An explosion in a fired hydrogen heater within a large oil refinery was the result of an improper design and failure to conduct pre-startup safety reviews prior to a routine startup. Specific activities normally included in a good safety management system could have prevented this accident. The willingness to share this information is an indication of the organization＇s commitment to process safety excellence within the industry as a whole. Industrial accident databases help to promote such information sharing and ultimately lead to more effective solutions to common safety problems.