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Safety Instrumented System Failures

Safety instrumented systems (SIS) are the last automated layer of protection before a hazardous condition becomes an incident; inadequate proof-testing, improper bypass management, and design deficiencies have undermined their effectiveness. The investigations below trace SIS failures within the broader accident context.

10 CSB investigations in this database involve safety instrumented system as a primary or contributing equipment factor, spanning 1998–2024.

Safety Instrumented System Failures (10)

Incident Date Industry Key Hazard
Marathon Martinez Renewable Fuels Fire 11/19/2023 Petroleum Refining Fire, Chemical Release
INDSPEC Chemical Corporation Oleum Release 10/11/2008 Chemical Manufacturing Chemical Release, Toxic Release
BP - Husky Oregon Chemical Release and Fire 09/20/2022 Petroleum Refining Chemical Release, Fire
DPC Enterprises Festus Chlorine Release 08/14/2002 Chemical Manufacturing Chemical Release, Toxic Release
Horsehead Holding Company Fatal Explosion and Fire 07/22/2010 Metals Explosion, Fire
Macondo Blowout and Explosion 04/20/2010 Oil And Gas Production Explosion, Fire
Morton International Inc. Runaway Chemical Reaction 04/08/1998 Chemical Manufacturing Runaway Reaction, Thermal Runaway
Packaging Corporation of America Hot Work Explosion 02/08/2017 Paper And Pulp Explosion, Fire
Watson Grinding Fatal Explosion and Fire 01/24/2020 Metals Chemical Release, Explosion
Pryor Trust Fatal Gas Well Blowout and Fire 01/22/2018 Oil And Gas Production Explosion, Fire

Fire · Chemical Release · Explosion · Overpressure · Structural Failure

Valve Failures in Process Plant Incidents · Gas Detector Failures and Toxic Release Incidents · Furnace · Storage Tank Fires and Explosions · Pressure Vessel Explosions and Failures · Transfer Hose

Data sourced from CSB.gov public investigation reports. This site is an independent project not affiliated with the U.S. CSB.