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Industry
News
Three Mile Island essentially ended the expansion of
nuclear power in the United States. While we are against the
expansion of nuclear power in any form because of the waste problem,
this article describes what went wrong and how it
could not have happened today.......
Have you seen the commercial where they say there is no
such thing as "clean coal"? While we disagree with the commercial
(because we know how effective scrubbers can be) , here is further progress
towards the goal in the form of a 90% reduction in
mercury.......
The
top ten
changes in NFPA 13 2010 are outlined in Fire
Protection Engineering's Emerging Trends
e-newsletter.....
The
economy puts a stake in the heart of another trade show, this time
the International Society of Automation Expo.......read
more about how these events are
struggling....
Sam
did a good job with
this article on passive smoke control in hospitals, but he
forgot about special inspection
requirements........
So
have you realized yet that the reason the Chinese lent us all that
money was because they wanted to kiss and make up for their drywall?
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Chemical Safety Board
News
Chemical Safety Board and
CITGO:
CSB Deploys to Fire at CITGO Refinery in Corpus
Christi, Texas
Washington DC,
July 20, 2009 – A four-member investigative team from the U.S.
Chemical Safety Board (CSB) is en route to the site of a fire that
began Sunday morning in the hydrogen fluoride (HF) alkylation unit
at the CITGO refinery in Corpus Christi, Texas.
One worker was
airlifted to a burn center in San Antonio as a result of the
accident at the 163,000 barrel per day refinery. The
alkylation unit was reported to be shut down.
The CSB
investigation team will be headed by Investigation Supervisor Robert
Hall, PE.
CSB Issues Urgent
Recommendations to CITGO; Finds Inadequate Hydrogen
Fluoride Water Mitigation System during Corpus Christi Refinery Fire
Last July
Houston,
Texas, December 9, 2009 – The U.S. Chemical Safety
Board (CSB) today issued urgent safety
recommendations calling on CITGO to immediately improve its
emergency water mitigation system in the event of another release of
potentially deadly hydrogen fluoride (HF) vapor, as occurred
following an explosion and fire July 19, 2009, at CITGO’s
Corpus Christi refinery. The Board also called on CITGO to
perform third-party audits to ensure the safety of its hydrogen
fluoride units at its Corpus Christi, Texas, and Lemont, Illinois,
refineries.
The CSB issues urgent
recommendations before completion of
final investigation reports in cases where CSB Board Members
determine an imminent hazard may be present and has the potential to
cause serious harm unless rectified in a short timeframe.
On the day of the
accident last July, hydrocarbons and hydrogen fluoride were suddenly
released from the refinery’s HF alkylation unit. The hydrocarbons
ignited, leading to a fire that burned for several days. The
fire critically injured one employee and another was treated for
possible hydrogen fluoride exposure.
CSB investigators
determined that a blockage of liquid caused by the sudden failure of
a control valve led to violent shaking within the process recycle
piping. The shaking broke threaded pipe connections resulting in the
release of hydrocarbons. The cloud of hydrocarbons reached an
adjacent unit and ignited. The ensuing fire caused multiple
additional fires and the release of approximately 42,000 pounds of
hydrogen fluoride from equipment and piping within the
unit.
The refinery used a
water spray system to absorb the released HF, but the CSB cited
scientific literature to conclude that at least 4,000 pounds of HF
likely escaped from the unit into the atmosphere and left the
facility. Investigators determined that during the first day of
response efforts CITGO nearly exhausted the stored water supply for
the water mitigation system. Approximately eleven-and-a-half
hours after the initial release, before the water supply was
completely exhausted, the refinery began pumping salt water from the
ship channel into the refinery fire water supply. Multiple failures
occurred during the salt water transfer including ruptures of the
barge-to-shore transfer hoses and water pump engine
failures.
CSB Chairman John
Bresland said, “It is imperative that refineries have the proper
emergency response resources available to control a release of
hazardous materials and protect against impact on the surrounding
community.”
The CSB’s urgent
recommendations call on CITGO to develop and initiate plans within
thirty days to ensure an adequate water supply to the refinery’s HF
mitigation system. The company should also report planned or
completed actions to the Refinery Terminal Fire Company and the
Local Emergency Planning Committee every thirty days until all
planned activities are fully implemented.
