102/2015/0225/246670/co

EP

ntent_246670.htm. Accessed on October 2 2015.

CNBC News. (2015). Dongying factory blast kills one, six execs arrested. CNBC News.

AC
C

Retrieved from http://www.cnbc.com/2015/08/31/major-explosion-reported-in-dongyingchina.html. Accessed on September 8 2015.

Cooke, D. L., & Rohleder, T. R. (2006). Learning from incidents: from normal accidents to high
reliability. System Dynamics Review, 22(3), 213-239.

Cortez, J. (2015). No injuries in gas pipeline explosion near stinnett. Amarillo Globe News.
Retrieved from http://amarillo.com/news/local-news/2015-04-13/no-injuries-gaspipeline-explosion-nearstinnett?utm_source=Recommendation_Widget&utm_medium=desktop&utm_campaign
=qrec&utm_content=image. Accessed on August 25 2015.
25 | P a g e

ACCEPTED MANUSCRIPT

Dailysabah. (2015). Explosion at fertilizer factory in Bursa Kills 1. Daily sabah Turkey.
Retrieved from http://www.dailysabah.com/nation/2015/07/19/explosion-at-fertilizerfactory-in-bursa-kills-1. Accessed on August 25 2015.
DNVGL. (2016). World Offshore Accident Database (WOAD).

RI
PT

Dougherty, C. (2015). Man Hospitalized after chemical leak. FOX23 News. Retrieved from
http://www.fox23.com/news/news/local/chemical-leak-sends-one-hospital/nnYGR/.
Accessed on September 15 2015.

DPSatish. (2014). Andhra: Toll in cracker manufacturing unit explosion climbs to 17. News 18.

SC

Retrieved from http://www.ibnlive.com/news/india/andhra-toll-in-cracker-

manufacturing-unit-explosion-climbs-to-17-721483.html. Accessed on September 10

M
AN
U

2015.

Drogaris, G. (1993). Learning from major accidents involving dangerous substances. Safety
Science, 16(2), 89-113.

Drupsteen, L., & Guldenmund, F. W. (2014). What is learning? A review of the safety literature
to define learning from incidents, accidents and disasters. Journal of Contingencies and
Crisis Management, 22(2), 81-96.

TE
D

Edwards, A. Investigators gain access to ammonium nitrate truck explosion site near Charleville
in south-west Qld. ABC News. Retrieved, from http://www.abc.net.au/news/2014-0907/investigators-gain-access-to-ammonia-truck-explosion-site/5725924. Accessed on
August 25 2015.

EP

EPA. Vocabulary Catalog. Retrieved, from

https://iaspub.epa.gov/sor_internet/registry/termreg/searchandretrieve/glossariesandkeyw

AC
C

ordlists/search.do?details=&vocabName=SHEMS%20Terms%20and%20Definitions&fil
terTerm=incident&filterMatchCriteria=Contains. Accessed on August 25 2016.European
Commission. NATECH Accident database. Retrieved, from
http://enatech.jrc.ec.europa.eu/. Accessed in May 2016.

EUDirective. (1997). Council Directive 96/82/EC of 9 December 1996 on the control of major
accident hazards involving dangerous substances. Official Journal of the European
Communities.

26 | P a g e

ACCEPTED MANUSCRIPT

Farmer, S. (2015). Explosion at liquid transfer terminals results in injury, fatality The PostSearchlight. Retrieved from http://www.thepostsearchlight.com/2015/08/21/explosion-atliquid-transfer-terminals-results-in-injury-fatality/. Accessed on September 3 2015.
Fegan, J. (2015). Update: Eight injured, evacuation order lifted after fire at Warsaw Chemical

RI
PT

Fox 28. Retrieved from http://www.fox28.com/story/28043832/2015/02/06/update-

seven-injured-evacuation-order-lifted-after-fire-at-warsaw-chemical. Accessed on August

25 2015.

Frank, W. (2007). Process safety culture in the CCPS risk based process safety model. Process

SC

Safety Progress, 26(3), 203-208.

Girgin, S., & Krausmann, E. (2016). Historical analysis of US onshore hazardous liquid pipeline

Industries, 40, 578-590.

M
AN
U

accidents triggered by natural hazards. Journal of Loss Prevention in the Process

GlobleTimes. (2015). Explosion and fire hit chemical plant in East China. Globle Times.
Retrieved from http://www.globaltimes.cn/content/926807.shtml. Accessed on August 30
2015.

Goldberg, B. (2015). Investigation Underway in Fiery Tennessee Train Crash. Insurance

TE
D

Journal. Retrieved from

http://www.insurancejournal.com/news/southeast/2015/07/06/374183.htm. Accessed on
August 28 2015.

Goldschmidt, G. B. T. M. D. (2015). Spokane, Washington, Chlorine accident leaves 8 in critical

EP

condition. CNN. Retrieved from.http://www.cnn.com/2015/08/12/us/washington-statechlorine-sickness/. Accessed on September 3 2015.

AC
C

Google. Googlebot. Retrieved, from

https://support.google.com/webmasters/answer/182072?hl=en. Accessed on February 26

2016.

Grattan, S. H. R. (2015). Fire engulfs chemical plant in Waller County. Houston Chronicle.
Retrieved from http://www.chron.com/news/houston-texas/houston/article/Fire-engulfs-

chemical-plant-in-Waller-County-6367182.php. Accessed on August 25 2015.

Greg Botelho, K. W. (2015). More than 500 injured in explosion at Taiwan water park. CNN.
Retrieved from http://www.cnn.com/2015/06/27/asia/taiwan-water-park-explosion/.
Accessed on August 30 2015.
27 | P a g e

ACCEPTED MANUSCRIPT

Gunter, M. M., Hill, R., O'Connor, M. B., Retzer, K. D., & Lincoln, J. M. (2013, April 26). Fatal
Injuries in Offshore Oil and Gas Operations United States, 20032010. Retrieved from
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6216a2.htm. Accessed on August 26 2016.

RI
PT

Guy Desjardins, R. s. (2012). Encyclopedic dictionary of pipeline integrity: Clarion Technical

Publishers.

HalifaxCourier. (2015). Tanker Spills hazardous chemicals on road. Halifax Courier. Retrieved
from http://www.halifaxcourier.co.uk/news/calderdale/tanker-spills-hazardous-

SC

chemicals-on-road-1-7337580. Accessed on August 30 2015.

He, H. (2015). 13 large accidents in the first 6 months of 2015. Sina News. Retrieved from

2015.

M
AN
U

http://news.sina.com.cn/c/2015-08-13/183732201263.shtml. Accessed on September 5

Hendershot, D. (2007). Process safety culture. J. Chem. Health Saf, 14(3), 39-40.
Herald, B. A. (2014). Investigation points to overheating as cause of Cordoba explosion. Buenos
Aires Herald. Retrieved from

http://www.buenosairesherald.com/article/174273/investigation-points-to-overheating-ascause-of-crdoba-explosion-. Accessed on August 20 2015.

TE
D

Hopkins, A. (2008). Failure to learn: the BP Texas City refinery disaster: CCH Australia Ltd.
Huang, P., & Zhang, J. (2015). Facts related to August 12, 2015 explosion accident in Tianjin,
China. Process Safety Progress, 34(4), 313-314.
Jones, S., Kirchsteiger, C., & Bjerke, W. (1999). The importance of near miss reporting to

EP

further improve safety performance. Journal of Loss Prevention in the Process

Industries, 12(1), 59-67.

AC
C

Kane, K. (2015). No injuries result from fire at Eastman Chemical Resins. Pittsburg PostGazette. Retrieved from http://www.post-gazette.com/local/south/2015/06/06/Fire-

breaks-out-at-Eastman-Chemical-Resins-in-Jefferson-Hills/stories/201506060138.
Accessed on August 25 2015.

