Industrial Incidents Caused by Management of Change Failure¶
Management of Change (MOC) failures occur when modifications to process chemistry, equipment, operating conditions, or staffing are made without a systematic review of the new hazards introduced. The CSB has cited MOC failures in some of its highest-consequence investigations — including the BP Texas City explosion, where unauthorised equipment modifications and procedural changes accumulated over years without formal hazard review.
56 investigations
Industries: Chemical Manufacturing, Petroleum Refining, Plastics
Years: 1998–2024
Incidents (56)¶
| Incident | Date | Location | Key Hazards |
|---|---|---|---|
| T2 Laboratories Inc. Reactive Chemical Explosion | 12/19/2007 | Jacksonville, FL | Runaway Reaction, Thermal Runaway |
| Optima Belle Explosion and Fire | 12/08/2020 | Belle, WV | Explosion, Fire |
| Marcus Oil and Chemical Tank Explosion | 12/03/2004 | Houston, TX | Explosion, Fire |
| Delaware City Refining Company | 11/29/2015 | Delaware City, DE | Flash Fire, Fire |
| TPC Port Neches Explosions and Fire | 11/27/2019 | Port Neches, TX | Chemical Release, Explosion |
| CAI / Arnel Chemical Plant Explosion | 11/22/2006 | Danvers, MA | Explosion, Fire |
| Marathon Martinez Renewable Fuels Fire | 11/19/2023 | Martinez, CA | Fire, Chemical Release |
| DuPont La Porte Facility Toxic Chemical Release | 11/15/2014 | La Porte, TX | Toxic Release, Chemical Release |
| E. I. DuPont De Nemours Co. Fatal Hotwork Explosion | 11/09/2010 | Buffalo, NY | Explosion, Fire |
| Hayes Lemmerz Dust Explosions and Fire | 10/29/2003 | Huntington, IN | Dust Explosion, Fire |
| First Chemical Corp. Reactive Chemical Explosion | 10/13/2002 | Pascgoula, MS | Runaway Reaction, Explosion |
| INDSPEC Chemical Corporation Oleum Release | 10/11/2008 | Petrolia, PA | Chemical Release, Toxic Release |
| PEMEX Deer Park Chemical Release | 10/10/2024 | Deer Park, TX | Hydrogen Sulfide Release, Toxic Release |
| US Ink Fire | 10/09/2012 | East Rutherford , NJ | Dust Explosion, Flash Fire |
| Formosa Plastics Propylene Explosion | 10/06/2005 | Point Comfort, TX | Chemical Release, Explosion |
| Xcel Energy Company Hydroelectric Tunnel Fire | 10/02/2007 | Georgetown, CO | Fire, Flash Fire |
| Isotec/Sigma Aldrich Nitric Oxide Explosion | 09/21/2003 | Miami Township, OH | Explosion, Chemical Release |
| BP - Husky Oregon Chemical Release and Fire | 09/20/2022 | Oregon, OH | Chemical Release, Fire |
| AirGas Facility Fatal Explosion | 08/28/2016 | Pensacola, FL | Explosion, Runaway Reaction |
| Bayer CropScience Pesticide Waste Tank Explosion | 08/28/2008 | Institute, WV | Runaway Reaction, Explosion |
| Sterigenics Ethylene Oxide Explosion | 08/19/2004 | Ontario, CA | Explosion, Fire |
| Honeywell Chemical Incidents | 07/20/2003 | Baton Rouge, LA | Chemical Release, Toxic Release |
| Motiva Enterprises Sulfuric Acid Tank Explosion | 07/17/2001 | Delaware City, DE | Explosion, Fire |
| Enterprise Pascagoula Gas Plant Explosion and Fire | 06/27/2016 | Moss Point, MS | Chemical Release, Explosion |
| Williams Olefins Plant Explosion and Fire | 06/13/2013 | Geismar, LA | Bleve, Chemical Release |
| Didion Milling Company Explosion and Fire | 05/31/2017 | Cambria, WI | Dust Explosion, Explosion |
| TS USA Molten Salt Eruption | 05/30/2024 | — | Explosion, Overpressure |
| Midland Resource Recovery Explosion | 05/24/2017 | Barbour County, WV | Explosion, Runaway Reaction |
