Industrial Incidents Caused by Human / Operator Error¶
Human and operator error is one of the most frequently cited contributing factors in CSB investigations — but the CSB consistently notes that operator error is rarely a root cause in itself. Behind almost every operator error lies inadequate training, poor procedure design, high cognitive load, or a management culture that normalised deviations from safe practice. These investigations document what the operators did, why, and what conditions made the error possible.
46 investigations
Industries: Chemical Manufacturing, Petroleum Refining, Oil And Gas Production
Years: 1998–2024
Incidents (46)¶
| Incident | Date | Location | Key Hazards |
|---|---|---|---|
| T2 Laboratories Inc. Reactive Chemical Explosion | 12/19/2007 | Jacksonville, FL | Runaway Reaction, Thermal Runaway |
| Environmental Enterprises Hydrogen Sulfide Release | 12/11/2002 | Cincinnati, OH | Hydrogen Sulfide Release, Toxic Release |
| Optima Belle Explosion and Fire | 12/08/2020 | Belle, WV | Explosion, Fire |
| Delaware City Refining Company | 11/29/2015 | Delaware City, DE | Flash Fire, Fire |
| ExxonMobil Baton Rouge Refinery Chemical Release and Fire | 11/22/2016 | Baton Rouge, LA | Chemical Release, Fire |
| 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 |
| DPC Enterprises Glendale Chlorine Release | 11/17/2003 | Glendale, AZ | Toxic Release, Chemical Release |
| Barton Solvents Flammable Liquid Explosion and Fire | 10/29/2007 | Des Moines, IA | Fire, Explosion |
| Aghorn Operating Inc. Waterflood Station Hydrogen Sulfide Release | 10/26/2019 | Odessa, TX | Hydrogen Sulfide Release, Toxic Release |
| 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 |
| 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 |
| Millard Refrigerated Services Ammonia Release | 08/23/2010 | Theodore, AL | Ammonia Release, Chemical Release |
| Sterigenics Ethylene Oxide Explosion | 08/19/2004 | Ontario, CA | Explosion, Fire |
| Sunoco Logistics Partners Flash Fire | 08/12/2016 | Nederland, TX | Flash Fire, Explosion |
| Horsehead Holding Company Fatal Explosion and Fire | 07/22/2010 | Monaca, PA | Explosion, Fire |
| Honeywell Chemical Incidents | 07/20/2003 | Baton Rouge, LA | Chemical Release, Toxic Release |
| Dow Louisiana Operations Explosions | 07/14/2023 | Plaquemine, LA | Explosion, Fire |
| Williams Olefins Plant Explosion and Fire | 06/13/2013 | Geismar, LA | Bleve, Chemical Release |
| Goodyear Heat Exchanger Rupture | 06/11/2008 | Houston, TX | Overpressure, Chemical Release |
| Kuraray Pasadena Release and Fire | 05/19/2018 | Pasadena, TX | Chemical Release, Fire |
| Veolia Environmental Services Flammable Vapor Explosion and Fire | 05/04/2009 | West Carrollton, OH | Explosion, Fire |
| AB Specialty Silicones, LLC | 05/03/2019 | Waukegan, IL | Chemical Release, Explosion |
| Kaltech Industries Waste Mixing Explosion | 04/25/2002 | New York , NY | Runaway Reaction, Explosion |
| Formosa Plastics Vinyl Chloride Explosion | 04/23/2004 | Illiopolis, IL | Explosion, Fire |
| Macondo Blowout and Explosion | 04/20/2010 | — | Explosion, Fire |
| MFG Chemical Inc. Toxic Gas Release | 04/12/2004 | Dalton, GA | Runaway Reaction, Toxic Release |
| D.D. Williamson & Co. Catastrophic Vessel Failure | 04/11/2003 | Louisville, KY | Overpressure, Explosion |
| Yenkin-Majestic Resin Plant Vapor Cloud Explosion and Fire | 04/08/2021 | Columbus, OH | Vapor Cloud Explosion, Explosion |
| Giant Industries Refinery Explosions and Fire | 04/08/2004 | Gallup, NM | Chemical Release, Explosion |
| 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 |
| ExxonMobil Torrance Refinery Explosion | 02/18/2015 | Torrance, CA | Explosion, Fire |
| Tesoro Martinez Sulfuric Acid Spill | 02/12/2014 | Martinez, CA | Chemical Release, Toxic Release |
| Technic Inc. Ventilation System Explosion | 02/07/2003 | Cranston, RI | Explosion, Fire |
| Little General Store Propane Explosion | 01/30/2007 | Ghent, WV | Chemical Release, Vapor Cloud Explosion |
| Wendland 1H Well Fatal Explosion | 01/29/2020 | Burleson County , TX | Explosion, Fire |
| Pryor Trust Fatal Gas Well Blowout and Fire | 01/22/2018 | Pittsburg County, OK | Explosion, Fire |
| Sierra Chemical Co. High Explosives Accident | 01/07/1998 | Mustang, NV | Explosion, Fire |
Common Patterns¶
Across these 46 investigations, the CSB consistently found human / operator error alongside these co-occurring failure modes, industries, and hazard types:
Co-occurring failure modes: Procedural Failure · Design Deficiency · Training Deficiency · Management of Change Failure · Communication Failure
Primary industries: Chemical Manufacturing, Petroleum Refining, Oil And Gas Production
Associated hazard types: Chemical Release · Fire · Explosion · Overpressure
Data sourced from CSB.gov public investigation reports. This site is an independent project not affiliated with the U.S. CSB.