Kennedy, K. (2014). Interstate 75 back open after Madison Co. chemical spill. WKYT. Retrieved
from http://www.wkyt.com/home/headlines/Chemical-spill-closes-I-75-in-Madison-Co279911602.html. Accessed on August 22 2015.
Kerin, T. (2015). The evolution of process safety standards and legislation following landmark
events-what have we learnt? Process Safety Progress.
28 | P a g e

ACCEPTED MANUSCRIPT

Kidam, K., & Hurme, M. (2013a). Analysis of equipment failures as contributors to chemical
process accidents. Process Safety and Environmental Protection, 91(1), 61-78.
Kidam, K., & Hurme, M. (2013b). Statistical analysis of contributors to chemical process
accidents. Chemical Engineering & Technology, 36(1), 167-176.

RI
PT

Krug, A. (2015, June 21, 2015). Two injured in ethanol plant explosion. KIMT News 3. Retrieved
from http://kimt.com/2015/06/21/three-injured-in-ethanol-plant-explosion/. Accessed on
August 25 2015.

L.Congostrina, A. (2015). Emergency alert lifted following explosion that triggered toxic cloud.

SC

El pais. Retrieved from

http://elpais.com/elpais/2015/02/12/inenglish/1423755192_794670.html. Accessed on

M
AN
U

August 25 2015.

Larionova, A. (2015). Nanjing Yangzi Petrochemical plant exploded this morning. Analytics of
Polymer Market. Retrieved from http://www.mrcplast.com/news-news_open308527.html. Accessed on September 1 2015.

Leis, B. (2015). Challenges of an ageing pipeline system: a US perspective. Journal of Pipeline

Engineering, 14(4).

TE
D

Lezon, D. (2015). Chemical leak under investigation at Dow plant near Freeport. Houston
Chronicle. Retrieved from http://www.chron.com/news/houston-texas/article/Chemicalleak-at-Dow-plant-near-Freeport-6374830.php. Accessed on September 18 2015.
LiuAnNews. (2015). An explosion in Bangfu city. LiuAn News. Retrieved from

EP

http://news.0564luan.com/newsshow-5465.html. Accessed on September 13 2015.

LNMJ(2015). Coal Mine Gold Fields Limited Liability Company "6.19" gas explosion. Bureau

AC
C

of Liaoning Coal Mine Safety Supervision. Retrieved, from

http://www.lnmj.gov.cn/sgkb/201506/t20150621_1706565.html. Accessed on August 25

2015.

Mannan, M. S., Mentzer, R. A., & Zhang, J. (2013). Framework for creating a Best-in-Class
safety culture. Journal of Loss Prevention in the Process Industries, 26(6), 1423-1432.

Marsh. (2013). The 100 Largest Losses 19742013. Large Property Damage Losses in the
Hydrocarbon Industry (pp. 5-6).

29 | P a g e

ACCEPTED MANUSCRIPT

Matthews, T. E. (2015). Another Jos Chlorine explosion victim dies. Daily post. Retrieved from
http://dailypost.ng/2015/07/31/another-jos-chlorine-explosion-victim-dies/. Accessed on
August 13 2015.
McKirdy, E. (2015). Explosion at South Korean chemical factory kills 4. CNN News. Retrieved

RI
PT

from http://www.cnn.com/2015/07/03/asia/south-korea-chemical-factory-explosion/.
Accessed on September 10 2015.

Mitchison, N., & Clement, C. (1998). Safety Management Systems in the Seveso II Directive.
S. Lydersen, GK Hansen &

SC

Moreno, V. C., & Cozzani, V. (2015). Major accident hazard in bioenergy production. Journal of
Loss Prevention in the Process Industries, 35, 135-144.

M
AN
U

Mosquera, A. w. E. (2015). West Virginia Train Derailment: Fireball Erupts into sky as
derailment sends tanker into river. abc news. Retrieved from

http://abcnews.go.com/US/west-virginia-train-derailment-fireball-erupts-skyderailment/story?id=29006943. Accessed on September 3 2015.

NorfolkConstabulary (2015). Hellesdon scene investigations. Retrieved, from
http://www.norfolk.police.uk/newsandevents/newsstories/2015/july/industrialincidenthell

TE
D

esdon.aspx. Accessed on August 25 2015.

Olivares, R. D. C., Rivera, S. S., & Mc Leod, J. E. N. (2014). Database for accidents and
incidents in the biodiesel industry. Journal of Loss Prevention in the Process Industries,
29, 245-261.

EP

Olivares, R. D. C., Rivera, S. S., & Mc Leod, J. E. N. (2015). Database for accidents and
incidents in the fuel ethanol industry. Journal of Loss Prevention in the Process

AC
C

Industries, 38, 276-297.

Olive, C., OConnor, T. M., & Mannan, M. S. (2006). Relationship of safety culture and process
safety. Journal of hazardous materials, 130(1), 133-140.

OSHA (2015), Proper protections could have saved four DuPont workers killed by gas. [Press
release]. Retrieved from https://www.osha.gov/newsrelease/reg6-20150514.html.
Accessed on August 25 2015.

30 | P a g e

ACCEPTED MANUSCRIPT

People.cn. (2015). A plurality of storage tanks in a refinery company in Changzhou city.

People.cn. Retrieved from http://js.people.com.cn/n/2015/0801/c360303-25799661.html.
Accessed on August 1 2015.
Phimister, J. R., Oktem, U., Kleindorfer, P. R., & Kunreuther, H. (2003). Near-miss incident

RI
PT

management in the chemical process industry. Risk Analysis, 23(3), 445-459.

Pittman, W., Han, Z., Harding, B., Rosas, C., Jiang, J., Pineda, A., & Mannan, M. S. (2014).
Lessons to be learned from an analysis of ammonium nitrate disasters in the last 100
years. Journal of hazardous materials, 280, 472-477.

SC

Plane, M. (2015). Chemical contained in Wycarbah three days after leak. The morning bulletin.
Retrieved from http://www.themorningbulletin.com.au/news/capricorn-hwy-closed-due-

M
AN
U

truck-explosion-danger/2751918/. Accessed on September 15 2015.

Powell-Price, M., Bond, J., & Mellin, B. The accident database: Capturing corporate memory.,
IChemE Symposium Series No 144, 1998.

PRAMEYANEWS7News. (2015). Explosion in China chemical plant injures 7 workers.

PRAMEYANEWS7 News. Retrieved from

http://www.prameyanews7.com/en/oct2015/globe/4045/Explosion-in-China-chemical-

TE
D

plant-injures-7-workers.htm. Accessed on October 10 2015

Prem, K. P., Ng, D., & Mannan, M. S. (2010). Harnessing database resources for understanding
the profile of chemical process industry incidents. Journal of Loss Prevention in the
Process Industries, 23(4), 549-560.

EP

PTI. (2014a). One killed, another injured in factory explosion. Business Standard.
http://www.business-standard.com/article/pti-stories/one-killed-another-injured-in-

AC
C

factory-explosion-114101800527_1.html. Accessed on July 31 2016.

PTI. (2014b). Toll in Andhra cracker manufacturing unit explosion climbs to 17. The Times of
India. http://timesofindia.indiatimes.com/india/Toll-in-Andhra-cracker-manufacturingunit-explosion-climbs-to-17/articleshow/44896479.cms. Accessed on July 31 2016.

PTI. (2015). 1 Killed in explosion at factory. The statesman. Retrieved from

http://www.thestatesman.com/news/delhi/1-killed-in-explosion-at-factory/56564.html.
Accessed on September 4 2015.

31 | P a g e

ACCEPTED MANUSCRIPT

Rasta, A. (2015). Massive fire, explosions rock DrillChem facility in Conroe. Click 2 Houston.
Retrieved from http://www.click2houston.com/news/massive-fire-explosions-rockdrillchem-facility-in-conroe. Accessed on August 25 2015.
Reuters. (2015a). Fuel storage tank fire spreads at Santos Port in brazil. Reuters. Retrieved from

idUSKBN0MV0II20150404. Accessed on August 28 2015.

