(588de) Root Cause Analysis of a Hydrocarbon Leak Near Miss: An Operational Learning-Based Approach in the Petrochemical Industry

This report presents a comprehensive root cause analysis of a high-potential near-miss incident at Unit 100 of a petrochemical facility in Iran. Despite abnormal operating conditions, a major accident was averted through system safeguards and operator intervention. The event involved repeated activation and manual override of the High Integrity Pressure Protection System (HIPPS), culminating in a hydrocarbon leak from a corroded pipeline.

The investigation identified multiple contributing factors, including deficiencies in control system design, procedural misalignment, and gaps in personnel training. Using advanced methodologies such as STAMP, Bowtie analysis, and consequence modeling via PHAST, the report reveals systemic vulnerabilities and cultural shortcomings within the Process Safety Management (PSM) framework.

A total of 59 direct and root causes were identified, and 104 corrective actions were proposed—spanning urgent technical interventions, cultural reforms, and long-term competency development. The incident was classified as a Tier 2 near miss under API RP 754 and CCPS guidelines, with escalation modeling indicating a potential vapor cloud explosion (VCE) and a damage radius of 21 meters.

Importantly, the insights derived from this case extend beyond the specific unit and are applicable to similar facilities across the petrochemical industry. The findings highlight recurring patterns—such as override practices, weak safety culture, and inadequate hazard recognition—that pose latent risks in comparable operational contexts. As such, this report offers a transferable framework for risk evaluation and safety enhancement.

A cost-benefit analysis demonstrates that implementing the proposed corrective actions—estimated at ~$245,000—could prevent incidents with potential losses exceeding $2.4 million. The return on safety investment is compelling, underscoring the ethical, operational, and economic imperative for immediate action.