Investigations
Supervisor Robert Hall, P.E., said, “Our investigation closely
examined emergency response actions related to this
accident. Investigators found that the CITGO water mitigation
system serves as the last line of defense to protect the community
from an HF release. The CSB’s urgent recommendation aims to
improve the reliability of CITGO’s Corpus Christi, Texas, HF water
mitigation system.”
A second urgent
recommendation called on CITGO to commission independent,
third-party audits of the safety of its two HF alkylation units at
refineries in Corpus Christi and Lemont, Illinois. The audits
should compare safety practices at the alkylation units to those
recommended by the American Petroleum Institute
(API). Investigators said that CITGO had never conducted such
an audit of the units, despite an existing industry recommendation
for audits every three years.
The CSB also
released video of the initial pipe failure, release, ignition, and
fire as captured by two refinery surveillance cameras. Chairman
Bresland noted, “The camera footage shows the release and spread of
the flammable vapor cloud and the moment when the flammable vapor
was ignited. It shows just how severe the release and fire were
during this incident.”
Chairman
Bresland said, however, that the company had raised objections to the CSB’s
release of the video, saying that doing so would “raise substantial
issues of national security” and would “only sensationalize this
unfortunate accident.” The CSB subsequently received affirmation from the
Department of Homeland Security that the
video did not fall under certain classifications requiring
protection from disclosure.
Chairman Bresland
said, “We found this claim disturbing and believe that it is
contrary to the intent of a recent law passed by Congress, following
similar secrecy claims by Bayer CropScience in Institute, West
Virginia. This law, the American Communities’ Right to Public
Information Act, states that national security classifications may
not be used to conceal corporate errors, prevent embarrassment, or
improperly delay the release of information to the public. An
important part of this CSB investigation is to ensure all relevant
information and visual materials regarding this accident are made
available to the residents of Corpus
Christi.”
CSB Investigative Team to Examine Hydrogen
Fluoride Release from ExxonMobil Refinery in
Illinois
Washington DC, August 7, 2009 - A four-member
investigative team from the U.S. Chemical Safety Board (CSB) is
deploying to the site of a release of propane and hydrogen fluoride
at the ExxonMobil refinery in Joliet, Illinois.
At approximately
12:30 p.m. on Thursday, there was a sudden release of propane and
hydrogen fluoride (HF) from the vicinity of a pump in the refinery's
alkylation unit, which uses HF as a catalyst. The leak did not
ignite, but one operator was transported to the hospital suffering
from what were described as serious, HF-related chemical burns; he
was initially reported in critical condition. A second operator
was examined at the hospital and released. The unit?s water
deluge system, which is designed to contain airborne HF releases,
was activated and the alkylation unit was shut down. Refinery
personnel were instructed to shelter in place.
Chairman John
Bresland stated: "We are concerned about the three apparent releases
of hydrogen fluoride from refinery alkylation units in Pennsylvania,
Texas, and now Illinois that have been reported since March
2009. Because of its high toxicity, any loss of primary
containment for hydrogen fluoride is a serious matter." Recent
reported releases include those at the CITGO refinery in Corpus
Christi, Texas, on July 19, 2009, and at the Sunoco refinery in
Philadelphia, Pennsylvania, on March 11, 2009. The CSB has an
investigative team currently at the CITGO Corpus Christi refinery
examining that incident.
The CSB
investigative team will be headed by Investigation Supervisor Robert
Hall, PE.
CSB Receives Award for
Safety Video on West
Virginia Propane Explosion that Killed Four;
Production Called
“Extremely Effective”
Washington, DC, August 14, 2009 – The U.S. Chemical
Safety Board (CSB) received a key communication award from a major online learning and teaching
organization for a CSB Safety Video on the West
Virginia propane explosion that killed four people
when a convenience store blew up in January 2007.
The award, presented Thursday, August 13, 2009 by the
Multimedia Educational Resource for Learning and Online Teaching, or
MERLOT, was the organization’s first-ever Fire Safety Editorial
Board Classics Award. It was issued in the
category of “Exemplary Materials” in teaching and
learning
CSB Director of Public Affairs Dr. Daniel
Horowitz
accepted the award at a ceremony Thursday night at a MERLOT
conference in San Jose, California. Dr. Horowitz stated, “We are pleased to
have this recognition of the CSB Safety Video program.
Our videos have been played millions of times online and we
have distributed almost 100,000 free DVDs to chemical safety
stakeholders, including members of the public.”
Dr. Horowitz was selected to give a presentation on the CSB
Safety Video program to MERLOT conference attendees on Saturday,
August 15.