RI
PT

http://www.reuters.com/article/2015/04/04/us-brazil-fire-fueltanks-

Reuters. (2015b). Petrobras fuel tank explodes in Brazil, killing two. Reuters. Retrieved from
http://www.reuters.com/article/2015/08/26/brazil-petrobras-blast-

SC

idUSL1N11126J20150826. Accessed on September 8 2015.

Richter, E. (2015). 1 injured in Monroe chemical explosion. Dayton Daily News. Retrieved from

M
AN
U

http://www.daytondailynews.com/news/news/chemical-explosion-people-hurt-atmonroe-plant/nkxGJ/. Accessed on August 25 2015.

ROCKETNEWS24Nee. The moment a chemical plant in China exploded in a mountain of

flames. ROCKETNEWS24 Nee Retrieved, from

http://en.rocketnews24.com/2015/07/17/the-moment-a-chemical-plant-in-chinaexploded-in-a-ball-of-flames-%E3%80%90video%E3%80%91/ Accessed on September

TE
D

20 2015.

Rootcauselive. Comprehensive list of causes; A tool for root cause analysis. Retrieved, from
http://www.rootcauselive.com/Files/Investigative%20Processes/Comprehensive%20List
%20of%20Causes.PDF. Accessed on June 28 2016.

EP

Rush, R. (2015). Acid Leak at Thermo Fisher Scientific. Loughborough Echo. Retrieved from
http://www.loughboroughecho.net/news/local-news/acid-leak-thermo-fisher-scientific-

AC
C

9562179. Accessed on August 28 2015.

Scinto, C. L. J. S. (2015). Fire at Jenkins Twp. manufacturing plant injures 1, forces high school
evacuation. The times-tribune. Retrieved from http://thetimes-tribune.com/news/fire-at-

jenkins-twp-manufacturing-plant-injures-1-forces-high-school-evacuation-1.1880862.
Accessed on August 25 2015.

Sepeda, A. L. (2006). Lessons learned from process incident databases and the processsafety
incident database (PSID) approach sponsored by the Center for Chemical Process Safety.
Journal of hazardous materials, 130(1), 9-14.

32 | P a g e

ACCEPTED MANUSCRIPT

Siddiqui, F. R. (2015). Chemical factory destroyed in a major fire in Kanpur. The Times of India.
http://timesofindia.indiatimes.com/city/kanpur/Chemical-factory-destroyed-in-a-majorfire-in-Kanpur/articleshow/48373039.cms. Accessed on August 6 2015.

from http://suzhou.house.sina.com.cn/news/2015-09-

RI
PT

Sina News. (2015). An explosion in a chemical plant in Changzhou city. Sina News. Retrieved

23/07356052233592107756498.shtml. Accessed on September 25 2015.

Snyder, M. (2015). Damage from miller chemical fire too extensive to rule cause. abc27 News.
Retrieved from http://abc27.com/2015/07/07/damage-from-miller-chemical-fire-too-

SC

extensive-to-rule-cause/. Accessed on August 25 2015.

Sohu News. (2015). 3 incident investigations in Ordos. Sohu News. Retrieved from

M
AN
U

http://news.sohu.com/20150701/n415981479.shtml. Accessed on September 26 2015.

Staff report. (2014). Massive explosion rocks German Chemical plant. RT. Retrieved from
https://www.rt.com/news/186492-germany-chemical-plant-explosion/. Accessed on
August 28 2015.

Staff report. (2015). OSHA proposes $87780 fine for MFG Chemical after poisonous chemicals
killed worker. Times Free Press. Retrieved from

TE
D

http://www.timesfreepress.com/news/local/story/2015/jan/06/osha-cites-mfg-chemicalinc-after-2-workers-injured-1-fatally/281256/. Accessed on August 25 2015.

Tait, M. (2015). Deadly explosion: Blast victim was meant to be home sick. NZ herald.
Retrieved from

EP

http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11514181. Accessed
on September 24 2015.

AC
C

The Times of India. (2014). 33 fall sick in ammonia gas leak at China chemical plant. The Times
of India. Retrieved from http://timesofindia.indiatimes.com/world/china/33-fall-sick-in-

ammonia-gas-leak-at-China-chemical-plant/articleshow/42006063.cms. Accessed on
September 10 2015.

Tixier, J., Dusserre, G., Salvi, O., & Gaston, D. (2002). Review of 62 risk analysis
methodologies of industrial plants. Journal of Loss Prevention in the Process Industries,
15(4), 291-303.

33 | P a g e

ACCEPTED MANUSCRIPT

Varghese, J. (2015). Zhejiang Explosion: Another Massive Blast at Chemical Plant Rocks China.
IBTIMES New. Retrieved from http://www.ibtimes.co.in/zhejiang-explosion-anothermassive-blast-chemical-plant-rocks-china-645696. Accessed on September 20 2015.
Variyar, M. (2015). Visakhapatnam: Chemical reactor blast at Pharma City kills 2, injures 5.

RI
PT

International Business Times. http://www.ibtimes.co.in/visakhapatnam-reactor-blastpharma-city-injures-four-workers-648331. Accessed on September 30 2015.

Viydo, T. (2015). Newport explosion closes Zodiac Aerospace indefinitely. KREM News.
Retrieved from http://legacy.krem.com/story/news/local/pend-

SC

oreille/2015/07/15/newport-explosion-closes-zodiac-aerospace-indefinitely/30223669/.
Accessed on September 3 2015.

M
AN
U

Wang, Y. A list of incidents in 2015. Yicai News. Retrieved on September 20 2015.

WangyiNews. (2015). A chemical explosion in Tangshan city. Wangyi News. Retrieved from
http://news.163.com/photoview/00AN0001/92227.html#p=ASDQCU9K00AN0001.
Accessed on August 31 2015.

Whitworth, J. (2015). 15 year veteran dies in creston chemical plant explosion. 12WHOTV.
Retrieved from http://whotv.com/2015/01/09/15-year-veteran-dies-in-creston-chemical-

TE
D

plant-explosion/. Accessed on August 25 2015.

XinhuaNews. (2015). Explosion and fire hit chemical plant in China. Xinhua News. Retrieved
from http://www.china.org.cn/photos/2015-06/13/content_35812015.htm. Accessed on
August 25 2015.

EP

YahooNews. (2015). Nanyang anti-corrosion coating Ltd. Dalian Chemical burst into flames.
Yahoo News. Retrieved from http://www.yacoo.com.cn/exhibitioninfo/7822. Accessed on

AC
C

September 1 2015.

Yang, M., Khan, F., & Amyotte, P. (2015). Operational risk assessment: A case of the Bhopal
disaster. Process Safety and Environmental Protection, 97, 70-79.

Zaveri, M. (2015). Death of Dow Contractor under investigation. Houston Chronicle. Retrieved
from http://www.houstonchronicle.com/news/houston-texas/houston/article/Death-of-

Dow-contractor-under-investigation-6376436.php. Accessed on September 18 2015.

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Appendix A: Table 1

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Database of incidents used in the current study giving details of the date, type of industry, type of incident, substance involved,
description of the incident, proximate causes, consequences and the sources of information

11/15/2014

La Porte, TX,
USA

7/2/2015

Maryville, TN,
USA

Type of
industry

Type of
incident

Substance involved

Description/events sequence

Proximate causes

Consequences

Methyl mercaptan

A toxic gas release took place

at DuPonts Chemical Plant in
La Porte, when an operator
opened a valve on a pipe
carrying methyl mercaptan.

Lack of work policies/standards/procedures for the task

Inadequate adjustment/ repair/maintenance
Lack of knowledge of hazards present
Inadequate emergency training effort

4 Fatalities/1
Injury/OSHA
proposed penalties of
$273,000 for one
repeat and four serious
violations in La Porte

Acrylonitrile

A single-tank car carrying

24,000 gallons of acrylonitrile,
derailed and caught on fire.
After burning for hours, the fire
was extinguished.

