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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.

Fatal Explosion Caused by An Intermittently-Used Fuel Gas Piping System

Mar 15, 2011
Russell A. Ogle
A fatal explosion occurred at a foundry during a routine test of an intermittently used propane standby system. Just prior to the explosion, maintenance personnel were preparing the propane standby system for a startup test. While preparing for the startup test, the group was alerted that employees...

The Buncefield Explosion: Were the Resulting Overpressures Really Unforeseeable?

Mar 14, 2011
Jérôme R. Taveau
On Sunday 11 December 2005, a severe unconfined vapour cloud explosion followed by several tank fires occurred at the Buncefield oil storage depot in England, causing widespread damage to homes and businesses surrounding the site, hopefully without any victim. The damage caused by the resulting...

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

Mar 14, 2011
Mike Broadribb
People have inherent strengths and weaknesses which can affect their performance. Issues such as fatigue, emotional stress, and motivation can adversely affect performance. Their performance is also influenced by factors external to the individual, such as poor equipment design, inadequate training...

Incident Investigation- Addressing Common Oversights

Mar 14, 2011
Julie D. White
Principles of incident investigation may be used in daily process troubleshooting and near miss events to identify root cause. Identifying and correcting daily process issues intervenes with the natural escalation to near miss events and incident investigations. Fundamentals of root cause analysis...

An Analysis of CSB Investigation Reports for Inherent Safety Learnings

Mar 14, 2011
Paul R. Amyotte
The Chemical Safety and Hazard Investigation Board (CSB) is an independent, nonregulatory federal organization in the United States dedicated to investigating serious accidents in the chemical industry. Accidents are investigated by a team of CSB employees and from the evidence collected a list of...

Kinetic Modeling of the Reactions Involved in the T2 Explosion

Mar 13, 2011
Ronald J. Willey
The runaway reaction at the chemical preparation facility called T2 laboratories in Jacksonville, Florida on December 19, 2007 is analyzed. The approached involved estimating kinetic parameters based on temperature time traces presented in the CSB final report for ARSST (Advance Reactive System...

Incident Investigation – Addressing the Worst That Could Have Happened

Mar 13, 2011
Samuel A. Rodgers
Incident Investigation techniques typically start with a detailed description of the actual consequence and work backward toward the root causes. A lot of time is spent to qualify and quantify the actual consequence so as to appropriately apply resources to prevent recurrence. A frequent outcome of...

Investigation of an Explosion in a Gasoline Purification Plant

Mar 23, 2010
Kees Van Wingerden
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 tank farm, an office building and some neighboring tank trucks were destroyed. There were no casualties in the accident, but at least two people...

Condensation Induced Water Hammer: Principles and Consequences

Mar 23, 2010
Carlos A. Barrera
An explosion occurred in the boiler room of a food processing plant as the steam generation system was coming online after a maintenance shutdown. The explosion shattered the case of the condensate return pump fatally injuring an employee, while another employee was burned by the escaping steam...

Imperial Sugar Refinery Combustible Dust Explosion Investigation

Mar 23, 2010
John Vorderbrueggen
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, resulted in 14 worker fatalities. Thirty six workers were treated for serious burns and injuries—some caused permanent, life altering conditions. The...

Consequence Modeling of Chlorine Release

Mar 22, 2010
Prakash Amulakh Shah
This paper describes the Consequence Modeling of Chlorine release from a Chlor Alkali plant as a part of Process Hazard Analysis. The objective was to carry out a Quantitative Risk Assessment Study of the liquid Chlorine storage area of the Chlor Alkali plant and build up in-house capability to...

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