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Inquiries, Investigations and Inquests
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397 items found
Intelligence and Security Committee (ISC) Report into the London Terrorist Attacks on 7 July 2005
The intelligence reports concluded that while MI5 had previously encountered two of the 7/7 bombers, they were considered "peripheral" to other plots, and the failure to stop them was a result of resource prioritisation rather than a "negligent" intelligence failure.
The Independent Inquiry into Child Sexual Abuse (IICSA)
Social Care, Police
The IICSA was a landmark statutory investigation that exposed decades of systemic, institutional failure to protect children from sexual abuse in England and Wales, describing the scale of the problem as "endemic".
Independent Review into Historic Child Sexual Exploitation (CSE) in Oldham
Social Care, Police
The review concluded that vulnerable children were left exposed to sexual exploitation due to "serious failings" by Oldham Council and Greater Manchester Police (GMP), though it found no evidence of a deliberate institutional cover-up.
The Blom-Cooper Inquiry (1992)
Health
The Blom-Cooper Inquiry described Ashworth as a "brutalising, stagnant, and closed" institution where a powerful nursing clique used physical violence and psychological intimidation to maintain a prison-like control over patients.
The Independent Review of Rampton Hospital (2007)
Health
The 2007 review found that while physical security and external management had significantly improved, "small pockets" of the old, closed culture remained, with some staff still prioritising institutional convenience over individual patient recovery.
The Tidmarsh Inquiry (Report into the Management of Rampton Hospital)
Health
The Tidmarsh Inquiry concluded that Rampton remained a "troubled institution" where clinical leadership was weak, medical records were dangerously inadequate, and the hospital had failed to break free from the "custodial" culture identified a decade earlier by Boynton.
Report of the Review of Rampton Hospital (The Boynton Report)
Health
The Boynton Report concluded that Rampton was a "closed and isolated" institution where a self-perpetuating staff culture had led to a breakdown in professional standards, resulting in the physical and emotional ill-treatment of vulnerable patients.
David 'Rocky' Bennett Inquiry (2004)
Health
The Bennett Inquiry concluded that David Bennett died from "prone restraint" following a "catalogue of failures," and famously ruled that the NHS was "institutionally racist" in the way it treated Black psychiatric patients.
The Rampton Hospital Inquiry (The Bennett Report)
Health
The Bennett Inquiry concluded that Rampton Hospital suffered from a "corrosive and dysfunctional" culture where a powerful group of nurses—dominated by the Prison Officers Association (POA)—prioritised security and personal interests over the therapeutic needs of patients.
The Fairfield Independent Progress Review (or "Casey 2")
Police, Legal
The Fairfield Progress Review is an independent investigation launched to verify whether the Metropolitan Police Service has effectively addressed the institutional racism, misogyny, and homophobia identified by Baroness Casey, or if more radical structural changes are now required.
Police, Legal
Baroness Casey Review: Final Report into the standards of behaviour and internal culture of the Metropolitan Police Service.
Police, Legal
The Casey Review (2023) provided a definitive judgment that the Metropolitan Police is institutionally discriminatory and fundamentally broken, triggering a massive national clear-out of unfit officers and a return to chief-led disciplinary powers.
An Independent Review of the Police Disciplinary System in England and Wales.
Police, Legal
The Chapman Review (2014) was a rapid independent review that moved police discipline from a private internal process to a transparent public one, introducing Legally Qualified Chairs and banning officers from resigning to escape investigation.
Taylor Review of Police Disciplinary Arrangements
Police, Legal
The Taylor Review of Police Disciplinary Arrangements (2005) recommended shifting the police misconduct system away from a slow, overly legalistic "blame and punishment" model toward a more efficient, manager-led approach focused on professional development and learning.
Morris Inquiry into Professional Standards and Employment Matters in the Metropolitan Police Service
Police, Legal
The Morris Inquiry (2004) was a landmark investigation that exposed a culture of "institutional racism" and unfairness within the Metropolitan Police’s disciplinary systems, recommending a shift from a punitive, quasi-criminal approach to a fairer, modern human resources model.
The Inquiry into the Care and Treatment of Michael Stone
Killings, Health, Social Care
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The Report of the Macur Review
Social Care
The Macur Review was a non-statutory investigation that concluded there was no evidence the original Waterhouse Inquiry had ignored or covered up the involvement of "establishment" figures in the North Wales child abuse scandal, though it heavily criticized the government’s poor archiving and destruction of key inquiry records.
Report of the Tribunal of Inquiry into the Abuse of Children in Care in the Former County Council Areas of Gwynedd and Clwyd since 1974
Social Care
The Waterhouse Inquiry was a comprehensive statutory investigation into widespread, systemic physical and sexual abuse of children within the care system of North Wales over a two-decade period, ultimately exposing catastrophic failures in local government oversight and child protection protocols.
