Xcel Energy Confined Space Accident-Chemical Safety Board releases report

Denver, Colorado, August 25, 2010—The tragic accident that took the lives of five industrial painting contractors deep inside an Xcel Energy hydroelectric plant tunnel in Georgetown, Colorado, was the result of several vital safety failures, the U.S. Chemical Safety Board (CSB) determined in a final investigation report issued today in Denver.
Nationally, the investigation identified 53 serious flammable atmosphere confined space accidents that occurred from 1993 to April 2010, causing 45 fatalities and 54 injuries, the majority since 2001.

(Note: Have a look at the training program below for Confined Space Entry Training)

The CSB also released a 15-minute safety video entitled “No Escape: Dangers of Confined Spaces,” which includes a detailed animation depicting the horrible tragedy that unfolded inside the mountain tunnel at Xcel’s Cabin Creek plant on October 2, 2007.

Here’s the video. Very graphic!

The accident occurred in the water tunnel, or penstock, of the hydroelectric plant, located 45 miles west of Denver. The penstock carries water from an upper reservoir to a lower one, driving power turbines. The painting contractors, from RPI Coating, Inc., were recoating a 1,530-foot steel portion of the 4,300-foot penstock when a flash fire suddenly erupted as the vapor from flammable solvent, used to clean the epoxy spraying wands, ignited, probably from a static spark in the vicinity of the spraying machine. The initial fire quickly grew, igniting additional buckets of the solvent, methyl ethyl ketone (MEK), and other combustible epoxy materials stored nearby.

The CSB concluded the causes of the accident included (1) a lack of planning and training for hazardous work by Xcel and its contractor, RPI Coating, Inc., (2) Xcel’s selection of RPI despite its h aving the lowest possible safety rating (zero) among competing contractors, and (3) allowing volatile flammable liquids to be introduced into a permit-required confined space without necessary special precautions.

The CSB report found that the permit-required confined space rule set by the U.S. Occupational Health and Safety Administration (OSHA) does not prohibit entry or work in confined spaces where the concentration of flammable vapor exceeds ten percent of the chemical’s lower explosive limit, or LEL. (The LEL is the concentration of vapor in air below which ignition will not occur.)

OSHA’s rule does state that an atmosphere exceeding ten percent of the LEL creates an atmosphere “immediately dangerous to life and health” and that steps should be taken to define safe entry conditions; however, the rule does not define what those safe entry conditions should be or specifically prohibit entry into such hazardous atmospheres, the report notes. The CSB recommended OSHA establish a fixed maximum percentage of the LEL for entry so that work in potentially flammable atmospheres would be prohibited.

(Note: For an excellent training program on how to select and use LEL gas monitors, for combustible gas detection, please see this)

Additionally, the Board made recommendations to the company, the governor of Colorado, the Colorado Public Utilities Commission, trade groups, and other organizations.

CSB Board Member William B. Wark said, “This tragedy should never have happened. The companies did not effectively plan for the dangers of bringing significant amounts of flammable liquids into the tunnel, which was a hazardous confined space. Doing so was an unacceptable deviation from good safety practices.”

There were ten workers in the tunnel and one at the entrance at the time of the fire. Five were unable to get around the fire on the painting platform to get to the only available exit – the improvised tunnel entrance. Five workers on the other side of the platform made it to safety, although three of those workers sustained injuries.

The CSB found that Xcel and RPI failed to have technically-qualified confined space rescue crews immediately standing by at the penstock in case of emergency, as required by regulations. Workers called 911 for help but responders entering the penstock had to retreat in the thick smoke, as did workers who had approached the fire with extinguishers.

The closest confined space technical rescue unit – equipped and trained to enter the smoke-filled tunnel – was approximately one hour and 15 minutes away. The trapped workers died about one hour before this response unit arrived, their escape blocked by a steep vertical section of the tunnel deep inside the mountain.

CSB Investigations Supervisor Don Holmstrom, who led the investigation, said, “The five trapped workers communicated with co-workers and emergency responders using handheld radios for approximately 45 minutes, desperately calling for help, before succumbing to smoke inhalation. Their lives likely could have been saved had qualified, company-provided rescuers been in a position to respond immediately to a fire or other emergency.”

Board Member Mark Griffon, joining Mr. Wark and Mr. Holmstrom at the news conference, said, “Even before the operation began, the stage was set for disaster. Xcel not only did not adequately plan for the operation, but it selected the painting contractor with the lowest possible safety rating among the bidders, and it did so mostly on the basis of cost – it was the lowest bid.”

