This is a curated database developed by Grok of significant CSB incidents organized by PSM element identified as one of the causes. Please let me know if any incidents should be added or if there are any inaccuracies at jim@psmnews.com.
Why This CSB Incident Database May Be Useful
This reference tool makes it easier to learn from real incidents by connecting them directly to the relevant PSM elements. Here are some practical ways it can be used:
- Safety Meetings & Toolbox Talks — Quickly find relevant incidents to discuss for specific PSM topics (e.g., Mechanical Integrity, Management of Change, or Hot Work).
- Shift Meetings & Operator Training — Use as a reference when reviewing procedures, lessons learned, or reinforcing operating discipline.
- PHA / Revalidation Preparation — Help teams identify past failures related to specific elements when conducting or updating Process Hazard Analyses.
- Incident Investigation Training — Study real examples of root causes and recurring failures in specific PSM areas.
- Audits & Compliance Reviews — Use as a checklist-style reference when evaluating the effectiveness of individual PSM elements.
- New Engineer / Employee Onboarding — Provide context and real-world examples to help new team members understand why each PSM element matters.
- Personal Learning & Research — Quickly locate relevant case studies when writing articles, preparing presentations, or refreshing knowledge on a topic.
- Continuous Improvement — Help leadership and technical teams spot patterns and drive stronger performance in weaker PSM areas.
Process Safety Information (PSI)
| Incident | Year | Hazard Type | Notes |
|---|---|---|---|
| DuPont La Porte Toxic Release | 2014 | Toxicity | Incomplete and inaccurate process safety information regarding reactive hazards |
| Chevron Richmond Refinery Fire | 2012 | Fire/Explosion | Outdated and incomplete PSI regarding material properties and corrosion rates |
| BP Texas City Refinery Explosion | 2005 | Fire/Explosion | Inadequate and outdated process safety information contributed to poor decision making |
| Motiva Enterprises Sulfuric Acid Tank Explosion | 2004 | Fire/Explosion | Poor documentation of tank design and inspection history |
| Formosa Plastics Explosion (IL) | 2004 | Fire/Explosion | Incomplete PSI regarding hazards and safe operating limits |
Process Hazard Analysis (PHA)
| Incident | Year | Hazard Type | Notes |
|---|---|---|---|
| DuPont La Porte | 2014 | Toxicity | Inadequate PHA for reactive chemistry |
| West Fertilizer | 2013 | Fire/Explosion | No formal PHA performed |
| Chevron Richmond | 2012 | Fire/Explosion | PHA failed to identify corrosion hazard |
| BP Texas City | 2005 | Fire/Explosion | Severe PHA deficiencies |
Operating Procedures
| Incident | Year | Hazard Type | Notes |
|---|---|---|---|
| DuPont La Porte | 2014 | Toxicity | Inadequate or not followed operating procedures |
| Chevron Richmond | 2012 | Fire/Explosion | Procedures did not address abnormal conditions |
| BP Texas City | 2005 | Fire/Explosion | Inadequate operating procedures |
| Formosa Plastics (IL) | 2004 | Fire/Explosion | Failure to follow procedures |
Training
| Incident | Year | Hazard Type | Notes |
|---|---|---|---|
| DuPont La Porte Toxic Release | 2014 | Toxicity | Inadequate training on the new process and emergency procedures contributed to the fatal incident. |
| West Fertilizer Explosion | 2013 | Fire/Explosion | Lack of training on the hazards of ammonium nitrate storage and emergency response. |
| Tesoro Martinez Refinery | 2010 | Fire/Explosion | Training deficiencies and lack of knowledge of abnormal conditions were factors. |
| BP Texas City Refinery Explosion | 2005 | Fire/Explosion | Inadequate operator training on startup procedures, abnormal situations, and troubleshooting. Training was outdated. |
| Motiva Enterprises Sulfuric Acid Tank Explosion | 2004 | Fire/Explosion | Inadequate training on tank inspection and maintenance procedures. |
| Formosa Plastics (Illinois) | 2004 | Fire/Explosion | Training deficiencies contributed to operators not understanding the process and bypassing safeguards. |
Mechanical Integrity (MI)
| Incident | Year | Hazard Type | Notes |
|---|---|---|---|
| Chevron Richmond Refinery Fire | 2012 | Fire/Explosion | Long-term corrosion of piping due to poor mechanical integrity program and inadequate inspection. |
| Williams Olefins Plant Explosion | 2013 | Fire/Explosion | Heat exchanger failure due to inadequate mechanical integrity and inspection practices. |