Under investigation

0 Fatalities/97
Injuries/Thousands
evacuated

- Knoxville News & Weather

(Goldberg, 2015)

Ferric chloride

A chemical spill shut down

portions of Interstate 75 in
northern Madison County. A
tanker truck was leaking ferric
chloride solution from one of
its valves.

Under investigation

0 Fatalities/0 Injuries

- WKYT (Kennedy, 2014)

- Herald Leader Lexington

Under investigation
Defective equipment

0 Fatalities/0
Injuries/Damage to the
facility: $20 million
dollars/Shelter-inplace within a mile
radius of the
warehouse

ABC27 News
(Snyder, 2015)

A series of explosions occurred

in an oil field chemical supply
company in Conroe.

Under investigation. Inadequate tools, equipment &

vehicles (Electrical, gas-powered equipment and
spontaneous combustion caused by disposal of oily
rags)

0 Fatalities/0 Injuries

- Click2 Houston
- (Rasta, 2015)

Not reported

An explosion and fire occurred

at one of manufacturing plant's
process units at Eastman
Chemical Resins in Jefferson
Hills. The fire was extinguished
about two hours after it began.

Unknown

0 Fatalities/0
Injuries/Shelter-inplace order was issued

Not reported

A fire broke out at Flowchem, a

company that makes pipeline
additives using synthetic
rubber. The site stored
flammable alcohol-based
chemicals and soy bean oil. The
fire did not reach them.

Unknown

0 Fatalities/0
Injuries/Shelter-inplace for residents
within two miles of
the plant

Madison County,
KY, USA

6/8/2015

Conewago
Township, PA,
USA

F, E

Not reported

8/14/2015

Conroe, TX, USA

F, E

Not reported

6/7/2015

Elizabeth
Borough, PA,
USA

7/5/2015

35 | P a g e

Brookshire, TX,
USA

AC
C

F, E

F, E

Fire and explosions occurred at

the Miller Chemical and
Fertilizer Complex, which
blended raw materials to
manufacture agricultural
products.

EP

10/21/2014

SC

Location

M
AN
U

Date

TE
D

Incident
number

Source

- OSHA(2015)

Pittsburgh Post-Gazette
(Kane, 2015)

- Houston Chronicle
(Grattan, 2015)

ACCEPTED MANUSCRIPT

6/21/2015

Glenville, MN,
USA

F, E

Not reported

Under investigation.
Inadequate tools, equipment & vehicles

Ethanol

Ethanol vapors leaked from

piping caught fire and caused
an explosion at the Poet
Ethanol Plant in Glenville. Two
out of four employees that were
in the plant were injured.

Under investigation

10

6/25/2014

Becancour,
Quebec, Canada

Chlorine

A tank containing chlorine

exploded at the Olin Chlor
Alkali Products plant in
Becancour. Workers in nearby
buildings were evacuated, but
employees at Olin Chlor Alkali
were told to remain at the
chemical plant.

11

8/4/2015

Marston, MO,
USA

F, E

Aluminum (molten
metal)

A natural gas pipeline

explosion and fire occurred at a
gas booster station as a crew
worked on a 4-inch gas line.
The workers were replacing
some gas lines, repairing a
ruptured line.

Unknown

0 Fatalities/4 Injuries

A natural gas pipeline that was

situated within a plowed field
exploded and caused a fire. The
location of the explosion helped
crews keep it contained.

Under investigation

0 Fatalities/0
Injuries/One home
was voluntarily
evacuated

- AmarilloGlobeNews
(Cortez, 2015)

Lack of knowledge of hazards present

Inadequate training effort
Lack of policies/standards/procedures for the task

0 Fatalities/10
Injuries/Evacuation of
17 buildings inside an
industrial park

- CNN
(Goldschmidt, 2015)

Crude bakken oil

A rail car with more than 100

tanks of crude oil derailed in
West Virginia, generating a
huge fireball, the evacuation of
hundreds of people and, a spill
into the Kanawha River.

Inadequate tools, equipment & vehicles (Rail defect)

0 Fatalities/1
Injuries/Hundreds
evacuated/FRE issued
CSX and Sperry Rail
Service $25.000 fines
each

- ABC News
(Mosquera, 2015)

Acetal

During the transfer of acetal

from one vessel to another a
fire and explosion occurred due
a chemical reaction, which
caused the rupture of one of the
vessels.

Under investigation

0 Fatalities/1 Injuries

- Dayton Daily News

(Richter, 2015)

13

4/13/2015

Stinnett, TX,
USA

F, E

Natural gas

14

8/13/2015

Spokane, WA,
USA

Chlorine

4/17/2015

36 | P a g e

Monroe, OH,
USA

F,E

EP

TE
D

Natural gas

AC
C

M
AN
U

0 Fatalities/33 Injuries

F, E

16

- CTVNews (Kennedy, 2014)

Hazardous work exposure

F, E

- Reuters (Krug, 2015)

A massive explosion in an
aluminum plant in Missouri
created a monumental smoke
column due to the fire.

White Deer, TX,

USA

Kanawha, WV,
USA

0 Fatalities/2
Injuries/Significant
damage to the facility

- The Spokesman-Review (Viydo,

2015)

0 Fatalities/1 Injury

6/26/2015

2/16/2015

0 Fatalities/5
Injuries/Newport city
manager estimate $1
million in damages to
the plant

Unknown

12

15

RI
PT

7/14/2015

An explosion occurred in an
aerospace company in Newport
which caused huge damages in
the structure of the facility.

SC

Newport, WA,
USA

There was a chlorine release at

Pacific Steel recycling plant.
The gas came from a cylinder
that workers were crushing for
scrap metal.

- Fox news
(AP, 2015e)

- Amarillo Globe News

(Arellano, 2015)

ACCEPTED MANUSCRIPT

17

5/13/2015

Jenkins
Township, PA,
USA

Acetone

An electrical discharge in
Acton Technologies company
caused a fire in a warehouse
were acetone was stored.

Hazardous work exposure

18

1/8/2015

Creston, IA, USA

Not reported (over

pressured air)

In a chemical plant that

produces fertilizer, carbon
dioxide and dry ice, a pipeline
explosion occurred.

Not reported

One worker died after

hazardous chemical vapors
released from an overpressurized reactor burned his
respiratory system. The worker
charged chemicals inside a
reactor vessel and a reaction
started before he could close it.

Dalton, GA, USA

1 Fatalities/2 Injuries

- 13WHOTV
(Whitworth, 2015)

Under investigation (Inadequate

management/supervision)

1 Fatalities/2
Injuries/OSHAs
proposed penalties
total $87,780

- Times free press

(Staff report, 2015)

Under investigation

0 Fatalities/8
Injuries/50 homes
were evacuated

- FOX 28
(Fegan, 2015)

RI
PT

Under investigation

SC

1/6/2015

-The times tribune

(Scinto, 2015)

M
AN
U

19

0 Fatalities/1
Injuries/School
evacuation

2/6/2015

Warsaw, IN,
USA

F, E, R

Methanol

21

8/19/2015

Bainbridge, GA,
USA

F, E

Sodium hydrosulfide

While a worker was welding on

top of a tank that contained one
million gallons of sodium
hydrosulfide a massive
explosion occurred.

Under investigation

1 Fatalities/1 Injuries

9/4/2015

Sapulpa, OK,
USA

A tank car was leaking

Anhydrous ammonia and the
cap from the tanker was
missing, which created a vapor
cloud.

Unknown

0 Fatalities/1 Injuries

A chemical release and fire

took place at the BASFs
Freeport site. The fire started
when a mixture of
cyclohexanone and
cyclohexanol escaped from a
vent stack due to a failure in the
reactor tube.

Under investigation

0 Fatalities/20 Injuries

Anhydrous ammonia

EP

22

TE
D

20

A tank ruptured in Warsaw

Chemical company, it
contained hazardous chemical
that caused a fire followed by
an explosion. After the fire
some chemicals spilled into
Winona lake.

