Case studies
Start with the sequence of work rather than the incident name. The FFG nitrogen release shows the danger of entering to rescue a co-worker; the PES refinery incident traces how a release escalated.
For similar equipment, compare the operating state, isolation arrangements and conditions for worker access. Keep investigation findings separate from editorial check questions, then use the relevant questions in a work-permit review or toolbox meeting.
The Slide Valve Was Closed, So Where Did the Air Go?: Husky Superior Refinery FCC Explosion
On April 26, 2018, air reached hydrocarbon equipment during an FCC shutdown at the Husky Superior Refinery and two absorbers exploded. 36 workers were injured and 2,507 residents were evacuated. Causes, protection layers and site questions.
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Can One Thinned Elbow Shut Down a Refinery?: PES Philadelphia HF Alkylation Fire
An elbow installed in 1973 thinned to 0.28 mm and ruptured. Causes, lessons across layers of protection, and questions for your site.
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A temporary walkway is still a structure: the Shaheen walkway collapse
Workers were injured when a temporary walkway between site cabins collapsed at the Shaheen project in Ulsan on 19 November 2025.
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One task changes another: The DuPont La Porte methyl mercaptan release
Four workers died in the 15 November 2014 DuPont La Porte release. CSB reported that a pressure problem thought unrelated was connected to pipe-clearing work.
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Can the level indication be trusted during startup?: The BP Texas City refinery explosion
The 23 March 2005 explosion at BP Texas City, United States, killed 15 people and injured 180. It illustrates interacting weaknesses in instrumentation, startup control, release systems and occupied-building siting.
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Can another trade ignite your work area?: The 2020 Icheon warehouse construction fire
A fire at an Icheon warehouse construction site in South Korea on 29 April 2020 killed 38 people and injured ten. The case highlights coordination across trades and the whole building.
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