Process & Chemical Industry
High-consequence process environments depend on multiple layers of protection, containment integrity, and operator response under abnormal conditions. Failures typically reveal gaps between assumed and actual system behavior when multiple safeguards are challenged simultaneously.
Common Failure Themes
- •Multiple independent protection layers failing or bypassed during the same operational window
- •Assumptions about containment or reaction control that are valid only within narrow operating ranges
- •Maintenance-induced vulnerabilities where protective functions are degraded without corresponding risk assessment
- •Test results or warning indicators interpreted as instrumentation problems rather than process condition signals
Case Analyses
Process & Chemical Industry
2010Tesoro Anacortes Refinery Disaster
Heat exchanger catastrophic rupture from High Temperature Hydrogen Attack—a silent degradation mechanism invisible to standard inspection.
Process & Chemical Industry
2005Buncefield Oil Storage Explosion
Multiple independent high-level protection failures occurred simultaneously during tank filling operations.
Process & Chemical Industry
2010Deepwater Horizon Blowout
Test results indicating well control problems were interpreted as equipment anomalies rather than well integrity signals.
Process & Chemical Industry
2005Texas City Refinery Explosion
Startup procedures and instrumentation configuration allowed overfilling of distillation column without adequate alarm response.
When multiple safeguards are required to prevent a high-consequence outcome, have you verified they remain independent under all credible scenarios?