- Fox 23 News
(Dougherty, 2015)

- Metroforensics
(Callahan, 2015)

9/5/2015

Freeport, TX,
USA

F, R

24

6/9/2015

Freeport, TX,
USA

Pyrolysis gasoline

There was a chemical leak in a

cracking unit at Dow
Chemical's Oyster Creek Plant.
In this incident the release did
not result in a fire.

Under investigation

0 Fatalities/0
Injuries/Nearby
residents and
employees were asked
to stay indoors

- Houston Chronicle
(Lezon, 2015)

25

6/7/2015

Freeport, TX,
USA

Not reported

A contractor died after entering

a confined space at Dow
Chemicals plant in Oyster
Creek.

Under investigation

1 Fatalities/0 Injuries

- Houston Chronicle
(Zaveri, 2015)

AC
C

23

37 | P a g e

Cyclohexanone,
Cyclohexanol

- The post searchlight

(Farmer, 2015)

ACCEPTED MANUSCRIPT

Ammonium nitrate
Diesel fuel

A truck carrying 50 tons of

ammonium nitrate crashed and
caught fire following an
explosion.

Not reported

Explosion in a plant that

produces industrial coatings.

Natural gas

Gas leaked out of a pipeline,

which had been damaged by
excavation work. Local news
reported that the pipe exploded
when it was hit by a digger. It
caught fire followed by an
explosion.

0 Fatalities/8
Injuries/Firefighters
trucks and bridge were
destroyed. Debris
found up to 1.5 km
away

- The Courier Mail Australia

(Edwards, 2014)

Unknown

1 Fatalities/"Several"
Injuries/Around 30 to
40 houses damaged

- RT News
(Staff, 2014)

Under investigation

1 Fatalities/"Several"
Injuries/An entire
neighborhood was
devastated

- Daily Mail UK
(AP, 2014)

Unknown

0 Fatalities/0
Injuries/Damaged
buildings

- eNews Channel Africa

(Africa, 2015)

26

9/5/2014

Charleville,
Queensland,
Australia

27

9/9/2014

Ritterhude,
Osterholz,
Germany

10/23/2014

Ludwigshafen,
RhinelandPalatinate,
Germany

29

3/26/2014

Durban,
KwaZulu-Natal,
South Africa

Not reported

Blaze in a warehouse next to oil

factory. Fire created massive
plumes of smoke in the area.
Fire spread to adjacent paint
factory.

30

11/6/2014

Cordoba,
Cordoba,
Argentina

Not reported

An explosion in a chemical
facility. A gas cloud was seen
above the area immediately
after the explosion.

Inadequate tools, equipment & vehicles

Inadequate engineering/design (a preliminary
investigation points to the overheating of a machine as
the cause of the explosion)

1 Fatalities/66
Injuries/Damaged
about 20 buildings and
left a crater in the
facility's backyard

31

4/5/2015

Manchester,
Greater
Manchester,
England

FE

Not reported

Fire in a chemical plant fueled

by unidentified chemicals. Two
explosions were reported, one
of them was a cylinder.

Unknown

0 Fatalities/0
Injuries/Smoke and
debris

- Manchester Evening News

(Bainbridge, 2015)

Inadequate management/supervision
Inadequate work planning

0 Fatalities/0
Injuries/Fine of around
USD $6.4 million (R$
22.5 million).
Environmental impact
causing death of
thousands of fish

- Reuters
(Reuters, 2015a)

Chemical leak at a metal

recycling plant. Firefighters
sealed the valve and dispersed
the vapor cloud.

Unknown

0 Fatalities/2
Injuries/Two workers
were treated at the
scene as a
precautionary measure

- BBC news
(BBCNews, 2014)

RI
PT

SC

ER

M
AN
U

TE
D

28

Under investigation

A fire started inside a depot

with 3 million liters of diesel
and the flames spread to four
neighboring storage tanks. The
fire lasted for 9 days.

- Buenos Aires Herald

(Herald, 2014)

4/2/2015

Santos, So
Paulo, Brazil

Diesel fuel

33

11/17/2014

South
Lanarkshire,
Hamilton,
Scotland

Not reported

34

5/14/2015

St. Leonards, East

Sussex, England

Ammonia

Ammonia release at recycling

center Workers was evacuated.
Shelter in place was issued in
nearby areas.

Under investigation

0 Fatalities/13 Injuries

- BBC news
(BBCNews, 2015d)

35

7/13/2015

Norwich,
Norfolk, England

EF

Not reported

Explosion as a result of a buildup of toxic fumes with ignition

causing a fire ball. The men
were killed while working in a
confined unit.

Under investigation

2 Fatalities/0
Injuries/Damaged
buildings

- Norfolk Constabulary
(NorfolkConstabulary, 2015)

38 | P a g e

AC
C

EP

32

ACCEPTED MANUSCRIPT

Loughborough,
Leicestershire,
England

Hydrochloric acid

Leak from a container of

hydrochloric acid when being
moved. Firefighters deposited a
neutralizing agent on the
ground.

Unknown

Not reported

Explosion at a fertilizer factory

from a gas entrapment in a
steam boiler. The stairway
where the steam boilers were
located had collapsed along
with the lift instalments.

Inadequate work plan

Inadequate engineering design
Inadequate assessment of needs and risk

Not reported

Employees at the plant were

carrying out their normal duties
when two chemical compounds
came into contact. An
explosion occurred releasing a
toxic cloud into the air.

0 Fatalities/0 Injuries

- Loughborough Echo
(Rush, 2015)

1 Fatalities/1
Injuries/Facility
damage

- Daily Sabah Turkey

(Dailysabah, 2015)

0 Fatalities/11
Injuries/Toxic cloud

- El Pais
(L.Congostrina, 2015)

Under investigation

0 Fatalities/13
Injuries/Damaged
buildings

- Fox News
(AP, 2015c)

Improperly prepared equipment

Inadequate engineering/design
Improper handling of materials (the chemical had
leaked from the tanks which were not properly secured)

0 Fatalities/0 Injuries

- Halifax Courier
(HalifaxCourier, 2015)

Explosion of chlorine cylinder

at the Lamingo Water Board
Treatment Plant. The explosion
happened at 4 a.m. caused an
excess chlorine inhalation by
the nearby residents.

Under investigation

9 Fatalities/>100
Injuries

- Daily Post
(Matthews, 2015)

A blaze in a chemical factory

after an explosion. The
explosion of propylene took
place in the Unipetrol plant.
Local authorities recommended
shelter in place.

Unknown

0 Fatalities/5 Injuries

- Daily star
(AP, 2015d)

Explosion in an oil and gas

production ship rented by
Petrobras. The explosion
occurred aboard the FPSO unit.
A leak of flammable substance
in the pump room was the cause
of the explosion.

Failure in following procedures

Lack of work rules/policies/standards/procedures
(breach of operational procedures for the pumping of
fluids)
Inadequate engineering/design
Inadequate management/supervision (installation of
equipment in pipe without proper technical
specification and registration of the change)
Work exposure to hazardous chemicals (flammable
substances)
Inadequate assessment of needs and risks

9 Fatalities/26 Injuries

- The Guardian
(AP, 2015a)

Gemlik, Bursa
Province, Turkey

2/12/2015

Igualada,
Province of
Barcelona, Spain

39

August/05

Krefeld, North
RhineWestphalia,
Germany

Nitrogen, titanium
dioxide

A nitrogen tank exploded and a

building collapsed at a chemical
plant. Explosion caused a
leakage of titanium dioxide and
nitrogen, but no high levels of
chemicals were detected in the
area.

40

7/1/2015

Huddersfield,
West Yorkshire,
England

Toxic chemical thought to be an oilbased solvent

Several main roads closed after

a tanker carrying potentially
hazardous chemicals spilled
some of its load.

