Don’t Miss “Obvious” Hazards: Lessons Learned From Chemical Safety Board Investigations

The United States Chemical Safety & Hazard Investigation Board (CSB) was conceived by Congress following a series of catastrophic industrial accidents in the mid to late 1980s. This federal agency is charged with investigating incidents at chemical and manufacturing facilities, determining the causes, and making recommendations to prevent future accidents. This paper focuses on the findings from several CSB investigations related to equipment failure. Numerous codes, standards, and good practice guidelines are in place to govern the design, maintenance, and operation of vessels. However, the CSB has found that serious accidents continue to occur because of poor implementation of established guidance. This paper uses actual case studies to illustrate problems with equipment that ultimately led to catastrophes. Lessons learned from these incidents include designing equipment with adequate overpressure protection, adjusting inspection frequencies based on actual observations, and requiring written procedures for critical phases such as startup. Additional good practices and recommendations from the CSB are discussed with each of the case studies.