Report of the Independent Inquiry into the Care and Treatment of John Barrett
Health, Killings, Police, Social Care, Legal
The John Barrett Inquiry was a 12-month independent investigation into the 2004 killing of Denis Finnegan, which concluded that the death was an avoidable tragedy caused by "seriously flawed" clinical decisions and a failure to prioritize public safety over patient liberty.
The Investigation of Events that followed the death of Cyril Mark Isaacs
Health, Legal
The Isaacs Report was a 2003 independent investigation that exposed the systemic, non-consensual retention of human organs for research in the UK, ultimately triggering the creation of the Human Tissue Act 2004 to legally mandate informed consent.
The Independent Medicines & Medical Devices Safety Review
Health, Legal, Safety
The Independent Medicines and Medical Devices Safety Review was a 29-month investigation that exposed a "system-wide failure" to listen to thousands of women and children harmed by pelvic mesh, Sodium Valproate, and Primodos.
Report on the Supply of Petroleum and Petroleum Products to Rhodesia
Legal, Finance
The Bingham Inquiry was a 16-month investigation commissioned in 1977 to expose how British oil companies BP and Shell bypassed international sanctions to fuel the illegal Ian Smith regime in Rhodesia. Led by Thomas Bingham QC, the report revealed that the companies used a complex "swap" arrangement with the French firm Total to keep oil flowing while British government officials looked the other way.
Inquiry into Crown Prosecution Service Decision-Making in Relation to Deaths in Custody and Related Matters
Custody, Police
The Butler Inquiry was an independent review into why the Crown Prosecution Service consistently failed to prosecute police officers following deaths in custody, despite inquest juries frequently returning verdicts of "unlawful killing."
Public-Private Partnerships UK
Finance, Politics
Death of Surjit Singh Chhokar
Police, Legal
The Chhokar inquiry consisted of two non-statutory reviews that investigated the systemic failures and institutional racism following the 1998 murder of Surjit Singh Chhokar in Scotland. These reports heavily criticized the police and prosecution for mishandling the case and failing to support the family, leading to over 100 recommendations for structural reform. Ultimately, the inquiry’s legacy triggered the 2011 Double Jeopardy Act, which enabled a successful retrial and the final conviction of Ronnie Coulter in 2016.
Independent maternity review – Nottingham University Hospitals NHS Trust
Health, Maternity
The review has been established in light of significant concerns raised regarding the quality and safety of maternity services at Nottingham University Hospitals NHS Trust (NUH) and concerns of local families. It replaces a previous regionally-led review after some families expressed concerns and made representations to the Secretary of State for Health and Social Care.
Cuisine Solutions Ammonia Release
Water, Chemical
The investigation found that a catastrophic malfunction in a refrigeration heat exchanger, combined with "critical deficiencies" in emergency planning, led to a toxic ammonia cloud that rendered ten employees unconscious during a botched evacuation.
Independent Inquiry into Grooming Gangs
Legal, Police, Social Care
The inquiry is a national, statutory investigation into the systemic failure of state institutions to protect children from group-based sexual exploitation, specifically examining the role of ethnicity, religion, and culture in the "blind eye" turned by authorities.
Inquiry into the battle of Orgreave
Police, Legal
A full statutory investigation into the violent 1984 clashes between police and striking miners at the Orgreave coking plant and the subsequent allegations of police perjury and evidence fabrication.
Bio Lab Conyers Chemical Release 2020
Chemical, Industry, Safety, Release, csb
The investigation concluded that rainwater entered a storage building and reacted with trichloroisocyanuric acid (TCCA), triggering a thermal decomposition that released a massive chlorine gas cloud and forced the closure of a major interstate highway.
Sierra Chemical Co. High Explosives Accident
Chemical, Industry, Safety, csb
On January 7, 1998, two explosions in rapid succession destroyed the Sierra Chemical Company Kean Canyon plant near Mustang, Nevada, killing four workers and injuring six others.
Union Carbide Corp. Nitrogen Asphyxiation Incident
Chemical, Industry, Safety, csb
On March 27, 1998, one worker was killed and another seriously injured when they were asphyxiated by nitrogen at Union Carbide Corporation's Taft/Star Manufacturing Plant in Hahnville, Louisiana. The incident occurred inside a temporary enclosure the workers had erected over the end of large open gas pipe, where the workers were conducting a black light inspection. The workers were not aware that the pipe was being purged with nitrogen, creating an oxygen-deficient atmosphere.
