Incident Investigation

Developing, sustaining, and enhancing the organization's incident investigation competency is one of four elements in the RBPS pillar of learning from experience. The characteristics of an effective incident program and how organizations might begin to enhance their own incident investigation process, can be found in this Introduction to Incident Investigation.

More information regarding incident investigation, check out CCPS' Guidelines on learning from experience.

Atmospheric Tank Failures: Mechanisms and an Unexpected Case Study

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Wednesday, April 13, 2016 - 4:05pm-4:35pm
Most of the literature on catastrophic failures of low pressure tanks focuses on the ignition of explosive mixtures in the vapor space of those tanks...

CSB Recommendations: Gems, Gewgaws, and Buried Treasure

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Tuesday, April 12, 2016 - 2:30pm-3:00pm
The US Chemical Safety and Hazard Investigation Board (CSB) was authorized by the Clean Air Act Amendments of 1990 (CAAA) and began operation in 1998...

Bhopal 30 Years Later

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Wednesday, April 29, 2015 - 3:45pm-4:30pm
On the early morning of December 3rd 1984 a large release of methyl isocyanate (MIC) gas occurred in a pesticide production plant located in Bhopal,...

Planning Early for Compressor Surge Avoidance

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Wednesday, April 29, 2015 - 1:30pm-2:00pm
Compressor stations are installed at regular interval to drive the flow of gas in a pipeline. The principal component of the compressor station is...

Fire from the Cascading Failure of an Oxygen Supply System

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Wednesday, April 29, 2015 - 1:30pm-2:00pm
This paper discusses the investigation, findings, and root cause analysis of a fire due to the loss of oxygen containment in an ethylene oxide...

Huaa...When Local Learning and Casual Sharing Is Not Enough

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Tuesday, April 28, 2015 - 2:30pm-3:00pm
As a consequence of the Deepwater Horizon blowout and explosion, Bhopal and Piper Alpha, we have the PSM standard and SEMS rule. This helps ensure...

Modelling Liquid Fuel Cascades with Open Foam

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Tuesday, April 28, 2015 - 10:15am-10:45am
Modelling Liquid Fuel Cascades with OpenFoam M. Macchi1, J.X. Wen2*, K. Volkov1 and Y. Chung2 1Centre for Fire and Explosion Studies, Kingston...

Relief Systems Design: Simplifying Assumptions Gone Wrong

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Wednesday, April 2, 2014 - 11:15am-11:45am
The process of evaluating an entire facility’s relief and flare systems design can be extremely time consuming and costly. In most cases, simplifying...

Impact of DDT on FPSO Explosion Risk Assessment

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Wednesday, April 2, 2014 - 10:45am-11:15am
In recent explosion accidents on onshore petrochemical facilities, it has been concluded that a deflagration-to-detonation-transition (DDT) took...

Vinyl Chloride Monomer Explosion

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Wednesday, April 2, 2014 - 9:00am-9:30am
2007 LPS best paper

Walk the Line

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Wednesday, April 2, 2014 - 9:00am-9:30am
Walk the Line Jerry Forest Global Process Safety Manager Celanese 225 E. John Carpenter Freeway Suite 1200 Dallas, TX 75234 (214) 417-1920 Jerry...

Engaging Senior Management In Process Safety: A Case History

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Wednesday, April 2, 2014 - 8:30am-9:00am
Traditional PowerPoint style presentations are good for transferring information but were not found to be an effective medium for engaging senior...

Hurricane Ike Recovery - Electrical & Instrument Systems

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Wednesday, April 2, 2014 - 8:30am-9:00am
On September 13, 2008 Hurricane Ike struck the Texas-Louisiana Coast causing severe damage to local chemical plant facilities and communities. This...

Are Unconfined Hydrogen Vapor Cloud Explosions Credible?

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Wednesday, April 2, 2014 - 8:00am-8:30am
A question is frequently raised by owner/operators of chemical processing and refinery sites as to whether unconfined hydrogen vapor cloud explosions...

Unknown Aspects of Metal Dust Explosions

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Tuesday, April 1, 2014 - 1:30pm-2:00pm
Dust explosions hazards have been addressed in a number of standards and guidelines aiming at supporting industry to work safely (including NFPA 61,...

Technology Qualification - Two Subsea Applications

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Tuesday, April 1, 2014 - 11:15am-11:45am
A project that deploys new technologies needs to be confident that the technology can be implemented successfully and will perform reliably as...

Systematic Analysis and Learning from Process Safety Incidents

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Tuesday, April 1, 2014 - 10:45am-11:15am
Numerous incidents have occurred in the process industries and caused hundreds of fatalities and injuries. The US Chemical Safety Board (CSB) has...

Improving Plant Safety - an Operator Centric View on Process Safety

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Tuesday, April 1, 2014 - 10:15am-10:45am
Improving Plant Safety - An Operator Centric View on Process Safety Dr.-Ing. Gregor Fernholz, Global Business Development Manager OTS, Invensys,...