7/25/2015

Jos, Plateau State,

Nigeria

8/13/2015

Litvnov, st nad
Labem, Czech
Republic

42

43

2/12/2015

39 | P a g e

Aracruz, Espirito
Santo, Brazil

Chlorine

TE
D

EP

41

Propylene

AC
C

38

Not reported

Under investigation

M
AN
U

7/19/2015

37

RI
PT

7/1/2015

SC

36

ACCEPTED MANUSCRIPT

46

9/15/2015

1/18/2015

Auckland, New
Zealand

Salvador, Bahia,
Brazil

Oil derivatives

Inadequate work planning

Anhydrous ammonia

Truck carrying anhydrous

ammonia began leaking
chemicals on the highway. The
highway was closed and a 1 km
exclusion zone was put in place
when the truck began leaking.

Inadequate assessment of potential failure (reports

suggest a pressure relief valve on the truck had failed)
Inadequate work planning

Not reported

Hydrogen

2 Fatalities/3 Injuries/

- Reuters
(Reuters, 2015b)

0 Fatalities/0 Injuries

- The Morning Bulletin

(Plane, 2015)

Unauthorized welding at the

top of the tank with flammable
vapors leading to explosion
.

Failure in following procedure (welding work was

incorrectly started)
Inadequate assessment of required skill level
Inadequate training/knowledge transfer
Inadequate management/supervision
Inadequate contractor selection & oversight
Inadequate work planning
Lack of rules/policies/standards/procedures
Lack of communication

1 Fatalities/2 Injuries/
Debris

- NZ Herald
(Tait, 2015)

An explosion occurred at one of

Petrobras refineries. The blast
occurred at a hydrogen conduit
in an enclosed space, causing a
flare and a displacement of air
that threw the contract workers
against the refinery's metal
structure.

Inadequate maintenance
Failure following procedures
Lack of work rules/policies/standards/procedures
Physical condition ( the accident may have been the
result of maintenance work being carried out under
tight deadlines and long shifts imposed on refinery
workers)
Mental stress
Mental state

0 Fatalities/3 Injuries

- Reuters
(Blount, 2015)

A fire started in a 5,000-liter

tank at the Milazzo refinery,
which is jointly owned by
Italys Eni and Kuwait
Petroleum. Firefighters
controlled the fire but the tank
burned until the oil tank was
empty. According to the fire
department, the fire was caused
by the collapse of the tank roof.

49

Sicily, Italy

9/16/2015

Maridi, Western
Equatoria, South
Sudan

40 | P a g e

Inadequate work planning

Inadequate maintenance (local media reported that
when the refinery caught fire, there was maintenance
work going on at the facility)
Inadequate management/supervision

0 Fatalities/0 Injuries

- The Malay Mail online

(AFP, 2014)

Tanker crash followed by a

blast took place on a road close
to the town of Maridi. The
leaking tanker along with
pilferage attempts led to an
explosion

Lack of knowledge of hazard present

Inadequate tools/equipment or vehicle
Inadequate work planning

85 Fatalities/>100
Injuries

- The New York Times

(AP, 2015b)

EP

9/27/2014

Oil

AC
C

48

Oil

RI
PT

8/25/2015

Wycarbah,
Queensland,
Australia

TE
D

47

Vitria, Espirito
Santo, Brazil

SC

45

8/26/2015

M
AN
U

44

A heating unit at a Petrobras

depot used to treat fuel for
ocean-going ships exploded.
The blast and resulting fire
broke out while workers were
doing planned maintenance on
the heating unit.

ACCEPTED MANUSCRIPT

10/18/2014

Chandausi, Uttar
Pradesh, India

Not reported

A boiler explosion occurred in

Kaka Chemical factory which
manufactures chemicals
required for making soaps.

Fire crackers

There was an explosion in the

firecracker production unit. 24
workers were on the premises
out of which 17 were killed.
The unit had applied for its
license renewal around the time
this incident occurred.

The incident occurred when

workers were weighing a barrel
of 4-hydroxybenzohydrazide.
There was a short circuiting in
the weighing scale which led to
an explosion.

Inadequate personal protective equipment

Inadequate isolation of process or equipment

RI
PT

50

1 Fatalities/ 1 Injury

- Business Standard
(PTI, 2014a)

17 Fatalities/ Chief
Minister of the state
announced ~ 3000
USD to each victim's
family as
compensation for loss

- The Times of India

(PTI, 2014b)

1 Fatality/ 11 Injuries

- Chemicals Technology
(Rasta, 2015)

10/20/2014

Kakinada,
Andhra Pradesh,
India

52

1/20/2015

Ankaleshwar,
Gujrat, India

4hydroxybenzohydrazide

53

4/8/2015

Greater Noida,
Delhi, India

Not reported

A chemical drum which is

speculated to have contained an
old chemical exploded at
Echotech fiber manufacturing
factory workshop.

Unknown

1 Fatality/ 2 Injuries

- The Statesman
(PTI, 2015)

Not reported

Fire in a chemical factory in

Chakeri area of Kanpur, Uttar
Pradesh, India. It took more
than 5 hours for 15 fire fighting
vehicles to extinguish the fire.
A large portion of the factory
and a storehouse adjacent to it
were destroyed.

Under investigation

0 Fatalities/0 Injuries

- The Times of India

(Siddiqui, 2015)

Under investigation

6 Fatalities/ 10 Injuries

- News 18
(DPSatish, 2014)

8/6/2015

Kanpur, Uttar
Pradesh, India

SC

Under investigation

M
AN
U

Defective equipment

55

3/29/2015

41 | P a g e

Vishakhapatnam,
Seemandhra,
India

AC
C

EP

54

TE
D

51

Fire crackers

A major explosion in a
firecracker unit occurred. The
unit was run illegally by the
owner who was later taken
under custody. Explosions in
firecracker units have been a
prevalent problem in the state
of Seemandhra, India which
needs to be addressed.

ACCEPTED MANUSCRIPT

60

61

62

9/22/2014

Lanzhou, Gansu,
China

9/23/2014

Huaihua, Hunan,
China

1/31/2015

linqi, Shandong,
China

2/8/2015

2/19/2015

42 | P a g e

Liaocheng,
Shandong, China

Yichang, Hubei,
China

Ammonia

Inadequate tools, equipment & vehicles (Mal-function

of Ammonia compressor);
Inadequate training/knowledge transfer
Lack of communication (hazards identification and
communication)
Lack of work rules/policies/standards/procedures

0 Fatalities/ 33 Injuries

- The Times of India

(TheTimesofIndia, 2014)

3 Fatalities/ 0 Injuries

- The China State Administration of

Work Safety (Drupsteen &
Guldenmund, 2014)

Limestone

The wall of the kiln collapsed

when 3 workers were
inspecting the kiln furnace.

Inadequate tools, equipment & vehicles

Inadequate training/knowledge transfer (Lack of
understanding the process of the calcination of
limestone);
Lack of work rules/policies/standards/procedures (lack
of standard procedures for inspections);
Inadequate work rules plan (lack of the pre-start safety
review before inspection).

Barium nitrate

An explosion occurred during

the maintenance of the mill in
Luxiang company

Inadequate training/knowledge transfer (Lack of

understanding the process);
Lack of work rules/policies/standards/procedures
(wrong procedures for inspections);
Inadequate work rules plan (lack of the pre-start safety
review before inspection).

6 Fatalities/ 0 Injuries

- The China State Administration of

Work Safety (Herald, 2014)

Inadequate training/knowledge transfer (Lack of

understanding the process);
Lack of work rules/policies/standards/procedures
(wrong procedures for inspections);
Inadequate work rules plan (lack of the pre-start safety
review before inspection).

4 Fatalities/ 4 Injuries

- The China State Administration of

Work Safety
(Chinasafety, 2014)

An explosion occurred when 8

personnel were working on the
repair of a catalyst tower.

Inadequate training/knowledge transfer (Lack of

understanding the process);
Lack of work rules/policies/standards/procedures
(wrong procedures for inspections);
Inadequate work rules plan (lack of the pre-start safety
review before inspection).

3 Fatalities/ 5 Injuries

- The China State Administration of

Work Safety
(Goldschmidt, 2015)

An explosion occurred due to

an overflow of a slurry mixing
tank, containing potassium
sulfide, potassium dihydrogen
phosphate, and MAP.