Herrig Brothers Farm Propane Tank Explosion
Chemical, Industry, Safety, csb
On April 9, 1998, an 18,000-gallon propane tank exploded at the Herrig Brothers farm in Albert City, Iowa. The explosion killed two volunteer firefighters and injured seven other emergency response personnel. Several buildings were also damaged by the blast.
Morton International Inc. Runaway Chemical Reaction
Chemical, Industry, Safety, csb
On April 8, 1998, an explosion and fire occurred during the production of Automate Yellow 96 Dye at the Morton International Inc. plant in Paterson, New Jersey. The explosion and fire were the consequence of a runaway reaction, which overpressurized a 2000-gallon chemical vessel and released flammable material that ignited. Nine employees were injured.
Sonat Exploration Co. Catastrophic Vessel Overpressurization
Chemical, Industry, Safety, csb
At approximately 6:15 p.m. on March 4, 1998, a catastrophic vessel failure and fire occurred near Pitkin, Louisiana, at the Temple 22-1 Common Point Separation Facility owned by Sonat Exploration Co. Four workers who were near the vessel were killed, and the facility sustained significant damage. The vessel lacked a pressure relief system and ruptured due to overpressurization during start-up, releasing flammable material which ignited.
Tosco Avon Refinery Petroleum Naphtha Fire
Chemical, Industry, Safety, Fire, Explosion, csb
On February 23, 1999, a fire occurred in the crude unit at Tosco Corporation. Avon oil refinery in Martinez, California. Workers were attempting to replace piping attached to a 150-foot-tall fractionator tower while the process unit was in operation. During removal of the piping, naphtha was released onto the hot fractionator and ignited. The flames engulfed five workers located at different heights on the tower. Four men were killed, and one sustained serious injuries.
Management of Change
Chemical, Industry, Safety, csb
The U.S. Chemical Safety and Hazard Investigation Board (CSB) issues this Safety Bulletin to focus attention on the need for systematically managing the safety effects of process changes in the chemical industry. This bulletin discusses two incidents that occurred in the United States in 1998. Each case history offers valuable insights into the importance of having a systematic method for the management of change (MOC). An MOC methodology should be applied to operational deviations and variances, as well as to preplanned changes—such as those involving technology, processes, and equipment.
Bethlehem Steel Corporation Gas Condensate Fire
Chemical, Industry, Safety, Explosion, Fire, csb
The investigation found that maintenance workers unknowingly opened a pipe containing trapped, highly flammable coke oven gas (COG) condensate, which sprayed out and was ignited by a nearby space heater, creating a fireball that trapped the crew on an elevated walkway.
Concept Sciences Hydroxylamine Explosion
Chemical, Industry, Safety, Reactive incident, csb
On February 19, 1999, a process vessel containing several hundred pounds of hydroxylamine exploded at the Concept Sciences Inc. production facility near Allentown, Pennsylvania. Employees were distilling an aqueous solution of hydroxylamine and potassium sulfate, the first commercial batch to be processed at the facility. After the distillation process was shut down, the HA in the process tank and associated piping explosively decomposed, most likely due to high concentration and temperature. Four CSI employees and a manager of an adjacent business were killed. Two CSI employees survived the blast with moderate-to-serious injuries. Four people in nearby buildings were injured. The explosion also caused significant damage to other buildings in the Lehigh Valley Industrial Park and shattered windows in several nearby homes.
Investigation into the Thermal Decomposition Incident at BP Amoco Polymers
Chemical, Industry, Safety, Reactive incident, csb
The investigation found that three workers were killed when a polymer catch tank exploded because of internal gas pressure generated by decomposing plastic, which went undetected due to a blocked pressure gauge.
Motiva Enterprises Sulfuric Acid Tank Explosion
Chemical, Industry, Safety, Explosion, Fire, csb
On July 17, 2001, an explosion occurred at the Motiva Enterprises refinery in Delaware City, Delaware. A work crew had been repairing a catwalk above a sulfuric acid storage tank farm when a spark from their hot work ignited flammable vapors in one of the tanks. This tank had holes in its roof and shell due to corrosion. The tank collapsed, and one the contract workers was killed; eight others were injured. A significant volume of sulfuric acid was released to the environment.
Improving Reactive Hazard Management
Chemical, Industry, Safety, Reactive incident, csb
In August 2000, following its investigation of a serious reactive incident at Morton International, the Board initiated a comprehensive review of reactive hazards nationwide. The purpose of the investigation was to develop recommendations to reduce the number and severity of such incidents.
Georgia-Pacific Corp. Hydrogen Sulfide Poisoning
Chemical, Industry, Safety, Release, csb
On January 16, 2002, highly toxic hydrogen sulfide gas leaked from a sewer manway at the Georgia-Pacific Naheola mill in Pennington, Alabama. Several people working near the manway were exposed to the gas. Two contractors from Burkes Construction, Inc., were killed. Eight people were injured--seven employees of Burkes Construction and one employee of Davison Transport, Inc. Choctaw County paramedics who transported the victims to hospitals reported symptoms of hydrogen sulfide exposure.