The video, “Half an Hour to
Tragedy,” derives its name from the approximately 30 minutes that
passed while a convenience store in Ghent, West Virginia, filled
with propane from a leak that occurred in a tank placed too close to
the store. The video features a computer
animation depicting the sequence of events in which propane
technicians and emergency responders failed to evacuate the store
and perished when the propane inside ignited.
MERLOT’s online website (www.merlot.org) features over 20,000
teaching and learning materials from a wide spectrum of
disciplines. A peer review board in one area,
fire safety, evaluated the CSB video, recommending it for
“Motivation and training for first responders and those working in
the HazMat response professions, including initial and recurrent
training.”
The peer review,
available through the MERLOT website, states, “Extremely effective.
This should get the point across to everyone about how to handle
HazMat emergencies; in particular, propane.”
MERLOT’s website notes the organization’s strategic goal is to “improve the effectiveness of
teaching and learning by increasing the quantity and quality of peer
reviewed online learning materials that can be easily incorporated
into faculty designed courses.”
CSB Chairman John
Bresland said, “We are honored by this award. Our
safety videos visually reinforce the information gathered in our
official CSB investigations of chemical accidents, such as the
tragedy that struck the convenience store in Ghent. We thank MERLOT for the recognition and
are pleased particularly that the Fire Safety Editorial Board found
so much to recommend in our video.”
Chairman Bresland noted that many CSB videos are in wide use
in emergency responder training, particularly a video released
earlier in the year, entitled “Emergency Preparedness: Findings from
CSB Accident Investigations.” The video uses computer animations,
interviews, and news footage to depict a series of chemical
accidents that illustrate the need for effective training,
communications, and community planning. In some
incidents, firefighters and police were overcome by toxic chemicals
and forced to retreat from neighborhoods; in others, firefighters
and workers were tragically killed and others injured.
CSB videos are available online at www.CSB.gov, and on YouTube. They can be ordered
free of charge as a two-DVD set by filling out the request form in
the Video Room of www.CSB.gov.
CSB Finds T2 Laboratories
Explosion Caused by Failure of Cooling System Resulting in Runaway
Chemical Reaction
Report Notes Company Did Not Recognize Hazards of
Chemical Process
Jacksonville, Florida, September 15, 2009 – The massive
December 2007 explosion and fire at T2 Laboratories in Jacksonville
was caused by a runaway chemical reaction that likely resulted from
an inadequate reactor cooling system, investigators from the U.S.
Chemical Safety Board (CSB) said in a final draft report released
today. The Board is to vote on the report findings and
recommendations at a public meeting in Jacksonville this
evening.
Concluding that T2 did not recognize all of the potential
hazards of the process for making a gasoline additive, the report
calls for improving the education of chemical engineering students
on reactive chemical hazards. The explosion and fire on
December 19, 2007, killed four T2 employees and injured four
others. In addition, 28 people working at nearby businesses
were injured when building walls and windows blew in. The blast
sent debris up to a mile away and damaged buildings within a
quarter-mile of the facility.
“This is one of the largest reactive chemical accidents
the CSB has investigated,” said Chairman John Bresland. “We hope our
findings once again call attention to the need for companies to be
aware of how to control reactive chemical hazards.” In 2002 the
CSB completed a study of reactive chemical hazards, which identified
167 accidents over a two-decade period and made recommendations to
improve reactive chemical safety.
The draft report on the T2 Laboratories explosion calls
on the American Institute of Chemical Engineers (AIChE) and the
Accreditation Board for Engineering and Technology (ABET) to work
together to include reactive chemical education in baccalaureate
chemical engineering curricula across the country.
The CSB found that although the two owners of the company
had undergraduate degrees in chemistry and chemical engineering,
they were nonetheless likely unaware of the potential or the
consequences of a runaway chemical reaction. The CSB noted that
most baccalaureate chemical engineering curricula in the U.S. do not
specifically address reactive hazard recognition or
management.
Chairman Bresland said, “It’s important that chemical
engineers recognize and are aware of the proper management of
reactive hazards.”
Investigation Supervisor Robert Hall, PE, said, “Our
recommendations aim to address the gap in the chemical engineering
curriculum. If future chemical engineers are given the proper
educational tools, they will be able to more fully comprehend the
hazards that exist during a chemical manufacturing
process.”
