An Examination of Major Process Safety Incidents
This interactive application analyzes major process safety incidents in the refining industry. It moves beyond a simple chronological review to explore the complex interplay between equipment, procedures, and human factors. By grouping incidents thematically and enabling direct comparison, we can better understand the recurring patterns of failure and identify the critical lessons needed to prevent future catastrophes. Use the dashboard below to begin your exploration.
Incident Overview Dashboard
Click on any card to highlight its details throughout the analysis sections below.
Thematic Root Cause Analysis
Major accidents are rarely the result of a single error. Explore the common themes of failure that connect these disparate events. The analysis reveals how technical, human, and organizational factors repeatedly interact to create the conditions for disaster.
Interactive Consequence Comparison
While every incident is a tragedy, their impacts vary. Use the chart below to visually compare the human cost of these events. Select or deselect incidents to focus your analysis and gain perspective on the scale of each failure.
Key Lessons & Recommendations
Overarching Lessons Learned
The case studies reveal a clear and troubling pattern: major accidents are systemic failures. This section summarizes the most critical, cross-cutting lessons learned, from the importance of a robust safety culture to the necessity of learning from near-misses before they become tragedies.
Filterable Recommendations
Investigations produce recommendations aimed at preventing recurrence. Use the filters to explore the specific actions directed at regulatory bodies, industry standard-setters, and the companies themselves.