Third Coast Industries Petroleum Products Facility Fire
Chemical, Industry, Safety, csb
On May 1, 2002, a fire erupted at Third Coast Industries in unincorporated Brazoria County, Texas. The facility, which blended and packaged motor oils and other automotive products, was not designed or equipped to prevent the spread of fire. Despite efforts of firefighters, the fire ultimately consumed 1.2 million gallons of combustible and flammable liquids and destroyed the site. One hundred nearby residents were evacuated, a local school was closed, and significant environmental cleanup was necessary due to fumes and runoff. No employees or firefighters were injured during the incident.
DPC Enterprises Festus Chlorine Release
Chemical, Industry, Safety, Release, csb
On August 14, 2002, a chlorine transfer hose ruptured during a rail car unloading operation at the DPC Enterprises chlorine repackaging facility near Festus, Missouri. The hose rupture ultimately led to the release of 48,000 pounds of chlorine, causing three workers and 63 residents to seek medical treatment.
Hazards of Nitrogen Asphyxiation
Chemical, Industry, Safety, confined space, csb
Every year people are killed by breathing “air” that contains too little oxygen. Because 78 percent of the air we breathe is nitrogen gas, many people assume that nitrogen is not harmful. However, nitrogen is safe to breathe only when mixed with the appropriate amount of oxygen. These two gases cannot be detected by the sense of smell. A nitrogenenriched environment, which depletes oxygen, can be detected only with special instruments. If the concentration of nitrogen is too high (and oxygen too low), the body becomes oxygen deprived and asphyxiation occurs.
Investigation into the Vapor Cloud Fire at BLSR Operating Ltd.
Chemical, Industry, Safety, Fire, csb
The investigation found that the unloading of highly volatile "gas condensate" waste into an open-air collection pit created a massive flammable vapor cloud that was sucked into the air intakes of idling diesel trucks, causing the engines to overspeed and ignite the fire.
Environmental Enterprises Hydrogen Sulfide Release
Chemical, Industry, Safety, Release, csb
On December 11, 2002, one maintenance employee was overcome when he inhaled hydrogen sulfide gas from a waste processing vessel at Environmental Enterprises, a hazardous waste treatment company in Cincinnati, Ohio. No other injuries or damage were reported, and the injured worker was subsequently pulled to safety.
Kaltech Industries Waste Mixing Explosion
Chemical, Industry, Safety, Reactive incident, csb
On April 25, 2002, an explosion occurred at Kaltech Industries, a sign manufacturer in the Chelsea neighborhood of New York City, injuring 36 people seriously enough to seek hospital treatment, including 14 members of the public. The explosion, which was the result of a reaction between waste chemicals, originated in the basement of a mixed-use commercial building and caused damage as high as the fifth floor.
First Chemical Corp. Reactive Chemical Explosion
Chemical, Industry, Safety, Reactive incident, csb
On October 13, 2002, a violent explosion occurred in a chemical distillation tower at First Chemical Corporation in Pascagoula, Mississippi, sending heavy debris over a wide area. Three workers in the control room were injured by shattered glass. One nitrotoluene storage tank at the site was punctured by explosion debris, igniting a fire that burned for several hours.
Catalyst Systems Inc. Reactive Chemical Explosion
Chemical, Industry, Safety, Reactive incident, csb
On January 2, 2003, a vacuum dryer holding nearly 200 pounds of benzoyl peroxide exploded at the Catalyst Systems Inc. production facility in Gnadenhutten, Ohio. Employees were in the process of drying granular benzoyl peroxide, which is unstable at high concentrations, when the explosion occurred. The explosion and subsequent fire damaged the production facility, and one Catalyst Systems employee received a minor injury while evacuating the building.
D.D. Williamson & Co. Catastrophic Vessel Failure
Chemical, Industry, Safety, Release, csb
On the morning of April 11, 2003, one worker was killed at the D.D. Williamson food additive plant in Louisville, Kentucky, when a process vessel became overpressurized and failed catastrophically. The failure caused a release of aqueous ammonia as well as extensive damage to the plant, which manufactures caramel coloring.
Sodium Hydrosulfide: Preventing Harm
Chemical, Industry, Safety, csb
This Safety Bulletin is published to increase awareness of the hazards associated with NaHS and to outline safety practices to minimize the potential for harm to workers and the public.