The draft report and safety recommendations will be
considered for approval by the Board at a public meeting tonight in
Jacksonville. The meeting will begin at 6:00 p.m. at the
Marriott Hotel located at 4670 Salisbury Road. All findings,
causes, and recommendations remain preliminary pending approval by
the Board. The Board will ask for public comments on the
investigation at the public meeting.
The CSB also today released a 3-D computer animation
depicting the events that led to the accident. Following
approval of the report, the CSB plans to release a new nine-minute
safety video, “Runaway: Explosion at T2 Laboratories,” containing
the 3-D computer animation and a description of the causes,
consequences, lessons, and recommendations resulting from the
accident.
The accident occurred during T2’s production of MCMT, a
gasoline additive, which the company manufactured in batches using a
2500-gallon reactor. On the day of the accident T2 was
producing its 175th batch of the chemical when operators
reported a cooling problem.
Mr. Hall said, “Despite a number of near-misses during
earlier production efforts, T2 failed to recognize the underlying
runaway reaction hazard associated with its manufacturing
process.”
Chemical testing by the CSB found that the recipe used by
T2 created two exothermic, or heat-producing, reactions; the first
was an intended part of producing MCMT but the second, undesired
reaction occurred if the temperature went above 390ºF, slightly
higher than the normal production temperature. The cooling
system likely malfunctioned due to a blockage in the water supply
piping or a valve failure. The temperature and pressure inside
the reactor began to rise uncontrollably in a runaway chemical
reaction. At 1:33 pm, approximately ten minutes after the
initial cooling problem was reported, the reactor burst and its
contents exploded.
Statement from CSB Chairman John Bresland on Bayer
CropScience
Announcement Concerning Methyl
Isocyanate
Washington, DC, August 26, 2009 - The CSB is continuing
to investigate the serious explosion that occurred one year ago at
the Bayer CropScience (Bayer) pesticide manufacturing site in
Institute, West Virginia. We have completed the collection of
most of the evidence on the causes of the explosion
itself. Consistent with a May 2009 request from
Congress, our investigation is currently examining options for Bayer
to reduce or eliminate the use and storage of highly toxic methyl
isocyanate (MIC) at the Institute site.
Yesterday, several Bayer officials briefed me and other
CSB personnel on a plan which they said would reduce the average
inventory of MIC at the Institute site by 80%. This would be
accomplished in part by eliminating the on-site production of two
MIC-derived carbamate pesticides, and in part by restricting the
inventory of MIC needed for producing two remaining
pesticides. They also stated the company would end the bulk
storage of MIC in aboveground tanks, including the 40,000-pound
capacity MIC “day tank” that was located approximately 80 feet away
from the point of origin of the August 28 explosion. That
tank, as I noted in Congressional testimony in April, was exposed to
potential projectiles and other hazards from the explosion.
Bayer indicated that all the changes should be completed
within about 12 months.
Any measures by Bayer to reduce the inventory of MIC at
the facility are a positive development, provided that the safety
and environmental risk is truly mitigated. If implemented in a
careful and conscientious manner, the steps Bayer has outlined will
lessen the risk to the public and the workforce from an uncontrolled
release of MIC. Bayer stated that the current round of changes
would be implemented at a cost of $25 million and without any loss
of jobs at the Institute plant.
The CSB team will continue to examine the feasibility of
switching to alternative chemicals or processes, as requested by
Congress. Our final report should be ready for consideration
in the first half of 2010, at which time I anticipate we will hold
another public meeting in West Virginia. In the meantime, I
urge Bayer to continue to pursue measures to improve the safety of
the site. These include ensuring that operating procedures are
up-to-date and are followed, that air monitoring systems are
adequate and are functional, and that there is adequate staffing and
training for all hazardous processes.
CSB Releases New Safety
Video,
“Runaway: Explosion at
T2 Laboratories”
Depicting Reactive Chemical
Accident
that Killed Four and Injured 32
Washington, DC,
September 22, 2009 – The U.S. Chemical Safety Board (CSB) today
released a new nine-minute computer animated safety video depicting
a tragic reactive chemical accident that devastated T2 Laboratories
in Jacksonville, Florida.
Entitled “Runaway:
Explosion at T2 Laboratories,” the video details the December 19,
2007, accident involving a thermal runaway chemical reaction at a
small chemical manufacturer. The video includes a
3-D computer animation of the sequence of events leading to the
runaway reaction and resulting explosion and fire.
The video is
available for viewing and downloading on the CSB’s website as well as the
agency’s YouTube channel.