The investigation found that Xcel hoped to compensate for RPI’s safety record by closely supervising the contract work, but did not do so even when the company learned of safety issues during the initial penstock work.

The CSB investigation found Xcel and RPI managers were aware of the plan to operate the epoxy sprayer in the tunnel and to use flammable solvent to clean the sprayer and other equipment.

Mr. Holmstrom said, “As a result of not performing a hazard evaluation of the work to be done, the companies failed to identify serious safety hazards involving use of flammable liquids within the confined space. Use of safer, nonflammable solvents was not evaluated, continuous air monitoring was not required, and key policies and permit forms did not establish a percentage limit for flammable vapor in the tunnel atmosphere.”

Board Member Wark noted the lack of planning for escape in an emergency. “The penstock had only one egress point – the tunnel entrance,” he said. “Xcel and RPI did actually identify this as a major concern in their planning. But despite this, no plans were made for prompt rescue in an emergency, and no rescuers qualified to enter this confined-space environment were standing by.”

The CSB investigation determined that while companies are required to perform a hazard analysis prior to issuing permits for work in confined spaces, regulatory standards pertaining to the use of flammables within confined spaces are inadequate.

Board Member Griffon stated, “Other OSHA regulations on confined and enclosed spaces – for example in the maritime industry and other sectors – prohibit work in such confined spaces above a specific percentage of the LEL, often ten percent. We are recommending that OSHA adopt such enforceable limits for all industry.”

The CSB recommended that OSHA amend its confined space rule to establish a maximum percentage substantially below the lower explosive limit for any given flammable for safe entry and occupancy while working.

The CSB made recommendations to nine other entities. These included that the governor implement an accredited firefighter certification program for technical rescue with specialty areas including confined space rescue; that the Colorado Public Utilities Commission (PUC) require regulated utilities to adopt provisions for selecting contractors based on safety performance measures and qualifications; and that the PUC require utilities to investigate all incidents resulting in death, serious injury or significant property damage and submit and make public written findings and recommendations within one year of the accident.

Numerous recommendations were made to RPI Coating, particularly aimed at revising its confined space entry program and guidance.

CSB investigators and board members cited difficulties encountered in the investigation resulting from efforts by Xcel Energy and RPI Coating to impede the investigation and prevent the release of the investigation report.

Citing a formal Letter of Admonishment sent to the Xcel chief executive officer earlier in the week, Board Member Wark said, “The lack of cooperation and efforts by Xcel to impede our investigation are unprecedented. Mr. Griffon and I join our chairman in criticizing these actions in the strongest terms.”

The letter, signed by CSB Chairperson Rafael Moure-Eraso, states Xcel Energy did not fully comply with CSB requests for documents or answers to questions in formal interrogatories. This required the CSB to seek assistance from the U.S. Attorney’s office in Denver, resulting in delays to the investigation and additional costs to taxpayers. In May, Xcel took the extraordinary and unprecedented step of going to federal court seeking to block release of the CSB report and the safety video. The court sided with the CSB in favor of release.

Xcel was given an advanced draft copy of the report last April for review for accuracy and for confidential business information in accordance with CSB review protocols. Xcel never responded, but in August 2010, contrary to the conditions of confidentiality attached to their receiving this preliminary copy, released it to a news organization.

The letter from Chairperson Moure to Xcel’s CEO concludes, “In light of this disappointing pattern of corporate conduct, I am writing you directly to ensure that you are personally aware of the actions taken by Xcel to delay the CSB investigation, block publication of the CSB final report, and distort the conclusions of the investigation by releasing an unauthorized draft copy of the CSB report. The CSB will issue a formal recommendation that Xcel shareholders be directly notified by management of the significant findings and recommendations of the CSB report, and of the actions Xcel management intends to take to implement needed safety improvements. In the wake of the corporate responsibility concerns raised by the Big Branch Mine accident in West Virginia and the disaster in the Gulf of Mexico, I strongly urge Xcel to renew its focus on safety and to swiftly implement the CSB’s recommendations.”

Hazardous Area Instrumentation e-learning course-get the latest version now from Abhisam Software

Miami, July 11- A new version of Abhisam Software’s popular e-learning course on Hazardous Area Instrumentation has been released, which covers all the changes that have taken place in the field of hazardous area instrumentation and control especially those related to IEC standards, ATEX regulations and implementing  Fieldbus in hazardous areas.