Removal of Hazardous Material from Piping Systems
Chemical, Industry, Safety, csb
This Safety Bulletin identifies specific tasks that facilities should include in all work activities involving piping or equipment opening to ensure the complete removal of hazardous material. In addition, guidance is provided on implementing generic (plant-wide) procedures for nonroutine work activities.
Technic Inc. Ventilation System Explosion
Chemical, Industry, Safety, Explosion, Fire, csb
On February 7, 2003, a worker was seriously injured in an explosion at Technic Inc. in Cranston, Rhode Island. The explosion occurred during maintenance on a ventilation system connected to multiple chemical reactors, evidently due to an accumulation of hazardous material inside. The plant manufactures precious metal processing chemicals.
Isotec/Sigma Aldrich Nitric Oxide Explosion
Chemical, Industry, Safety, Explosion, Fire, csb
On September 21, 2003, a violent explosion destroyed an underground distillation tower at the Isotec chemical manufacturing plant in Miami Township, Ohio, injuring one worker. The explosion ruptured a carbon monoxide gas pipe and led to a precautionary evacuation of about 2000 residents. The Isotec facility manufactures rare forms of oxygen and nitrogen, known as stable isotopes, which are used in research and medicine.
West Pharmaceutical Services Dust Explosion and Fire
Chemical, Industry, Safety, Explosion, Fire, csb
On January 29, 2003, an explosion and fire destroyed the West Pharmaceutical Services plant in Kinston, North Carolina, causing six deaths, dozens of injuries, and hundreds of job losses. The facility produced rubber stoppers and other products for medical use. The fuel for the explosion was a fine plastic powder, which accumulated above a suspended ceiling over a manufacturing area at the plant and ignited.
CTA Acoustics Dust Explosion and Fire
Chemical, Industry, Safety, Explosion, Fire, csb
On February 20, 2003, an explosion and fire damaged the CTA Acoustics manufacturing plant in Corbin, Kentucky, fatally injuring seven workers. The facility produced fiberglass insulation for the automotive industry. CSB investigators have found that the explosion was fueled by resin dust accumulated in a production area, likely ignited by flames from a malfunctioning oven. The resin involved was a phenolic binder used in producing fiberglass mats.
Honeywell Chemical Incidents
Chemical, Industry, Safety, csb
On July 20, 2003, there was a release of chlorine gas from the Honeywell refrigerant manufacturing plant in Baton Rouge, Louisiana. The accident resulted in the hospitalization of four plant workers and required residents within a half-mile radius to shelter in their homes. On July 29, 2003, a worker was fatally injured by exposure to antimony pentachloride when a gas cylinder released its contents to the atmosphere. On August 13, 2003, two plant workers were exposed to hydrofluoric acid, and one was hospitalized.
Hayes Lemmerz Dust Explosions and Fire
Chemical, Industry, Safety, Explosion, Fire, csb
On the evening of October 29, 2003, a series of explosions severely burned two workers, injured a third, and caused property damage to the Hayes Lemmerz manufacturing plant in Huntington, Indiana. One of the severely burned men subsequently died. The Hayes Lemmerz plant manufactures cast aluminum automotive wheels, and the explosions were fueled by accumulated aluminum dust, a flammable byproduct of the wheel production process.
Giant Industries Refinery Explosions and Fire
Chemical, Industry, Safety, Explosion, Fire, csb
On April 8, 2004, four workers were seriously injured when highly flammable gasoline components were released and ignited at the Giant Industries Ciniza refinery, east of Gallup, New Mexico. The release occurred as maintenance workers were removing a malfunctioning pump from the refinery's hydrofluoric acid (HF) alkylation unit. Unknown to personnel, a shut-off valve connecting the pump to a distillation column was apparently in the open position, leading to the release and subsequent explosions.
Acetylene Service Company Gas Explosion
Chemical, Industry, Safety, Explosion, Fire, csb
On January 25, 2005, a gas explosion killed three workers at the Acetylene Service Company plant in Perth Amboy, NJ. The blast originated in a wooden shed located near six large storage tanks that received liquid waste from the plant's acetylene generating system. The plant produces, repackages, and distributes acetylene used in welding.
Sterigenics Ethylene Oxide Explosion
Chemical, Industry, Safety, Explosion, Fire, csb
At approximately 3:00 p.m. on August 19, 2004, an explosion occurred inside an ethylene oxide sterilization chamber and an associated thermal oxidizer at the Sterigenics facility in Ontario, California. Four employees suffered minor injuries and the facility was rendered unusable.