Free DVDs can be requested by completing the
online request form in the Video Room
of CSB.gov.
T2 Laboratories
was attempting to produce a batch of the gasoline additive MCMT when
the reactor cooling system apparently malfunctioned – perhaps due to
a blockage in the water supply piping or a valve failure. As the
video shows, the temperature of the material in the reactor rose
uncontrollably. The rupture disk burst on the reactor, but it was
too late to relieve the pressure and the entire vessel blew apart,
killing four workers including one of the company’s two
owners. Four other T2 employees and 28 workers at
nearby businesses were also injured.
The CSB’s final report on
the accident was approved at a public meeting in Jacksonville on September 15; the Board recommended
increased education of undergraduate chemical engineers on reactive
chemistry hazards. CSB Safety Videos were
recently recognized by the Multimedia Educational Resource for
Learning and Online Teaching (MERLOT) organization, which presented
its first-ever Fire Safety
Editorial Board Classics Award to the CSB.
CSB Releases
Safety Bulletin on the Dangers of Purging
Gas Piping
into Buildings, Urges Outdoor Venting of
Gases
Washington, DC,
October 2, 2009 – In a new safety
bulletin based on preliminary findings
from the ConAgra Foods natural
gas explosion in Garner, North Carolina,
the U.S. Chemical Safety Board (CSB) urged companies, gas
installers, and contractors to follow safe practices during gas
purging operations, including venting purged gases outdoors whenever
practicable.
The explosion,
which occurred at the Slim Jim meat processing plant on June 9,
2009, killed three workers when a large section of the building
collapsed. The blast critically burned four others and sent a
total of seventy-one people to the hospital. About 18,000
pounds ammonia were released from the plant’s refrigeration system
as a result of the explosion and subsequent emergency response
activities. ConAgra has announced that approximately 300
employees will be laid off due to the accident.
The explosion
occurred during the installation of a new natural gas-fired
industrial water heater located in an interior utility room of the
plant. An employee of Energy Systems Analysts, a North Carolina
firm under contract to ConAgra, was purging a new three-inch gas
line in preparation for commissioning the heater. Purged gases
were vented directly into the utility room. Although a number
of individuals noticed the smell of gas, purging was continued
intermittently over several hours, eventually leading to the
accumulation of natural gas above the lower explosive limit
(LEL). Combustible gas detectors were not used during the
purging operation to monitor the concentration of gas within the
utility room. Over 200 employees were inside the building at
the time of the purging.
The CSB safety
bulletin emphasizes five key lessons to
prevent fires and explosions during fuel gas purging
operations. The CSB urged that companies ensure that their
personnel and contractors vent purged gases directly to a safe
location outdoors, away from people and ignition sources, whenever
practicable. Purging indoors should be restricted to situations
where outdoor purging is not practicable and should require strict
safeguards, including the evacuation of non-essential personnel, the
elimination of ignition sources, proper ventilation, and the use of
gas detectors to always maintain the gas level well below the
LEL.
The bulletin
identifies several other serious gas explosions that occurred during
purging operations, including a 2008 blast at a Hilton Hotel in San
Diego that injured 14 and an explosion at a Cary, North Carolina,
fitness center a decade ago. All were linked to venting gas
indoors without proper monitoring or safeguards. The bulletin
warns against relying on odor alone to detect the release of fuel
gases, noting that an individual’s ability to detect odor is highly
variable and subject to “odor fatigue” during prolonged
exposures. New gas pipes also have a tendency to absorb the
odorant from natural gas and propane, an effect termed “odor
fade.”
The North Carolina
Building Code Council, which oversees the state’s fuel gas code,
enacted emergency changes to the code last month in response to
preliminary findings from the ConAgra investigation. The
council adopted new safety measures including a requirement that
workers purging fuel gas lines vent the gases outdoors.
“I strongly
commend North Carolina for taking immediate action to protect
workers following this tragic explosion,” said CSB Chairman John
Bresland. “I urge code officials around the country to review
the new safety bulletin as well as heed the positive steps taken by
North Carolina.”
The CSB
investigation of the ConAgra explosion is continuing, with a final
report expected next year. The collapsed section of the
building remains too dangerous for investigators to
enter. Following the explosion, ConAgra developed a new
procedure for gas purging that requires venting outdoors, personnel
evacuation, and extensive gas monitoring.