This updated training course covers all aspects of Hazardous Area Instruments and Controls, with changes to the IEC standards and ATEX directives fully reflected in the course contents. The original Hazardous Area Instrumentation training course was very well received by engineers and technicians in oil & gas, chemical processing, pulp & paper, power and other industries, as also by engineering consultants, contractors and even regulatory authorities. The updated version of this course is even better than the earlier version. Furthermore, the updated version will be available free of cost, to all customers of Abhisam Software who have purchased the earlier version within the past one year.
This new version of the Hazardous Area Instrumentation training course consists of the following six modules.
1. Basic Concepts
2. Classification (Area Classification, Material Classification and Temperature Classification)
3. Methods of protection (including explosionproof, intrinsic safety, increased safety, pressurization and other methods)
4. Using Fieldbus in hazardous areas (covers entity, FISCO, high power trunk, amongst other topics)
5. Certification and Labeling
6. Inspection and Maintenance

Though the module names are the same as the earlier version, the content has been revised to a great extent. The changes in the IEC standards and the ATEX directives have been included in the relevant modules, so that this course is now all that you need to have for becoming a pro as regards Instrumentation and Control systems in Hazardous Areas. These modules contain several topic pages containing Flash based animations, actual photographs of hazardous area instruments and equipment, rich graphics and easy to understand text, so that the subject becomes very easy to learn. Engineers and technicians who work in the process industries are sometimes intimidated and confused by the array of standards, systems and acronyms that are used by experts in hazardous areas. This course makes it all so very easy to understand that after completing it one can easily apply the various hazardous area concepts and standards to actual workplaces to enhance the safety of assets and people. The course is also available in an online LMS based system which would be ideal for corporations, universities and training institutes, who may wish to train large numbers of people in this subject. All training reports including learner login times, modules accessed, scores obtained on tests and other data can be made available in a spreadsheet for training records and tracking. Learners can also take an online test and qualify for a certificate at no additional charge. As a limited time bonus, Abhisam Software is also giving away a copy of their popular ebook “Practical Guide to Hazardous Area Classification” alongwith this updated course. For more information about the updated course please click here .

The  most interesting aspect is that Abhisam Software says that if somebody has purchased the earlier version of the course within the past one year, then they may be eligible for a FREE upgrade.

CSB finally agrees to investigate root causes of the BP Transocean Deepwater Horizon Oil Rig and oil spill disaster

22nd June, 2010 -Finally, acceding to requests from members of the public and their elected representatives, the US Chemical Safety Board, has agreed to investigate in depth (pun not intended), the circumstances that led to the explosion and sinking of  BP’s Transocean Deepwater Horizon and consequent oil spill that has become a national disaster, worse than Hurricane Katrina or the Exxon Valdez oil spill. The fact that the CSB is likely to investigate this accident was already reported on this blog, if you remember.

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For comprehensive and easy to understand training courses on Hazardous Area Instrumentation, Gas Detection and Safety Instrumented Systems (including SIL training) please click here.

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Here is the full text of the letter written by Chairman John Bresland of the CSB to Hon. Henry Waxman and  Hon. Bart Stupak , both of the  US House Committee on Energy and Commerce.