MFG Chemical Inc. Toxic Gas Release
Chemical, Industry, Safety, Reactive incident, csb
On the evening of April 12, 2004, a chemical reactor overheated at the MFG Chemical manufacturing plant, releasing toxic allyl alcohol vapor. The resulting cloud sent 154 people to a local hospital and forced the evacuation of nearby residents. Vegetation and aquatic life near the plant were killed
Marcus Oil and Chemical Tank Explosion
Chemical, Industry, Safety, Explosion, Fire, csb
On the evening of December 3, a storage tank failed catastrophically at the Marcus Oil and Chemical polyethylene wax facility in Houston. The blast, which was felt up to 20 miles from the plant site, ignited large fires that burned for several hours, and two firefighters were injured during the emergency response. Off-site buildings near the facility - including two churches, a house, and a social club - exhibited structural damage, such as broken windows and cracked walls.
Praxair Flammable Gas Cylinder Fire
Chemical, Industry, Safety, Explosion, Fire, csb
On June 24, 2005, fire swept through thousands of flammable gas cylinders at the Praxair gas repackaging plant in St. Louis, Missouri. Dozens of exploding cylinders were launched into the surrounding community and struck nearby homes, buildings, and cars, causing extensive damage and several small fires.
Formosa Plastics Propylene Explosion
Chemical, Industry, Safety, Explosion, Fire, csb
A forklift towing a trailer collided with a line containing highly flammable liquid propylene, causing a release and a vapor cloud explosion. Sixteen workers were injured, the process unit was heavily damaged, and a nearby school was evacuated
Positive Material Verification: Prevent Errors
Chemical, Industry, Safety, Explosion, Fire, csb
On July 28, 2005, 4 months after a devastating incident in the Isomerization (Isom) Unit that killed 15 workers and injured 180, the BP Texas City refinery experienced a major fire in the Resid Hydrotreater Unit (RHU) that caused a reported $30 million in property damage. One employee sustained a minor injury during the emergency unit shutdown and there were no fatalities.
Valero Delaware City Refinery Asphyxiation Incident
Chemical, Industry, Safety, confined space, csb
Two contract employees were overcome and fatally injured by nitrogen as they performed maintenance work near a 24-inch opening on the top of a reactor. One of the workers died attempting rescue.
Combustible Dust Hazard Investigation
Chemical, Industry, Safety, Explosion, csb
In 2003, the CSB launched investigations of three major industrial explosions involving combustible powders. These explosions - in North Carolina, Kentucky, and Indiana - cost 14 lives and caused numerous injuries and substantial property losses. The Board responded by launching a nationwide study to determine the scope of the problem and recommend new safety measures for facilities that handle combustible powders.
DPC Enterprises Glendale Chlorine Release
Chemical, Industry, Safety, Release, csb
On November 17, 2003, there was a release of chlorine gas from the DPC Enterprises chlorine repackaging facility in Glendale, Arizona, near Phoenix. Fourteen people, including ten police officers, required treatment for chlorine exposure. The release occurred when chlorine vapors from a rail car unloading operation escaped from a system designed to recapture the material, known as a scrubber. Owing to the exhaustion of absorbent chemicals in the scrubber, chlorine gas was released.
Formosa Plastics Vinyl Chloride Explosion
Chemical, Industry, Safety, Explosion, Fire, csb
On April 23, 2004, five workers were fatally injured and two others were seriously injured when an explosion occurred in a polyvinyl chloride (PVC) production unit at Formosa Plastics in Illiopolis, Illinois, east of Springfield. The explosion followed a release of highly flammable vinyl chloride, which ignited. The explosion forced a community evacuation and lighted fires that burned for several days at the plant.
Bethune Point Wastewater Plant Explosion
Chemical, Industry, Safety, Explosion, csb
The investigation found that sparks from a cutting torch ignited flammable methanol vapours escaping from a tank vent, which then flashed back through a corroded and ineffective aluminium flame arrester into the storage tank, causing a fatal explosion.
Investigation into the BP America (Texas City) Refinery Explosion
Chemical, Industry, Safety, Fire, Explosion, csb
The investigation identified a catastrophic failure in corporate safety culture and process management, where a distillation tower was overfilled during startup, leading to a geyser-like release of flammable liquid that ignited and destroyed a cluster of occupied office trailers.
Universal Form Clamp Co. Explosion and Fire
Chemical, Industry, Safety, Explosion, Fire, csb
One fatality and five injuries resulted from an explosion and fire in a mixing room at the Universal Form Clamp facility. Workers were heating and mixing flammable solvents in an open top tank. During the heating process, there was a sudden evolution of flammable vapors that ignited, resulting in the explosion and fire.
Partridge Raleigh Oilfield Explosion and Fire
Chemical, Industry, Safety, Fire, Explosion, csb
Three contractors died and one contractor suffered serious injuries in an explosion and fire at the Partridge-Raleigh Oilfield. The contractors, all employees of Stringer Oilfield Services, were standing on top of a series of four oil production tanks. They were preparing to weld piping to the tanks when a welding tool likely ignited flammable vapors from the tanks.