CSB
Releases New Safety Video,
“Inferno: Dust Explosion at Imperial
Sugar”
Washington,
DC, October 7, 2009 – The U.S. Chemical Safety Board (CSB) today
released a new nine-minute safety video on the
combustible dust explosion at the Imperial Sugar refinery in Port
Wentworth, Georgia, which claimed the lives of 14 workers, injured
36, and caused extensive property damage on February 7,
2008.
Entitled
“Inferno: Dust Explosion at Imperial
Sugar,” the video
includes a new four-minute 3-D computer animation depicting the
first explosion – known as a “primary event” – that likely occurred
inside a recently enclosed sugar conveyor, which was followed by
massive secondary dust explosions that destroyed the plant’s sugar
packing buildings.
As CSB
Chairman John Bresland noted in the video, “The accident at Imperial
Sugar was the deadliest industrial dust explosion in the United
States in decades. It illustrates the extremely serious nature
of combustible dust hazards.”
The CSB’s
final report on the
accident was approved at a public meeting in Savannah on September
24, 2009. At the meeting the CSB recommended that OSHA move
forward expeditiously with a new combustible dust standard, as the
CSB first recommended in 2006, and urged Imperial Sugar and several
trade associations to take other actions to reduce the
hazard.
CSB
investigators determined that the explosion resulted from ongoing
releases of sugar from inadequately designed and maintained dust
collection equipment, conveyors, and sugar handling equipment.
Inadequate housekeeping practices allowed highly combustible sugar
dust and granulated sugar to build up throughout the refinery’s
packing buildings.
CSB Issues Final Report on Oleum
Release from INDSPEC Chemical Corp. that Forced Thousands to
Evacuate in October 2008; Report Cites Use of Pump Power Supply that
Lacked Safeguards
Washington, DC, October 5, 2009
– The Chemical Safety Board (CSB) released a
final report today on the uncontrolled
oleum release from INDSPEC Chemical Corporation in Petrolia,
Pennsylvania, which forced the evacuation of three
surrounding towns in October 2008. In the report the CSB
encouraged companies that handle hazardous chemicals to follow
proper management-of-change procedures, monitor deviations from
written operating procedures, and implement appropriate
safeguards to mitigate human errors.
The accident
that took place on Saturday, October 11, 2008, forced over two
thousand residents of Petrolia, Bruin, and Fairview, to evacuate or
to shelter-in-place for approximately eight hours. Oleum, also
known as fuming sulfuric acid, was released when a tank transfer
operation was left unattended during weekend operations and an oleum
storage tank overflowed. The oleum formed a toxic sulfur
trioxide gas, which mixed with moisture in the air to form a dense,
corrosive, sulfuric acid cloud that threatened the neighboring
towns.
CSB Chairman
John Bresland said, “The managers of companies that handle highly
hazardous substances, such as oleum, need to exercise special care
that appropriate process safeguards are in place. In this
accident, the CSB found that for many years, operators had been
using an auxiliary pump power supply that lacked safety interlocks
to prevent tank overfilling.”
Owned by the
Occidental Petroleum Corporation and located approximately 50 miles
northeast of Pittsburgh, the INDSPEC facility produces resorcinol, a
chemical used for making tires and other products. The CSB
report noted that three operators were involved in bulk liquid
loading and unloading work from Monday to Friday. However, to
maintain operations on a continuous, seven-day-per-week schedule, an
operator would regularly perform work on weekends, transferring
oleum from pressure vessels to storage tanks used to supply the
resorcinol manufacturing process.
The CSB
investigation determined that the normal power supply for the three
oleum transfer pumps was equipped with a safety interlock, which
would automatically shut off the flow of oleum when the receiving
tank was full, preventing a dangerous overflow. However, the
oleum storage building also had an auxiliary or “emergency” power
supply that had been installed in the late 1970s. It was originally
intended as a temporary way to keep the pumps functioning during
interruptions of the normal power supply but eventually the
emergency power supply became a permanent fixture. Facility
management never installed interlocks for the emergency power and
written operating procedures did not address how or when the
emergency power supply should be used.
The CSB found
that to save time on weekends, operators typically ran two oleum
transfer pumps simultaneously, using both the normal (interlocked)
and emergency (non-interlocked) power supplies. Current
managers and engineers stated they were unfamiliar with the
practice. The practice had not been considered or described in
process hazard analyses or operating procedures for the transfer
operations.
