Category

Incident Investigation

103 articles
incident-investigation

Philadelphia Refinery Fire: 5 Signals That Failed to Change the Work

The June 21, 2019 Philadelphia Energy Solutions refinery explosion was not only a failure of refinery equipment and process-safety governance. The U.S. Chemical Safety and Hazard Investigation Board investigation exposed how incomplete records, weak integrity decisions, and unclear accountability allowed a serious risk to remain present until the system failed catastrophically.

7 min
incident-investigation

Piper Alpha: How a Permit Handover Became a Catastrophic Control Failure

The Piper Alpha disaster is often remembered as an offshore fire, but the deeper case is about information that did not travel with the work. This narrative case study examines how permit handover, isolation status, emergency communication, and barrier ownership interacted before the 1988 catastrophe, then turns the lessons into a practical test for high-risk operations.

6 min