Industrial Incidents Caused by Procedural Failure¶
Procedural failures — missing procedures, procedures that were present but not followed, or procedures that were inadequate for the actual hazard — appear in the majority of CSB investigations. These failures range from informal workarounds that became routine practice to the complete absence of written procedures for high-hazard tasks. Each investigation details the specific procedural gap and the CSB's recommendations for corrective action.
107 investigations
Industries: Chemical Manufacturing, Petroleum Refining, Plastics
Years: 1998–2024
Incidents (107)¶
| 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 |
| NDK Crystal Inc. Explosion with Offsite Fatality | 12/07/2009 | Belvidere, IL | Explosion, Overpressure |
| 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 |
| 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 |
| DuPont La Porte Facility Toxic Chemical Release | 11/15/2014 | La Porte, TX | Toxic Release, Chemical Release |
| Wacker Polysilicon Chemical Release | 11/13/2020 | Charleston, TN | Chemical Release, Toxic Release |
| Allied Terminals Fertilizer Tank Collapse | 11/11/2008 | Chesapeake, VA | Chemical Release, Structural Failure |
| E. I. DuPont De Nemours Co. Fatal Hotwork Explosion | 11/09/2010 | Buffalo, NY | Explosion, Fire |
| Valero Delaware City Refinery Asphyxiation Incident | 11/05/2005 | Delaware City, DE | Asphyxiation |
| Barton Solvents Flammable Liquid Explosion and Fire | 10/29/2007 | Des Moines, IA | Fire, Explosion |
| Hayes Lemmerz Dust Explosions and Fire | 10/29/2003 | Huntington, IN | Dust Explosion, Fire |
| Aghorn Operating Inc. Waterflood Station Hydrogen Sulfide Release | 10/26/2019 | Odessa, TX | Hydrogen Sulfide Release, Toxic Release |
| Caribbean Petroleum Corporation (CAPECO) Refinery Tank Explosion and Fire | 10/23/2009 | Bayamón, PR | Chemical Release, Explosion |
| 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 |
| EQ Hazardous Waste Plant Explosions and Fire | 10/05/2006 | Apex, NC | Fire, Explosion |
| Xcel Energy Company Hydroelectric Tunnel Fire | 10/02/2007 | Georgetown, CO | Fire, Flash Fire |
| Evergreen Packaging Paper Mill - Fire During Hot Work | 09/21/2020 | Canton, NC | 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 |
| Bio Lab Conyers Chemical Release | 09/14/2020 | Conyers, GA | Thermal Runaway, Toxic Release |
| Arkema Inc. Chemical Plant Fire | 08/29/2017 | Crosby, TX | Fire, Chemical Release |
| 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 |
| Bio-Lab Lake Charles Chemical Fire and Release | 08/27/2020 | Lake Charles, LA | Runaway Reaction, Toxic Release |
| 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 |
| DPC Enterprises Festus Chlorine Release | 08/14/2002 | Festus, MO | Chemical Release, Toxic Release |
| Sunoco Logistics Partners Flash Fire | 08/12/2016 | Nederland, TX | Flash Fire, Explosion |
| Chevron Richmond Refinery Pipe Rupture and Fire | 08/06/2012 | Richmond, CA | Chemical Release, Fire |
| Cuisine Solutions Ammonia Release | 07/31/2024 | Sterling, VA | Ammonia Release, Toxic Release |
| Packaging Corporation Storage Tank Explosion | 07/29/2008 | Tomahawk, WI | Explosion, Fire |
| LyondellBasell La Porte Fatal Chemical Release | 07/27/2021 | La Porte, TX | Chemical Release, Toxic Release |
| 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 |
| CITGO Refinery Hydrofluoric Acid Release and Fire | 07/19/2009 | Corpus Christi, TX | Fire, Chemical Release |
| Barton Solvents Explosions and Fire | 07/17/2007 | Valley Center, KS | Explosion, Fire |
| Motiva Enterprises Sulfuric Acid Tank Explosion | 07/17/2001 | Delaware City, DE | Explosion, Fire |
| Dow Louisiana Operations Explosions | 07/14/2023 | Plaquemine, LA | 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 |
| Goodyear Heat Exchanger Rupture | 06/11/2008 | Houston, TX | Overpressure, Chemical Release |
| ConAgra Natural Gas Explosion and Ammonia Release | 06/09/2009 | Garner, NC | Explosion, Ammonia Release |
| Partridge Raleigh Oilfield Explosion and Fire | 06/05/2006 | Raleigh, MS | Explosion, Fire |
| 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 |
| 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 |
| Third Coast Industries Petroleum Products Facility Fire | 05/01/2002 | Brazoria County, TX | Fire, Pool Fire |
| Husky Energy Superior Refinery Explosion and Fire | 04/26/2018 | Superior, WI | Explosion, Fire |
| 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 |
| West Fertilizer Explosion and Fire | 04/17/2013 | West, TX | Fire, Explosion |
| 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 |
| 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 |
| Loy Lange Box Company Pressure Vessel Explosion | 04/03/2017 | St. Louis , MO | Explosion, Overpressure |
| 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 |
| Carbide Industries Fire and Explosion | 03/21/2011 | Louisville, KY | Explosion, Overpressure |
| BP Amoco Thermal Decomposition Incident | 03/13/2001 | Augusta, GA | Chemical Release, Explosion |
| Sonat Exploration Co. Catastrophic Vessel Overpressurization | 03/04/1998 | Pitkin, LA | Overpressure, Fire |
| Tosco Avon Refinery Petroleum Naphtha Fire | 02/23/1999 | Martinez, CA | Fire, Flash Fire |
| CTA Acoustics Dust Explosion and Fire | 02/20/2003 | Corbin, KY | Dust Explosion, 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 |
| Kleen Energy Natural Gas Explosion | 02/07/2010 | Middletown, CT | Explosion, Chemical Release |
| Imperial Sugar Company Dust Explosion and Fire | 02/07/2008 | Port Wentworth, GA | Dust Explosion, Explosion |
| 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 |
| Hoeganaes Corporation Fatal Flash Fires | 01/31/2011 | Gallatin, TN | Flash Fire, Dust Explosion |
| Synthron Chemical Explosion | 01/31/2006 | Morganton, NC | Runaway Reaction, Vapor Cloud Explosion |
| 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 |
| West Pharmaceutical Services Dust Explosion and Fire | 01/29/2003 | Kinston, NC | Dust Explosion, Explosion |
| Foundation Food Group Fatal Chemical Release | 01/28/2021 | Gainesville , GA | Chemical Release, Asphyxiation |
| Watson Grinding Fatal Explosion and Fire | 01/24/2020 | Houston, TX | 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 |
| BLSR Operating Ltd. Vapor Cloud Fire | 01/13/2003 | Rosharon, TX | Vapor Cloud Explosion, Flash Fire |
| Silver Eagle Refinery Flash Fire and Explosion and Catastrophic Pipe Explosion | 01/12/2009 | Woods Cross, UT | Flash Fire, Explosion |
| Bethune Point Wastewater Plant Explosion | 01/11/2006 | Daytona Beach, FL | Explosion, Fire |
| 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 |
| Catalyst Systems Inc. Reactive Chemical Explosion | 01/02/2003 | Gnadenhutten, OH | Explosion, Fire |
Common Patterns¶
Across these 107 investigations, the CSB consistently found procedural failure alongside these co-occurring failure modes, industries, and hazard types:
Co-occurring failure modes: Design Deficiency · Training Deficiency · Management of Change Failure · 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.