On the day of
the accident, an operator began transferring oleum at about 11:45
a.m. using two pumps and both power supplies. Although he shut
down one of the pumps, he evidently did not shut down the other
pump, which was connected to the non-interlocked emergency power
supply, before departing the facility at 2:15 p.m. One of the
storage tanks began overfilling with oleum; about an hour later acid
mist began escaping from a vent, and by 4:30 p.m. the mist was
flowing from the building. Facility personnel were unable to
control the release, and both the facility and the surrounding towns
were evacuated.
“By installing the emergency power supply without the same safety
devices as the normal power supply, former facility managers traded
safety for efficiency,” said CSB Investigator Jeff Wanko, P.E.,
C.S.P., who led the investigation. “Facilities should evaluate
changes, even those considered to be temporary, to determine their
potential to cause an accident. That which is temporary can
easily become permanent.”
The CSB case study report identified four key safety lessons
for companies: thoroughly evaluating temporary process changes,
ensuring uniform safeguards for different modes of operation,
monitoring deviations from operating procedures, and ensuring hazard
analysis teams have complete information to perform their
tasks.
CSB to Examine Fire
at Tesoro Refinery in Salt Lake
City
Washington, DC, October 22, 2009 - A three-person
investigative team from the U.S. Chemical Safety Board (CSB) will be
examining a fire that occurred Wednesday evening at the Tesoro
refinery in Salt Lake City, Utah, following a power outage earlier
in the day.
According to
refinery officials, liquid hydrocarbons were released from a flare
stack during an effort to restart the refinery's crude
unit. The hydrocarbons were ignited in a pool fire that
extended from the base of the stack and damaged a trailer and other
equipment that were positioned nearby.
CSB Investigator
Cheryl MacKenzie will lead the three-person team from the CSB's
Western Regional Office in Denver, Colorado. The team is
expected to arrive at the site today.
CSB Chairman
Bresland said the CSB inquiry would seek to determine if there are
any similarities to the 2005 accident at the BP Texas City refinery,
which occurred when flammable liquid erupted from a blowdown stack
during a unit startup, leading to a massive vapor cloud explosion
that killed 15 workers in nearby trailers and injured 180
others. The CSB recommended numerous changes to regulations,
enforcement, and industry safety practices following that
accident.
"Nearly four years
after the disaster in Texas City, there continues to be a disturbing
number of fires, explosions, and releases at the nation's
refineries. These events endanger workers and the public and
can disrupt the supply of needed transportation fuels," said
Chairman John Bresland. "A sudden release of flammable liquid
from a flare or blowdown stack poses a potential risk to people,
equipment, and the environment and warrants a close
look."
No injuries were
reported in the fire at Tesoro, but smoke and flames were visible
over a wide area in Salt Lake City, and an interstate highway and a
commuter rail line were closed temporarily. Refinery and
municipal firefighters extinguished the blaze within an
hour.
CSB Investigative
Team Deploying to Silver Eagle
Refinery Explosion and Fire
near Salt Lake City
Washington
DC, November 4, 2009 - A six-member team from the U.S. Chemical
Safety Board (CSB) is deploying to the scene of today’s explosion
and fire at the Silver Eagle Refinery in Woods Cross, Utah.
According to local officials, the explosion in the diesel
hydrotreater unit caused damage to homes in the surrounding area and
was felt several miles away from the facility.
The investigation team will be led by CSB Investigations
Supervisor Donald Holmstrom and will be arriving Wednesday evening
and Thursday morning.
The CSB is an independent federal agency charged with
investigating industrial chemical accidents. The agency's board
members are appointed by the president and confirmed by the Senate.
CSB investigations look into all aspects of chemical accidents,
including physical causes such as equipment failure as well as
inadequacies in regulations, industry standards, and safety
management systems.
For more information, contact (on scene) Sandy Gilmour
202-251-5496 (cell) or Director of Public Affairs Dr. Daniel
Horowitz, 202-261-7613, cell
202-441-6074.
Chairman Bresland's New YouTube Safety Message States
Concern for Continued Pressure Vessel Explosions; Urges States to
Adopt the ASME Pressure Vessel Code
Washington, DC, November 12, 2009 - CSB Chairman John
Bresland released a new video safety message
today asking jurisdictions across the country to adopt the ASME
Pressure Vessel Code to reduce the number of accidents involving
catastrophic pressure vessel failures in process
industries.
The safety message can be viewed on CSB.gov and on the
CSB’s safety message channel, www.youtube.com/safetymessages, and the text can be also read on
http://safetymessages.blogspot.com, an agency blog
site.