Inadequate training/knowledge transfer (Lack of

understanding the process);
Lack of work rules/policies/standards/procedures
(wrong procedures for inspections);
Inadequate work rules plan (lack of the pre-start safety
review before inspection).

5 Fatalities/ 2 Injuries

- The China State Administration of

Work Safety (Chinasafety, 2015)

A gas leak followed by

explosion occurred during an
inspection process due to the
loose of valve bolt.

Coke

- BusinessLine- The Hindu

(Variyar, 2015)

RI
PT

Ammonia gas and highly

concentrated ammonia liquids
spurted out from a flare piping
in the southeast corner of the
plant after the flare was
distinguished.

2 Fatalities/ 5 Injuries

Unknown

SC

Not reported

M
AN
U

59

Yichuan, Ninxia,
China

TE
D

58

9/7/2014

EP

57

9/28/2015

A chemical reactor blast

occurred at a pharmaceutical
unit The company produced
bulk drugs and intermediates in
the pharma unit. This incident
was the 6th incident in Pharma
hub in past 2 years.

Ethanol

AC
C

56

Vishakhapatnam,
Seemandhra,
India

Urea-based fertilizer;
nitro-based fertilizer

ACCEPTED MANUSCRIPT

3/3/2015

Ordos, Inner
Mongolia, China

Hydrogen,
ammonia

A high-pressure steam (3.7

MPa) discharge occurred
during a maintenance process,
resulting in three field workers
burned to death.

Lack of work rules/policies/standards/procedures

(wrong procedures for inspections);
Inadequate work rules plan (lack of the pre-start safety
review before inspection).

Inadequate tools, equipment & vehicles (Electrical

appliances shortcut)
Failure in following procedure (improper shutdown)

RI
PT

63

3 Fatalities/ 0 Injuries

- The China State Administration of

Work Safety
(Olivares et al., 2015)

0 Fatalities/ 0 Injuries

- Yangzi Newspaper
(Scinto, 2015)

3/10/2015

Changzhou,
Jiangsu, China

Not reported

65

3/18/2015

Binzhou,
Shandong, China

Hydrogen peroxide

An explosion occurred when 6

personnel were working on the
repair of a catalyst tower.

Lack of work rules/policies/standards/procedures

(wrong procedures for inspections);
Inadequate work rules plan (lack of the pre-start safety
review before inspection).

4 Fatalities/ 2 Injuries

- The China State Administration of

Work Safety
(Whitworth, 2015)

A blast occurred in a pumping

station, after leaking oil caught
fire. 177 fire engines and more
than 800 firefighters were
rushed to the blaze, and more
than 14,000 residents in the
surrounding area were
evacuated.

Improper use of protective methods (Improper welding

of conveying pipe)

0 Fatalities/ 14 Injuries

- British Broadcasting Corporation

(BBC)
(BBCNews, 2015c)

Inadequate tools, equipment & vehicles (Aerobic tank

no special ventilation equipment)

3 Fatalities/ 2 Injuries

- The China State Administration of

Work Safety
(Whitworth, 2015)

Oil and gas

A crack occurred in a pipeline

(diameter 200mm) conveying
oil and gas, and the following
fire damaged three pumps and
some instrumentation.

Inadequate tools, equipment & vehicles (Equipment

failure: sealing failure and pipe leak)

0 Fatalities/ 0 Injuries

- The China State Administration of

Work Safety (Fegan, 2015)

Ammonia

A fire occurred in a company

producing ammonia, and other
chemical products. The facility
was severely damaged in the
catastrophic fire.

Under investigation

0 Fatalities/ 3 Injuries

- Sina News
(He, 2015)

Paraxylene

67

4/9/2015

Weifang,
Shandong, China

Hydrogen sulfide

4/10/2015

Dalian, Liaoning,
China

4/21/2015

Zhangjiagang,
Jiangsu, China

69

43 | P a g e

ER

AC
C

68

M
AN
U

Zhangzhou City,
Fujian, China

TE
D

4/6/2015

Two employees accidently fell

in an aerobic tank sewage
treatment station. Two more
employees fell into the aerobic
tank in the subsequent rescue.

EP

66

SC

64

Four reactors exploded after an

initial fire in a warehouse in the
plant. The toxic gas released
due to the fire and explosion
affected the local community.
Electrical short circuit and
improper shutdown was the
reason that triggered the
incident.

ACCEPTED MANUSCRIPT

70

4/21/2015

Nanjing, Jiangsu,
China

Glycol

An explosion occurred in a
glycol unit refining tower of a
petrochemical plant.

0 Fatalities/ 1 Injury

- Analytics of Polymer Market

(Larionova, 2015)

Unknown

NA Fatalities/ 0
Injuries

- LiuAn News
(LiuAnNews, 2015)

Unknown

5/10/2015

Bangfu, Anhui,
China

FE

Sodium

72

5/16/2015

Jincheng, Shanxi,
China

Carbon disulfide

A leakage of Carbon disulfide

cooling pipe occurred in
Ruixing company. 8 killed and
6 injured in the following
rescue process.

Inadequate tools, equipment & vehicles (pipe leaking)

8 Fatalities/ 6 Injuries

73

5/18/2015

Dialian, Liaoning,
China

Xylene

An explosion occurred in a
chemical container.

Unknown

0 Fatalities/ 4 Injuries

74

5/25/2015

Laozhou, Jiangxi,
China

Terpene

A fire occurred in the terpene

resin production line reactor
overheating, and it damaged an
area of 800-900 square meters.

Inadequate tools, equipment & vehicles (overheat from

reactor of Terpene dilute resin leads the final pipeline
explosion)

0 Fatalities/ 0 Injuries

An epoxyethane device got

exploded and then triggered a
fire. The fire spread to three of
six chemical tanks nearby. Each
tank has a storage capacity of
1,000 cubic meters. More than
200 fire fighters arrived at the
site to put out the fire.

Unknown

0 Fatalities/ 0 Injuries

- Globle Times
- Xinhua News (GlobleTimes,
2015; XinhuaNews, 2015)

Three killed when feeding

additives - naphthalene
sulfonate to a reaction pool at a
chemical fertilizer company.

Failure in following procedure (Improper operation)

3 Fatalities/ 0 Injuries

- The China State Administration of

Work Safety (Tait, 2015)

TE
D

M
AN
U

SC

RI
PT

71

An explosion, caused by
sodium metal reacting with
water, occurred in a chemical
plant in Mohekou Bengbu City
Industrial Park. The fire was
put off in one hour.

- The China State Administration of

Work Safety
(Lezon, 2015)

- Yahoo News
(YahooNews, 2015)

- Sina News
(He, 2015)

6/13/2015

Nanjing, Jiangsu,
China

FE

Epoxyethane

76

6/18/2015

Haolianghe,
Heilongjiang,
China

Ammonia

77

6/18/2015

Tangshan, Hebei,
China

Coal dust

An explosion occurred in a
thermal power generation
company preparation plant.

Unknown

NA Fatalities/ 0
Injuries

- 163 News (WangyiNews, 2015)

78

6/19/2015

Dandong,
Liaoning, China

Methane, coal dust

A gas explosion occurred in

confined space in coal mine
industry.

Under investigation

3 Fatalities/ 0 Injuries

Bureau of Liaoning coal mine

safety supervision(LNMJ, 2015)

44 | P a g e

AC
C

EP

75

ACCEPTED MANUSCRIPT

6/27/2015

Taipei, Taiwan,
China

81

6/28/2015

Ordos, Inner
Mongolia, China

82

6/29/2015

Xiangtan, Hunan,
China

83

84

6/30/2015

7/16/2015

Dongsheng,
Shandong, China

Rizhao City,
Shandong, China

Not reported

4 killed in a gas explosion

happened in the coal mine in
Enshi city.

Colored powder

Flammable color powder

exploded in at a recreational
water park in Taiwan.

