Incident Library

Propellant mixing

Illustrative case: propellant ignited while an operator manually scraped a mixer bowl; flash fire injured operator.

Root cause: Non-conductive tool, ESD build-up, procedure allowed scraping with energized mixer interlocks bypassed.

Lessons: Remote operations, conductive tools, interlock integrity checks, operator shielding.

Dust collection

Illustrative case: accumulated nitrocellulose fines ignited in a dry dust collector.

Root cause: Inadequate housekeeping and no explosion venting/isolation.

Lessons: Wet collectors for energetics, NFPA 660 DHA, isolation valves, cleaning frequency.

Energetic storage

Illustrative case: lightning struck an earth-covered magazine with an incomplete LPS; no detonation but damage to headwall.

Root cause: Air terminal bonding not inspected after repairs.

Lessons: Periodic LPS inspection per NFPA 780 / DESR, bonding verification after any modification.

Process control

Illustrative case: SIS trip bypass left active after maintenance; overtemperature in curing oven not tripped.

Root cause: Weak bypass management and alarm handling.

Lessons: Bypass authorization, time-limited bypasses, IEC 61511 management of change.

Open burn / open detonation

Illustrative case: fragments from open detonation landed beyond the planned exclusion zone.

Root cause: Charge size exceeded permit assumptions; wind not checked.

Lessons: Enforce permit limits, fragment distance calc, weather go/no-go criteria.

Solvent recovery

Illustrative case: solvent vapor released during filter change ignited by non-rated portable lamp.

Root cause: Temporary equipment not matched to zone classification.

Lessons: Zone-rated portable equipment control, hot work permits, gas testing.

Fire protection

Illustrative case: UV/IR detection activated but deluge valve did not open due to closed isolation valve.

Root cause: Valve supervision alarm ignored; ITM overdue.

Lessons: Valve supervision, NFPA 25 ITM, response time testing.

Control systems

Illustrative case: vendor remote-access path allowed unauthorized change to PLC logic.

Root cause: Flat network, shared credentials.

Lessons: IEC 62443 zones and conduits, MFA, change detection.