In the safety message, Chairman Bresland warned that
without appropriate safeguards, pressure vessels can pose lethal
dangers. Chairman Bresland said, “Pressure vessels store
tremendous amounts of energy and you should never become complacent
about the risks.”
Particular danger exists when vessels are improperly
installed, welded, or modified, or when they lack effective pressure
relief systems. Mr. Bresland refers to several incidents
investigated by the CSB including an explosion at a Louisiana
natural gas well that killed four workers when a tank rated only for
atmospheric pressure was exposed to gas pressure up to 800 pounds
per square inch.
In April 2003, an 8-foot tank used to heat sugar caramel
exploded when the vent line became blocked, killing an overnight
operator, releasing large amounts of ammonia, and forcing a
community evacuation. The vessel had no pressure-relief
system.
Additionally, in 2004 a pressure vessel weighing
50,000-pounds exploded at a chemical plant in Houston, Texas,
throwing heavy fragments into the community, which damaged a church
and businesses. The CSB found that the company improperly
modified and welded the vessel.
Chairman Bresland stated that these accidents can be
avoided if states implement long-established codes for safe
use. He said, “There are only eleven states that do not require
companies to follow the Pressure Vessel Code of the American Society
of Mechanical Engineers (ASME). I ask all jurisdictions to
adopt the Pressure Vessel Code and related boiler
standards. Lives will be saved as a
result.”
The ASME Code provides the fundamental safeguards for
pressure vessels, including design, welding procedures and
fabrication, testing, and pressure relief. In 2006, the CSB
called upon the City of Houston to adopt the Code to protect
residents and industrial facilities from these
incidents. However, Houston has failed to implement this
recommendation despite reoccurring pressure vessel failures such as
a summer of 2008 heat exchanger explosion in a resin-production
facility that killed a veteran
supervisor.
CSB Conducting
Full Investigation of Massive
Tank Fire at Caribbean
Petroleum Refining; Investigative Team Plans to Thoroughly Examine
Facility Safety Practices
Bayamon, PR, November 17,
2009 – The U.S. Chemical Safety Board (CSB) today announced that it
will be conducting a full investigation of the October 23, 2009
explosion and fire at Caribbean Petroleum Refining. CSB
investigators continue to examine the events and circumstances
surrounding the catastrophic tank explosion and
fire.
At 12:23 a.m. on October
23, a large vapor cloud ignited at the Caribbean Petroleum facility
near San Juan, Puerto Rico. The blast damaged homes and businesses
over a mile from the facility. Investigators from the U.S. Chemical
Safety Board arrived in Puerto Rico that evening. Over the past few
weeks the five-person investigation team has conducted numerous
interviews, requested hundreds of pages of documents and catalogued
key pieces of evidence.
CSB Board Member William
Wright said, “The CSB will conduct a thorough and comprehensive
investigation of this accident; our team will uncover exactly what
events led to an explosion of this magnitude. Our goal is to
determine not only what happened, but why it
happened.”
Caribbean Petroleum is a
significant petroleum products supplier for Puerto Rico. The
facility includes a tank farm and refinery that was shutdown in
2000. Prior to October 23 the tank farm stored gasoline, diesel
fuel, jet fuel, and fuel oil in approximately 30 operational
aboveground storage tanks.
At the time of the incident
a tank was being filled with gasoline from a ship docked in San Juan
harbor. Investigators have determined that a likely scenario leading
to the release was an accidental overfilling of the tank. Gasoline
spilled from the tank without detection; as the material spilled it
vaporized and spread across the facility. CSB investigators estimate
that the vapor cloud spread to a 2000 foot diameter until it reached
an ignition source in the northwest section of the
facility.
The CSB found that on the
evening of the incident, the liquid level in the tank could not be
determined because the facility’s computerized level monitoring
system was not fully operational. In order to monitor the level in
the tank, operators used a mechanical gauge on the tank’s exterior
wall. Therefore as the gasoline , employees located in the
facility’s control room were unaware of the
emergency.
“The filling of a tank without a functioning monitoring system is
the type of activity the CSB will be examining very closely,” said
Investigator-in-Charge Jeffrey Wanko, P.E. CSP. “The CSB’s
investigation will examine operations particular to Caribbean
Petroleum, but will also look at the regulations and best practices
surrounding the industry as a whole in an effort to improve safety
practices at similar facilities.”
*********************************************************************************************************************************************
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