Thermal Runaway Incident Database Summary Report (2018–2023)

Thermal runaway—a self-amplifying exothermic reaction where heat generation exceeds removal capacity—remains a leading cause of catastrophic chemical incidents. The 2018–2023 Summary Report synthesizes over 120 verified incidents from global sources including CSB investigations, HSE reports, industry incident sharing consortia (e.g., CCPS, SACHE), and peer-reviewed case studies. Each entry includes standardized metadata: reaction type (e.g., nitration, polymerization), thermal stability data (e.g., onset temperature, adiabatic temperature rise), failure modes (e.g., cooling system loss, incorrect dosing sequence), and human/organizational factors (e.g., inadequate SOPs, alarm fatigue). A core analytical methodology involves causal tree mapping using the Swiss Cheese Model and Layer of Protection Analysis (LOPA) to quantify barrier effectiveness. The report emphasizes latent system vulnerabilities—not just technical failures—and highlights recurring themes such as misapplied laboratory-scale kinetics to plant-scale operations, underestimation of secondary decomposition reactions, and insufficient emergency pressure relief sizing. Its structured format enables statistical trend analysis (e.g., 68% of incidents involved manual addition errors or control system override), supporting targeted training, procedure revision, and inherently safer design initiatives.