Emergency Shutdown Systems for Chlorine Transfer
Chemical, Industry, Safety, Release, csb
This bulletin compares two chlorine releases investigated by the CSB. In both, a railcar unloading hose failed and chlorine was released. In the first incident, an emergency shutdown system malfunctioned, resulting in a release of 48,000 pounds of chlorine and a significant community impact. In the second, the emergency shutdown system worked to minimize the release, and the community was not impacted.
Synthron Chemical Explosion
Chemical, Industry, Safety, Reactive incident, csb
One worker was fatally burned and about a dozen others were injured when a powerful explosion devastated the Synthron Inc. chemical manufacturing facility. CSB investigators believe the explosion was related to the process inside a 1500-gallon batch reactor at the plant, which contained butyl acrylate along with the flammable solvents toluene and cyclohexane.
EQ Hazardous Waste Plant Explosions and Fire
Chemical, Industry, Safety, Explosion, Fire, csb
Explosions and fire at a hazardous waste facility forced the evacuation of approximately 16,000 residents from Apex, North Carolina, on October 5, 2006. The incident likely began in the oxidizer section of the EQ North Carolina waste facility, where chemicals such as pool chlorination tablets were stored. The fire was allowed to burn out and the facility was destroyed.
CAI / Arnel Chemical Plant Explosion
Chemical, Industry, Safety, Explosion, csb
During the early morning hours of November 22, a powerful explosion destroyed the CAI/Arnel ink and paint manufacturing facility in Danvers, Massachusetts. Scores of nearby homes and businesses were damaged, some beyond repair. A number of residents were hospitalized. There were no injuries in the plant, which was unoccupied at the time.
Barton Solvents Explosions and Fire
Chemical, Industry, Safety, Explosion, Fire, csb
The investigation concluded that the transfer of a non-conductive flammable liquid into a storage tank created a massive static charge which ignited the vapour-air mixture in the tank's headspace, resulting in a fireball and projectile damage to the local community.
Valero McKee Refinery Propane Fire
Chemical, Industry, Safety, Fire, csb
On February 16, 2007, a propane fire erupted at the Valero McKee Refinery in Sunray, Texas, north of Amarillo. Three workers suffered serious burns, and the refinery was forced to shut down. The fire began following a leak in the propane deasphalting unit and spread quickly, in part because of the rapid collapse of a major pipe rack carrying flammable hydrocarbons. Some of the rack's support columns had not been fireproofed.
Investigation into the Flammable Liquid Explosion at Barton Solvents (Des Moines)
Chemical, Industry, Safety, Explosion, Fire, csb
The investigation found that a static electrical spark ignited flammable ethyl acetate vapours during the "splash filling" of a portable steel tank that was not effectively grounded, resulting in a fire that destroyed the facility’s packaging area.
Little General Store Propane Explosion
Chemical, Industry, Safety, Explosion, csb
Four people were killed and five others were seriously injured when propane vapors from a storage tank ignited and exploded at the Little General convenience store and gas station in Ghent, West Virginia. Propane was used as fuel inside the building, which was completely destroyed.
Allied Terminals Fertilizer Tank Collapse
Chemical, Industry, Safety, csb
The investigation found that a 2-million-gallon fertilizer tank ruptured due to defective welds performed during a major modification, exacerbated by the company's decision to have contractors repair leaks while the tank was being filled to its maximum capacity for the first time.
T2 Laboratories Inc. Reactive Chemical Explosion
Chemical, Industry, Safety, Reactive incident, Explosion, csb
On December 19, 2007, four people were killed and 13 others were transported to the hospital when an explosion occured at T2 Laboratories Inc. during the production of a gasoline additive called methylcyclopentadienyl manganese tricarbonyl.
Imperial Sugar Company Dust Explosion and Fire
Chemical, Industry, Safety, Explosion, Fire, csb
On February 7, 2008, a huge explosion and fire occurred at the Imperial Sugar refinery northwest of Savannah, Georgia, causing 14 deaths and injuring 38 others, including 14 with serious and life-threatening burns. The explosion was fueled by massive accumulations of combustible sugar dust throughout the packaging building.
INDSPEC Chemical Corporation Oleum Release
Chemical, Industry, Safety, Release, csb
On October 11, 2008, a transfer operation overflowed an oleum process tank, filling a vent system and releasing the oleum into a storage building at Indspec Chemical Corporation in Petrolia, Pennsylvania . The release of oleum created a cloud of sulfuric acid mist that filled the building and flowed out into the facility and surrounding community. Plant personnel evacuated the facility, while emergency responders evacuated about 2,500 residents from the towns of Petrolia, Bruin, and Fairview.