| BP Texas City Refinery Explosion | 2005 | Fire/Explosion | Failed mechanical integrity on the blowdown drum and related equipment; poor inspection and maintenance. |
| Motiva Enterprises Sulfuric Acid Tank Explosion | 2004 | Fire/Explosion | Tank integrity failure due to inadequate mechanical integrity and maintenance program. |
| Formosa Plastics (IL) | 2004 | Fire/Explosion | Equipment integrity issues contributed to the release. |
Pre-Startup Safety Review (PSSR)
| Incident | Year | Hazard Type | Notes |
|---|---|---|---|
| BP Texas City Refinery Explosion | 2005 | Fire/Explosion | No PSSR was conducted prior to startup after turnaround; critical deficiencies not identified |
| DuPont La Porte Toxic Release | 2014 | Toxicity | Inadequate PSSR for modified process and temporary equipment |
| Williams Olefins Plant Explosion | 2013 | Fire/Explosion | Inadequate PSSR and MOC for restarted heat exchanger |
| Bayer CropScience | 2008 | Fire/Explosion | Incomplete PSSR; critical safety systems not fully verified before startup |
Compliance Audits
| Incident | Year | Hazard Type | Notes |
|---|---|---|---|
| BP Texas City Refinery Explosion | 2005 | Fire/Explosion | Weak compliance audits failed to identify serious PSM deficiencies |
| Chevron Richmond Refinery Fire | 2012 | Fire/Explosion | Audits did not effectively identify or correct long-standing mechanical integrity issues |
| DuPont La Porte Toxic Release | 2014 | Toxicity | Inadequate audits failed to detect gaps in process safety systems |
| Formosa Plastics Explosion (IL) | 2004 | Fire/Explosion | Audits did not identify recurring procedural and operational issues |
Hot Work Permit
| Incident | Year | Hazard Type | Notes |
|---|---|---|---|
| DuPont Buffalo (Tonawanda) Fatal Hot Work Explosion | 2010 | Fire/Explosion | Hot work on tank containing flammable vapors; inadequate gas testing and permitting |
| Sunoco Logistics (Texas) Flash Fire | 2016 | Fire/Explosion | Hot work on pipe containing residual flammable material; deficient hot work procedures |
| Long Brothers Oil Company | 2012 | Fire/Explosion | Fatal hot work explosion while cutting on tank |
| Omega Protein | 2014 | Fire/Explosion | Hot work on tank containing organic material led to explosion |
| Motiva Enterprises Sulfuric Acid Tank | 2004 | Fire/Explosion | Hot work contributed to tank explosion due to poor permitting and hazard evaluation |
Contractors
| Incident | Year | Hazard Type | Notes |
|---|---|---|---|
| BP Texas City Refinery Explosion | 2005 | Fire/Explosion | Inadequate contractor training, oversight, and safety integration. Contractors made up much of the workforce during turnaround and were involved in the incident. |
| Chevron Richmond Refinery Fire | 2012 | Fire/Explosion | Contractor personnel involved in maintenance activities; deficiencies in contractor management and communication. |
| Formosa Plastics Explosion (IL) | 2004 | Fire/Explosion | Contractor actions contributed to the incident; poor contractor oversight and training on process hazards. |
| Motiva Enterprises Sulfuric Acid Tank Explosion | 2004 | Fire/Explosion | Contractor involved in tank maintenance; inadequate contractor safety management. |
Emergency Planning & Response
| Incident | Year | Hazard Type | Notes |
|---|---|---|---|
| West Fertilizer Explosion | 2013 | Fire/Explosion | Inadequate emergency planning and response; firefighters not informed of explosive hazards |
| DuPont La Porte Toxic Release | 2014 | Toxicity | Inadequate emergency response procedures and training for toxic release |
| Chevron Richmond Refinery Fire | 2012 | Fire/Explosion | Deficiencies in emergency response planning and community notification |
| BP Texas City Refinery Explosion | 2005 | Fire/Explosion | Inadequate emergency response planning and evacuation procedures |
| Formosa Plastics Explosion (IL) | 2004 | Fire/Explosion | Poor emergency response coordination and training |
Safety Culture
| Incident | Year | Hazard Type | Notes |
|---|---|---|---|
| DuPont La Porte | 2014 | Toxicity | Weak safety culture |
| Chevron Richmond | 2012 | Fire/Explosion | Normalization of deviance |
| Tesoro Martinez | 2010 | Fire/Explosion | Serious safety culture deficiencies |
| BP Texas City | 2005 | Fire/Explosion | Production over safety culture |
Operational Discipline (OD)
| Incident | Year | Hazard Type | Notes |
|---|---|---|---|
| DuPont La Porte | 2014 | Toxicity | Breakdown in operational discipline |
| BP Texas City | 2005 | Fire/Explosion | Poor adherence to procedures |
| Formosa Plastics (IL) | 2004 | Fire/Explosion | Bypassing of safeguards |