This investigation report examines a vessel explosion that occurred on April 11, 2003, at D. D. Williamson & Co., Inc., in Louisville, Kentucky. The explosion caused a massive release of aqua ammonia. Twenty-six residents were evacuated, and 1,500 people were sheltered in place. This report identifies the root and contributing causes of the incident and makes recom- mendations on overpressure protection, hazard evaluation sys- tems, layers of protection, and operating procedures and training. The U.S. Chemical Safety and Hazard Investigation Board (CSB) is an independent Federal agency whose mission is to ensure the safety of workers, the public, and the environment by investigat- ing and preventing chemical incidents. CSB is a scientific investi- gative organization; it is not an enforcement or regulatory body. Established by the Clean Air Act Amendments of 1990, CSB is responsible for determining the root and contributing causes of accidents, issuing safety recommendations, studying chemical safety issues, and evaluating the effectiveness of other govern- ment agencies involved in chemical safety. No part of the conclusions, findings, or recommendations of CSB relating to any chemical incident may be admitted as evidence or used in any action or suit for damages arising out of any matter mentioned in an investigation report (see 42 U.S.C. § 7412 [r][6][G]). CSB makes public its actions and decisions through investigation reports, summary reports, safety bulletins, safety recommendations, case studies, incident digests, special technical publications, and statistical reviews. More information about CSB may be found at www.csb.gov

This report examines the catastrophic vessel failure and fire that occurred on March 4, 1998, near Pitkin, Louisiana, at an oil and gas production facility owned by Sonat Exploration Company. Four workers were killed in the incident. The root causes of the incident are identified, and recommendations are made concerning engineering and design management systems and the development of good-practice guidelines. The Chemical Safety and Hazard Investigation Board (CSB) is an independent federal agency whose mission is to ensure the safety of workers and the public by preventing or minimizing the effects of chemical incidents. The CSB is a scientific investigative organization; it is not an enforcement or regulatory body. Established by the Clean Air Act Amendments of 1990, the CSB is responsible for determining the root and contributing causes of accidents, issuing safety recommendations, studying chemical safety issues, and evaluating the effectiveness of other government agencies involved with chemical safety. No part of the conclusions, findings, or recommendations of the CSB relating to any chemical incident may be admitted as evidence or used in any action or suit for damages arising out of any matter mentioned in an investigation report. See 42 U.S.C. § 7412(r)(6)(G). The CSB makes public its actions and decisions through investigation reports, summary reports, safety studies, safety recommendations, special technical publications, and statistical reviews. More information about the CSB may be found on the World Wide Web at http://www.chemsafety.gov.

This is a print on demand edition of a hard to find publication. On April 20, 2010, a well control event allowed hydrocarbons to escape from the Macondo well onto Transocean¿s ¿Deepwater Horizon,¿ resulting in explosions and fire on the rig. This is the report of an internal BP incident invest. team. It presents an analysis of the events leading up to the accident, 8 key findings related to the causal chain of events, and recommend. to enable the prevention of a similar accident. The invest. team worked separately from any invest. conducted by other co. involved in the accident, and it did not review its analyses, conclusions or recommend. with any other co. or invest. team. Other invest., such as the U.S. Coast Guard, U.S. Justice Dept., and Bur. of Ocean Energy Mgmt., and the Pres. Nat. Comm. are ongoing.

What Went Wrong? 6th Edition provides a complete analysis of the design, operational, and management causes of process plant accidents and disasters. Co-author Paul Amyotte has built on Trevor Kletz’s legacy by incorporating questions and personal exercises at the end of each major book section. Case histories illustrate what went wrong and why it went wrong, and then guide readers in how to avoid similar tragedies and learn without having to experience the loss incurred by others. Updated throughout and expanded, this sixth edition is the ultimate resource of experienced-based analysis and guidance for safety and loss prevention professionals. 20% new material and updating of existing content with parts A and B now combined Exposition of topical concepts including Natech events, process security, warning signs, and domino effects New case histories and lessons learned drawn from other industries and applications such as laboratories, pilot plants, bioprocess plants, and electronics manufacturing facilities

NASA commissioned the Columbia Accident Investigation Board (CAIB) to conduct a thorough review of both the technical and the organizational causes of the loss of the Space Shuttle Columbia and her crew on February 1, 2003. The accident investigation that followed determined that a large piece of insulating foam from Columbia's external tank (ET) had come off during ascent and struck the leading edge of the left wing, causing critical damage. The damage was undetected during the mission. The Columbia accident was not survivable. After the Columbia Accident Investigation Board (CAIB) investigation regarding the cause of the accident was completed, further consideration produced the question of whether there were lessons to be learned about how to improve crew survival in the future. This investigation was performed with the belief that a comprehensive, respectful investigation could provide knowledge that can protect future crews in the worldwide community of human space flight. Additionally, in the course of the investigation, several areas of research were identified that could improve our understanding of both nominal space flight and future spacecraft accidents. This report is the first comprehensive, publicly available accident investigation report addressing crew survival for a human spacecraft mishap, and it provides key information for future crew survival investigations. The results of this investigation are intended to add meaning to the sacrifice of the crew's lives by making space flight safer for all future generations.