CITGO Refinery Hydrofluoric Acid Release and Fire
Chemical, Industry, Safety, Release, csb
A fire in the alkylation unit at CITGO's Corpus Christi refinery led to a release of hydrofluoric acid (HF). The alkylation unit makes high-octane blending components for gasoline. One worker was critically burned.
ConAgra Natural Gas Explosion and Ammonia Release
Chemical, Industry, Safety, Explosion, csb
On the afternoon of June 9, 2009, 4 workers were fatally injured and dozens of others were injured when an explosion occurred at the ConAgra Foods facility in Garner, North Carolina.
Packaging Corporation Storage Tank Explosion
Chemical, Industry, Safety, Explosion, Fire, Hot work, csb
On July 29, 2008, three workers died and a fourth was injured when an explosion occurred inside an 80-foot-tall storage tank at the Packaging Corporation of America (PCA) corrugated cardboard mill in Tomahawk, Wisconsin. The workers were on a catwalk above the tank and performing hot work (welding) at the time of the explosion. The storage tank held a mixture of recycled paper pulp and water which the CSB found decomposed to form flammable hydrogen.
Kleen Energy Natural Gas Explosion
Chemical, Industry, Safety, Explosion, csb
Six workers were fatally injured during a planned work activity to clean debris from natural gas pipes at Kleen Energy in Middletown, CT. To remove the debris, workers used natural gas at a high pressure of approximately 650 pounds per square inch. The high velocity of the natural gas flow was intended to remove any debris in the new piping. During this process, the natural gas found an ignition source and exploded.
Veolia Environmental Services Flammable Vapor Explosion and Fire
Chemical, Industry, Safety, Explosion, Fire, csb
On May 4, 2009, flammable vapors were suddenly released into the atmosphere. The vapors found an ignition source, leading to an explosion and fire that seriously injured two workers and damaged twenty residences.
Xcel Energy Company Hydroelectric Tunnel Fire
Chemical, Industry, Safety, confined space, csb
On October 2, 2007, five people were killed and three others injured when a fire erupted 1,000 feet underground in a tunnel at Xcel Energy Company's hydroelectric power plant in Georgetown, Colorado, located approximately 45 miles west of Denver. The fatally injured workers were trapped deep underground during an operation to coat the inside of the tunnel with epoxy using highly flammable solvents. The tunnel is several thousand feet long and connects two reservoirs with electricity-generating turbines.
Bayer Crop Science Pesticide Waste Tank Explosion
Chemical, Industry, Safety, Explosion, Fire, csb
The investigation found that a massive explosion occurred when a chemical "residue treater" vessel underwent a runaway thermal decomposition after operators bypassed safety interlocks and failed to properly pre-fill the tank with solvent during a rushed unit restart.
Goodyear Heat Exchanger Rupture
Chemical, Industry, Safety, Explosion, Fire, csb
On June 11, 2008, one worker was killed and approximately seven others were injured, during a maintenance operation on a heat exchanger. Ammonia overpressured inside the exchanger, causing it to rupture.
DuPont La Porte Facility Toxic Chemical Release
Chemical, Industry, Safety, Release, csb
The accident at DuPont’s facility, located east of Houston, killed four workers and injured a fifth when methyl mercaptan, a toxic chemical used in the company’s insecticide and fungicide manufacturing process, was released.
Texas Tech University Chemistry Lab Explosion
Chemical, Industry, Safety, Reactive incident, csb
An explosion severely injured a graduate student at Texas Tech University in Lubbock, Texas, in the chemistry department during the handling of a high-energy metal compound, which suddenly detonated. Texas Tech had entered into an agreement with Northeastern University, which holds a contract from the U.S. Department of Homeland Security to study the high-energy materials.
Oil Tank Safety Study
Chemical, Industry, Safety, Explosion, csb
On April 13, 2010, the CSB released a safety video, entitled “No Place to Hang Out”. The video tells the story of the tragic deaths of 18-year-old Wade White and 16-year-old Devon Byrd, killed on October 31, 2009, when an oil tank, located in a clearing in the woods near the home of one of the boys in the town of Carnes, Mississippi, suddenly exploded. On April 14, 2010, a fiery explosion took the life of a 21-year-old member of the public in Weleetka, Oklahoma, at an unattended oil and gas production site that was unsecured and likely lacked fire or explosion warning signs.
Hoeganaes Corporation Fatal Flash Fires
Chemical, Industry, Safety, Explosion, Fire, csb
Three combustible dust incidents over a six month period occurred at the Hoeganaes facility in Gallatin, TN, resulting in fatal injuries to five workers. The facility produces powdered iron and is located about twenty miles outside of Nashville.
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