| Kuraray Pasadena Release and Fire | 05/19/2018 | Pasadena, TX | Chemical Release, Fire |
| D.D. Williamson & Co. Catastrophic Vessel Failure | 04/11/2003 | Louisville, KY | Overpressure, Explosion |
| Donaldson Enterprises, Inc. Fatal Fireworks Disassembly Explosion and Fire | 04/08/2011 | Waipahu, HI | Explosion, Fire |
| Giant Industries Refinery Explosions and Fire | 04/08/2004 | Gallup, NM | Chemical Release, Explosion |
| Morton International Inc. Runaway Chemical Reaction | 04/08/1998 | Patterson, NJ | Runaway Reaction, Thermal Runaway |
| KMCO LLC Fatal Fire and Explosion | 04/02/2019 | Crosby, TX | Vapor Cloud Explosion, Flash Fire |
| Tesoro Anacortes Refinery Fatal Explosion and Fire | 04/02/2010 | Anacortes, WA | Explosion, Fire |
| Union Carbide Corp. Nitrogen Asphyxiation Incident | 03/27/1998 | Hahnville, LA | Asphyxiation, Toxic Release |
| BP America (Texas City) Refinery Explosion | 03/23/2005 | Texas City, TX | Explosion, Fire |
| BP Amoco Thermal Decomposition Incident | 03/13/2001 | Augusta, GA | Chemical Release, Explosion |
| Tosco Avon Refinery Petroleum Naphtha Fire | 02/23/1999 | Martinez, CA | Fire, Flash Fire |
| Concept Sciences Hydroxylamine Explosion | 02/19/1999 | Allentown, PA | Explosion, Chemical Release |
| ExxonMobil Torrance Refinery Explosion | 02/18/2015 | Torrance, CA | Explosion, Fire |
| Valero McKee Refinery Propane Fire | 02/16/2007 | Sunray, TX | Fire, Flash Fire |
| Tesoro Martinez Sulfuric Acid Spill | 02/12/2014 | Martinez, CA | Chemical Release, Toxic Release |
| Packaging Corporation of America Hot Work Explosion | 02/08/2017 | Deridder, LA | Explosion, Fire |
| Technic Inc. Ventilation System Explosion | 02/07/2003 | Cranston, RI | Explosion, Fire |
| Bethlehem Steel Corporation Gas Condensate Fire | 02/02/2001 | Chesterton, IN | Fire, Explosion |
| Synthron Chemical Explosion | 01/31/2006 | Morganton, NC | Runaway Reaction, Vapor Cloud Explosion |
| West Pharmaceutical Services Dust Explosion and Fire | 01/29/2003 | Kinston, NC | Dust Explosion, Explosion |
| Watson Grinding Fatal Explosion and Fire | 01/24/2020 | Houston, TX | Chemical Release, Explosion |
| Honeywell Geismar Chlorine and Hydrogen Fluoride Releases | 01/23/2023 | Geismar, LA | Chemical Release, Explosion |
| DuPont Belle Toxic Chemical Releases | 01/23/2010 | Belle, WV | Toxic Release, Chemical Release |
| Pryor Trust Fatal Gas Well Blowout and Fire | 01/22/2018 | Pittsburg County, OK | Explosion, Fire |
| Georgia-Pacific Corp. Hydrogen Sulfide Poisoning | 01/16/2002 | Pennington, AL | Hydrogen Sulfide Release, Toxic Release |
| Silver Eagle Refinery Flash Fire and Explosion and Catastrophic Pipe Explosion | 01/12/2009 | Woods Cross, UT | Flash Fire, Explosion |
| Texas Tech University Chemistry Lab Explosion | 01/07/2010 | Lubbock, TX | Explosion, Runaway Reaction |
| Sierra Chemical Co. High Explosives Accident | 01/07/1998 | Mustang, NV | Explosion, Fire |
Common Patterns¶
Across these 56 investigations, the CSB consistently found management of change failure alongside these co-occurring failure modes, industries, and hazard types:
Co-occurring failure modes: Procedural Failure · Design Deficiency · Training Deficiency · Human / Operator Error · Communication Failure
Primary industries: Chemical Manufacturing, Petroleum Refining, Plastics
Associated hazard types: Chemical Release · Fire · Explosion · Structural Failure
Data sourced from CSB.gov public investigation reports. This site is an independent project not affiliated with the U.S. CSB.