FE

Ammonia

An explosion and fire was

caused by the failure of
ammonia synthesis equipment.

Not reported

An explosion occurred in a
petrochemical company in
Xiangtan Jiuhua Industrial
Zone. There was huge smoke.

Not reported

Gas leakage and explosions

happened in the Mao
Dongsheng industrial zone. It
was reported that the spill
affected 56 primary schools
students and a teacher, and they
were then sent to the hospital.

Liquid hydrogen

4 Fatalities/ 0 Injuries

- Sohu News
(SohuNews, 2015)

Unknown

14 Fatalities/ 524
Injuries

- CNN News
(Greg Botelho, 2015)

Unknown

3 Fatalities/ 6 Injuries

- Sohu News
(SohuNews, 2015)

Unknown

0 Fatalities/ 0 Injuries

- Sina News
(Herald, 2014)

Unknown

0 Fatalities/ 57 Injuries

- Sina News
(He, 2015)

A massive explosion occurred

in a chemical plant. 130
firefighters came to control the
blaze. The explosion occurred
after a large-size tank
containing liquid hydrogen
caught fire.

Inadequate tools, equipment & vehicles (leak of a 1000

square meters tank containing petrochemical product)

0 Fatalities/ 0 Injuries

- ROCKETNEWS24 Nee
(ROCKETNEWS24Nee, 2015)

A leak and explosion occurred

in a distillation unit with a 3
million ton annual capacity in
China National Petroleum
corporation Qin Yang Location.
This incident happened after a 9
days inspection and
maintenance.

Inadequate tools, equipment & vehicles (mechanical

failure of a small component caused the leak of oil)

3 Fatalities/ 6 Injuries

- The China State Administration of

Work Safety
(Chemicals-technology, 2015)

Under investigation

RI
PT

80

SC

Enshi, Hubei,
China

M
AN
U

6/21/2015

TE
D

79

85

7/26/2015

Qin Yang, Gansu,

China

86

7/31/2015

Changzhou,
Jiangsu, China

Not reported

A fire and explosion occurred

to the storage tanks containing
raw material.

Unknown

0 Fatalities/ 0 Injuries

87

8/5/2015

Changzhou,
Jiangsu, China

Methylbenzene

Two methylbenzene storage

tanks exploded.

Unknown

0 Fatalities/ 0 Injuries

45 | P a g e

AC
C

EP

Oil derivatives

- Bureau of Liaoning Coal Mine

Safety Supervision
(People.cn, 2015)

- Yicai News
(Wang, 2015)

ACCEPTED MANUSCRIPT

88

8/12/15

Tianjin, Tianjin,
China

Ammonium nitrate

The explosion took place at a

warehouse at the port which
contained hazardous and
flammable chemicals, including
calcium carbide, sodium
cyanide, potassium nitrate,
ammonium nitrate and sodium
nitrate.

89

8/22/2015

Zibo, Shandong,
China

FE

Not reported

A warehouse in Zibo city

exploded, triggering a fire.
Huge flames were visible.

90

8/31/2015

Dongying,
Shandong, China

Not reported

An explosion occurred in a
chemical plant, and the fire was
controlled after five hours.

91

9/7/2015

Lishui, Zhejiang,
China

Not reported

Ammonia

94

7/3/2015

46 | P a g e

Ulsan, South
Korean

Aluminum

- BBC News
(BBCNews, 2015a)

Unknown

1 Fatalities/0 Injuries

- CNBC News
(CNBCNews, 2015)

A massive explosion occurred

in a chemical plant. The fire
was reported to be "very
fierce".

Unknown

0 Fatalities/ 0 Injuries

- IBTIMES New
(Varghese, 2015)

A synthetic ammonia leak at a

chemical plant in Central
China's Henan province
poisoned 20 residents in a
nearby village It was reported
that there were 300 kg of
synthesized ammonia leaked
from a cracked pipe.

Inadequate tools, equipment & vehicles (Pipe crack)

0 Fatalities/ 20 Injuries

- CHINADAILY News
(CHINADAILYNews, 2015)

An explosion occurred in a
chemical plant dealing with
waste aluminum melting. The
explosion occurred when the
operator was melting the
aluminum.

Under investigation

2 Fatalities/ 2 Injuries

- Sina News
(SinaNews, 2015)

Not reported

Under investigation

4 Fatalities/ 1 Injury

- CNN News
(McKirdy, 2015)

SC

RI
PT
Unknown

M
AN
U

9/22/2015

Changzhou,
Jiangsu, China

1 Fatalities/ 9 Injuries

TE
D

Pingdingshan,
Henan, China

- BBC News
(BBCNews, 2015b)

EP

93

9/18/2015

AC
C

92

173 Fatalities/ 720

Injuries

Under investigation

An explosion occurred at a
chemical plant. Before the
explosion, some workers were
welding the interior of waste
water storage. The blast tore out
the upper structure of the
storage facility, which
subsequently collapsed.

ACCEPTED MANUSCRIPT

10/5/2015

Shangyu,
Zhejiang, China

Hexane

Sodium chlorate

An explosion occurred in a
chemical plant. 70 firefighters
and 22 fire engines were used
to prevent the flames from
reaching a nearby warehouse
containing 50 tons of
flammable chemicals, including
sodium chlorate.

Under investigation

0 Fatalities/ 0 Injury

- THESTAR News (N. Cheng,

2015)

0 Fatalities/ 7 Injuries

- PRAMEYANEWS7 News
(PRAMEYANEWS7News, 2015)

RI
PT

Bukit Jalil,
Malaysia

Under investigation

AC
C

EP

TE
D

M
AN
U

96

5/12/2015

SC

95

An explosion and fire razed a

chemical factory in the Bandar
Kinrara Industrial Park Fire &
Rescue Department deployed
eight fire trucks and 54 fire
fighters. It was reported that the
spark from the factory's
production floor ignited the
highly flammable Hexane

Appendix A: Table 2: Analysis of incidents based on a risk-based framework

1 indicates a lack of competence in a particular element, while 0 indicates compliance or absence of information for an element.
For example, when 1 has been attributed to the Process Safety Culture (E-1) and Compliance with Standards (E-2) risk-based
47 | P a g e

ACCEPTED MANUSCRIPT

elements, this indicates that there was a lack in the competency exhibited of those elements which eventually led to the incident. When
0 was attributed to the Incident Investigation element (E-17), it meant that either the incident investigation was conducted or the

RI
PT

information about that element has not been mentioned explicitly in the source surveyed.

Inci
den
t
No.

Understand hazard and risk

Process
Safety
Culture

Compli
ance
with
standar
ds

Proce
ss
Safet
y
Comp
etenc
y

Work
force
invol
veme
nt

Stak
ehol
der
outre
ach

No.

E-1

E-2

E-3

E-4

4
5

Manage risk

Co
ntr
act
or
ma
nag
em
ent

Opera
ting
proce
dures

E-5

E-6

E-7

E-8

E-9

E-10

10

11

12

13

TE
D

Process
Knowledge
management

Hazard
Identification
and risk
analysis

Safe
wor
k
pract
ices

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Asse
t
integ
rity
and
relia
bilit
y

Learn from experience

Traini
ng
and
perfor
manc
e
Assur
ance

Manag
ement
of
change

Operati
onal
Readin
ess

Co
nd
uct
of
ope
rati
ons

Emer
gency
mana
geme
nt

Inciden
t
investi
gation

Meas
ureme
nt and
metric
s

Au
diti
ng

Manageme
nt review
and
continuous
improveme
nt

E11

E-12

E-13

E-14

E15

E-16

E-17

E-18

E19

E-20

M
AN
U

Commit to process safety

SC

CCPS Risk-based process safety Principles [Key 1 Lack of adherence; 0 - Compliance/lack of information]

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Highlights:

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1. A web-based collection and analysis of process safety incidents from across the world
2. Proximate cause and risk-based analysis to identify deficiencies in process safety
management
3. 96 incidents analyzed with deficiencies identified in critical safety management areas