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.

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...

Critical Alarm Management : Connecting the Dots

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
April 3, 2012
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
April 3, 2012
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
April 3, 2012
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
April 3, 2012
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
April 2, 2012
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...

Acid Release From Catalyst Tanks

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
March 15, 2011
This is the story of how the cumulative effects of several seemingly innocent changes to a catalyst system resulted in a near miss Process Safety...

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

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

Incident Investigation- Addressing Common Oversights

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

Investigation of an Explosion in a Gasoline Purification Plant

Conference Presentation
AIChE Spring Meeting and Global Congress on Process Safety
March 23, 2010
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
March 22, 2010
This paper describes the Consequence Modeling of Chlorine release from a Chlor Alkali plant as a part of Process Hazard Analysis. The objective was...

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...

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...

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...

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-...

Sponsored Webinar: 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 with the collection and management of data related to injuries, fires, regulatory/citation issues,...

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 discussing the difficulties of predicting them. You’ll learn that once black swan events occur,...

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.

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.

My Neighborhood Radioactive Waste Dump

February 22, 2016
Like so many of us, I jog through my neighborhood in pursuit of 10,000 steps a day. My urban journey through Queens, NY, is a slow blur of delis, liquor marts, and grocery stores...

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...

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...

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