Effect of Flammable Cloud Treatment On Predicted Blast Loads

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Wednesday, May 1, 2013 - 11:15am-11:45am
Effect of Flammable Cloud Treatment on Predicted Blast Loads J. Kelly Thomas and Jihui Geng Baker Engineering and Risk Consultants 3330 Oakwell Court...

Baha Blanca, Argentina. Explosin Catastrfica De Polvo En Un Silo

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Tuesday, April 30, 2013 - 4:00pm-4:30pm
El 13 de marzo de 1985 a las 0.15 horas un incendio en el puerto dio inicio a uno de los accidentes más grandes ocurridos en la República Argentina...

Worker Behavior Changing by Dynamic Culture

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Tuesday, April 30, 2013 - 9:00am-9:30am
INTRODUCTION The chemical industries need appropriated project of process to control safety and production avoiding accidents and environmental...

Unique Failure Mode for API Seal Plan 76

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Monday, April 29, 2013 - 2:30pm-3:00pm
Unique Failure Mode for API Seal Plan 76 Double mechanical seals with a pressure alarm in the containment chamber are commonly used in LPG and other...

Near Misses - Private or Public Concern?

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Monday, April 29, 2013 - 11:30am-12:00pm
Near miss incidents include those releases and/or fires that do not result in significant employee injury or costs. In many cases there are federal...

Where Process Safety Must Move

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Monday, April 29, 2013 - 11:30am-12:00pm
Description: Process safety has long embodied the adage, “If you always do what you’ve always done, you’ll always get what you’ve always got.”...

Process near Misses Identification, Investigation and Challenges

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Monday, April 29, 2013 - 11:00am-11:30am
Topic: - Near Misses/Preventing Process Incidents Title: -Process Near misses identification, investigation and challenges Author: - Anil Singh Email...

Critical Alarm Management : Connecting the Dots

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Tuesday, April 3, 2012 - 12:00am
In the aftermath of some high profile national security incidents, investigations starting with the catastrophe or near miss and working backwards...

Go out and lead on Process Safety Management

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Tuesday, April 3, 2012 - 12:00am
This paper will share the UK's experience of risk control for major hazards and will emphasise the key role corporate governance and leadership plays...

Why Smaller Companies Struggle with Process Safety

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Tuesday, April 3, 2012 - 12:00am
Proposed title: Why smaller companies struggle with Process Safety Author: John Herber, Principal Consultant, Process Hazard Management Services, LLC...

Fire From Iron

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Tuesday, April 3, 2012 - 12:00am
Although the potential consequences of combustible dust explosions are becoming more widely known, the potential consequences of combustible dust...

Management of Change: Quality Implementation and Performance

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Monday, April 2, 2012 - 12:00am
It is often said that the only thing which is permanent in this world is change. In the process industry, as elsewhere, change is a main lever for...

Incident Investigation- Addressing Common Oversights

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Monday, March 14, 2011 - 8:00pm
Principles of incident investigation may be used in daily process troubleshooting and near miss events to identify root cause. Identifying and...

It's People, Stupid! Human Factors In Incident Investigation

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Monday, March 14, 2011 - 8:00pm
People have inherent strengths and weaknesses which can affect their performance. Issues such as fatigue, emotional stress, and motivation can...

Kinetic Modeling of the Reactions Involved in the T2 Explosion

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Sunday, March 13, 2011 - 8:00pm
The runaway reaction at the chemical preparation facility called T2 laboratories in Jacksonville, Florida on December 19, 2007 is analyzed. The...

Condensation Induced Water Hammer: Principles and Consequences

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Tuesday, March 23, 2010 - 8:00pm
An explosion occurred in the boiler room of a food processing plant as the steam generation system was coming online after a maintenance shutdown...

Imperial Sugar Refinery Combustible Dust Explosion Investigation

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Tuesday, March 23, 2010 - 8:00pm
On February 7, 2008, at about 7:15 p.m., a series of sugar dust explosions at the Imperial Sugar manufacturing facility in Port Wentworth, Georgia,...

Investigation of an Explosion in a Gasoline Purification Plant

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Tuesday, March 23, 2010 - 8:00pm
On May 24, 2007 an explosion and subsequent fire destroyed a tank farm located at a gasoline purification plant in Sløvåg, Norway. In addition to the...

Consequence Modeling of Chlorine Release

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Monday, March 22, 2010 - 8:00pm
This paper describes the Consequence Modeling of Chlorine release from a Chlor Alkali plant as a part of Process Hazard Analysis. The objective was...

Safety Culture and Operational Discipline

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
Monday, April 27, 2009 - 9:30am
This session focuses on the cultural aspects of a successful Process Safety program. Papers that are presented cover new and innovative ideas on...

Incident Investigation

Public (classroom) Course
Incidents are minor occurrences and are often the result of a single failure or defect. Join Incident Investigation expert Brian Kelly for an in-...
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