Dear Chairman Waxman and Chairman Stupak:
I write in response to your letter of June 8, 2010, requesting a CSB investigation of the causes of the BP/Transocean rig explosion that occurred on April 20, 2010. We recognize that this human and ecological disaster is one of the most significant chemical accidents of the current era. We also agree, as noted in your letter, that the CSB’s past work on BP’s safety culture and corporate safety oversight places us in a unique role to understand important aspects of this tragedy. In addition, as we stated to you in our letter of May 7 we are of the opinion that we have the legal authority to investigate this accident. All of us share your hope that every possible lesson will be learned from this accident so that nothing similar ever occurs again.
For all these reasons, the CSB intends to proceed with an investigation of the root causes of the accidental chemical release that destroyed the Deepwater Horizon rig and took the lives of 11 workers. The investigation will include the key investigators who were involved in the CSB’s 2005-2007 investigation of the March 23, 2005, explosion at the BP Texas City refinery. We intend to prioritize this work and to apply all of our available resources to ensure the best possible investigation.
Although we will be vigilant for any similarities to the Texas City explosion, as suggested in your letter, we believe it is also important that this investigation be approached without any preconceptions and that all possible underlying factors and causes are thoroughly
and objectively examined. Like other CSB investigations, the investigation should include an examination of key technical factors, the safety cultures involved, and the effectiveness of relevant laws, regulations, and industry standards. We further note that there are numerous other investigations of the April 20 accident that have either been announced or are underway, including those of your own committee, various federal regulatory agencies, and the presidential oil spill commission. To the extent possible, we will seek to coordinate and to avoid duplication of effort with those important activities, without compromising our statutory independence.
We would particularly welcome the Committee’s assistance in promoting cooperation with the other investigations that are currently underway, including help with obtaining relevant documents already collected from companies or other parties or otherwise in the possession of federal regulatory agencies. Additionally, we would appreciate the Committee’s help in ensuring the integrity and independence of the CSB investigation, as distinct from any criminal inquiries that may occur. Although we have the highest respect for those inquiries, it is important that law enforcement investigators collect information directly from the parties involved and not via the CSB investigative process, which requires an open exchange of information between key witnesses and our civilian safety investigators.
The CSB plans to focus on events prior to and including the explosion on April 20; we believe that an examination of the response to the disaster and the impact of the ongoing massive oil spill is beyond the CSB’s current resources and abilities.
To conduct this work, the Board will have to make some difficult choices and decisions. As you know, the CSB had a record-high caseload even before this disaster occurred. We already have a higher number of open investigations than we have actual investigators on staff. Accordingly, to investigate the rig disaster, we anticipate that certain extraordinary measures will be required, including:
Bringing certain ongoing investigations to a very rapid conclusion, including investigations of the major explosions at the Kleen Energy power plant (Middletown, CT) and the ConAgra Slim Jim facility (Garner, NC) Terminating certain smaller investigations and placing other investigations on hold pending a further definition of the scope for the BP/Transocean investigation Temporarily reassigning personnel within the agency to support the new investigation Subject to existing Congressional and OMB notification requirements, drawing upon the Board’s $847,000 emergency investigative fund to put in place appropriate contracts and experts as rapidly as possible Requesting supplemental funding, as needed, to ensure a thorough and complete investigation. We note that the total cost of the CSB’s prior investigation on BP Texas City was approximately $2.5 million. However, the new BP/Transocean investigation presents in many respects an even higher level of cost and complexity.
We thank you and the Committee for your recognition of the importance of our safety investigations and for your longstanding support of our mission.

Sincerely,
(Signed)
John S. Bresland
Chairman

Vermont Yankee Nuclear Power Plant leak-complete shutdown averted

For an excellent e-learning course on Emergency Shutdown Systems and Safety Instrumented Systems, please click here.

June 16, 2010- The Vermont Yankee Nuclear Power plant, operated by Entergy, reportedly had a near emergency shutdown recently when a cooling water valve started leaking heavily. The leak was of the order of 1.6 gallons of radioactive water per minute (far above the “legally allowable” limit of 1 gallon per minute). However regulatory officials and the plant management claimed that there was no immediate danger.

The maintenance team replaced the faulty valve within about five hours after the incident. If they had been unsuccessful, probably the plant would have had to do an emergency shutdown as per the rules. Local sources said that the 38 year old plant was prone to “many leaks” in the recent past, but these reports could not be independently verified. The latest incident underscores however that the public belief that nuclear energy is “far better” than fossil fuel based energy (after the BP Deepwater Horizon Oil Spill) is not correct. Nuclear power plants also have their risks, although the proper engineering and management of the safety systems can mitigate these risks to a large extent. This was also thought before the BP Oil Spill about offshore drilling….now of course we know how that went awry.

Obama says BP oil spill disaster is the worst that America has ever faced

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June 16, 2010- US President Barack Obama, in a nationally televised address today said that the current BP oil spill disaster is the worst that America has ever faced. He said that tomorrow, when he would be meeting BP’s Chairman, he would ask that BP set aside enough resources to compensate everybody who has been adversely affected by the oil spill, which maybe includes the lost income of shrimp farmers, fishermen as well as oil workers who are unable to earn due to the moratorium on drilling operations in the Gulf.

This environmental disaster is proving to be worse than the Exxon Valdez oil spill a decade back. In fact some experts say that this present BP oil spill is the equivalent of having an Exxon Valdez type disaster every four days!