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 Toxic Chemical Release at Dupont

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
April 3, 2019
Fatal Toxic Chemical Release at DuPont Tamara Qureshi Attorney Advisor-Investigations United States Chemical Safety and Hazard Investigations Board 1...

Case Study of Steam Hammer Event in an Ethylene Plant

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
April 2, 2019
A steam explosion incident occurred on a Steam Line in a Gulf Coast Ethylene Production Facility. A detailed review of the third party failure...

"Just the Facts" a Bad Way to Communicate Process Safety

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
April 2, 2019
"Just the facts" a Bad Way to Communicate Process Safety The qualities making a person a good engineer are often the same qualities making them poor...

Caribbean Petroleum Explosion Case Study

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
April 2, 2019
Caribbean Petroleum Explosion Case Study Q.A. Baker, J.K. Thomas, D.R. Malik and M.T. Edel Baker Engineering and Risk Consultants 3330 Oakwell Court...

Humans Make Mistakes...Which Cause Events

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
April 2, 2019
When reviewing investigations reports associated with Loss of Primary Containment (LOPC) events, it is not uncommon to find human error identified as...

Getting Incident Investigations Right

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
April 2, 2019
When safety investigations are conducted like criminal investigations, they tend to be backward-looking and focused on learning who to blame, rather...

Management of Change for Complex Organizations

Archived Webinar
May 1, 2019
Are you interested in learning about the components of an effective MOC program? Join this 60-minute webinar to learn what makes a best-in-class MOC program.

Fire Behavior: Part 1

Archived Webinar
Oct 11, 2017
What if you could predict fire behavior and better protect your people and structures? Take this webinar to learn more. In 60 minutes, you’ll gain an overview of fire event modeling, how source...

Incident Reporting and Investigation

Archived Webinar
Jun 22, 2016
The thorough investigation, analysis and follow-up of incidents—including near misses—is one of the most effective ways to improve safety and reliability of process facilities. Yet, many struggle...

Black Swans in the Chemical Processing Industries

Archived Webinar
Mar 16, 2016
Catastrophic events continue to happen in the chemical processing industries. Learn how to protect yourself against “black swan” occurrences. This webinar presents examples of black swan events while...

Safety in the LNG Value Chain

Archived Webinar
Dec 12, 2012
In this webinar, presenters describe and examine potential LNG (liquefied natural gas) hazards and risk-reduction methods for the LNG value chain ― production and consumption.

Explosion at T2 Laboratories

Archived Webinar
Sep 22, 2010
This webinar discusses the CSB investigation and findings related to the explosion and chemical fire at T2 Laboratories, Inc. in December 2007.

Incidents That Define Process Safety

March, 2008
Incidents That Define Process Safety describes approximately fifty incidents that have had a significant impact on the chemical and refining industries' approaches to modern process safety. Events are described in detail so readers get a fundamental understanding of the root causes, the...

Produced Water Tank Explosion Case Study

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
March 29, 2017
Produced Water Tank Explosion Case Study J. Kelly Thomas, Ph.D. Baker Engineering and Risk Consultants 3330 Oakwell Court, Suite 100 San Antonio, TX...

Elongated VCE Blast Waves and Structural Damage

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
March 27, 2017
Elongated congested volumes are common at chemical processing and petroleum refining facilities due to the arrangement of processing units, but there...

Human Error. a Myth Eclipsing Real Causes

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
March 27, 2017
Abstract Human Error. A myth eclipsing real causes For years the professionals involved in the investigation of industrial accidents have identified...

CSB Recommendations: Gems, Gewgaws, and Buried Treasure

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
April 12, 2016
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...

Vapor Cloud Explosions

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
April 12, 2016
TBA Copyright © American Institute of Chemical Engineers. All rights reserved.

Bhopal 30 Years Later

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
April 29, 2015
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
April 29, 2015
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
April 29, 2015
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
April 28, 2015
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
April 28, 2015
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
April 2, 2014
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
April 2, 2014
In recent explosion accidents on onshore petrochemical facilities, it has been concluded that a deflagration-to-detonation-transition (DDT) took...

Walk the Line

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
April 2, 2014
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
April 2, 2014
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
April 2, 2014
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
April 2, 2014
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
April 1, 2014
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
April 1, 2014
A project that deploys new technologies needs to be confident that the technology can be implemented successfully and will perform reliably as...

"All in" Means "All the Time"

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
April 1, 2014
Process safety must be the responsibility of all technical and operations personnel. As such, this responsibility is not limited to attendance at PHA...

The Role Of Sequential Automation In Improving Process Safety

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
April 1, 2014
The ISA106 Committee has released the first technical report for this standard dealing with Sequential Automation for Continuous Process Operations (...

Chemical Explosion Isolation For Small Contained Vessels

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
April 1, 2014
Particle size reduction equipment are used in many branches of the process industries, such as food, chemical, pharmaceutical and energy. According...

Popcorn Polymer Fouling in Light Ends Units

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
March 31, 2014
Popcorn polymer fouling is thought to be exclusive to Butadiene plants, but in fact, there are dozens of isolated cases of popcorn polymer fouling...

CSB Investigation of Chevron Richmond Refinery Fire

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
May 1, 2013
On August 6, 2012 a hydrocarbon fire occurred at approximately 6:30 p.m. in the crude unit of the Chevron Richmond Refinery in Richmond, California...

Effect of Flammable Cloud Treatment On Predicted Blast Loads

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

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