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.
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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.
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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.”
NFPA amends the Fuel Gas Code to prevent purging of pipelines using natural gas after Kleen explosion
Aug 11, 2010- The National Fire Protection Association (NFPA), through an emergency revision to the NFPA 2009 code, has prohibited the purging of gas pipelines by using natural gas. This is a direct fallout of the Kleen Energy accident investigation, after the US Chemical Safety Board concluded that the purging by natural gas led to the accident. The CSB had also appealed to standards and regulatory bodies like OSHA and NFPA to amend the codes that regulate natural gas piping and operations in view of these findings. We had reported all about it here.
The NFPA has now responded by issuing aTentative Interim Amendment to Section 54 of the Natural Gas Code. This can be downloaded from here.
(Note: The code specifically talks about installing a gas detector to detect the presence of natural gas-if you would like to know how to specify, select, install, calibrate and maintain these gas detectors, please click here)
The CSB was glad to hear about this and the agency has issued a statement reproduced below.
Here’s the CSB statement (in Italics)
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Emergency Change to National Fuel Gas Code Addresses Cause of Fatal June 2009 Blast at ConAgra Slim Jim Plant in North Carolina
On February 4, 2010, I presided at a Chemical Safety Board public meeting in Raleigh, North Carolina, to present the CSB’s findings on the June 9, 2009, natural gas explosion at the ConAgra Slim Jim manufacturing plant in the nearby community of Garner.
That tragic and preventable accident cost four lives, injured 67 others, and led to a decision to close the plant, with the loss of hundreds of jobs in the region. The accident occurred during an operation to purge (or clear air) from a new steel gas-supply pipe that was connected to a newly installed industrial water heater. The pipe was connected at the other end to the building’s natural gas distribution system. During the purging operation, gas was allowed to flow through the pipe and exit through an open valve inside the utility room where the water heater was located. Due to difficulties in lighting the water heater, the purging operation was continued for an unusually long time, eventually causing gas to accumulate above the lower explosive limit inside the building. The gas contacted an ignition source and exploded, causing extensive sections of the large facility to collapse.
The CSB noted that the accident at ConAgra was but one of a number of similar explosions caused by an intentional, planned work activity that inadvertently led to a large and unsafe release of natural gas into a workplace.
At the time of the accident, indoor purging of natural gas systems was not prohibited under the National Fuel Gas Code, a key consensus code of the National Fire Protection Association (NFPA) that has been adopted by many states and localities across the country. At the February 4 public meeting, the Board voted to make urgent recommendations to NFPA and the International Code Council to prohibit indoor purging and require companies and installers to purge flammable fuel gases to safe locations outdoors, away from workers and ignition sources.
I am pleased that the NFPA made our recommendation a high priority and took immediate steps to improve the National Fuel Gas Code. Last week, on August 5, the NFPA Standards Council gave final approval to an emergency code change, known as a Tentative Interim Amendment, that will prohibit indoor purging of industrial gas lines operating at greater than two pounds per square inch gauge (psig) or meeting certain pipe size criteria. According to the NFPA, the new requirements are designed to require outdoor purging for industrial, large commercial, and large multifamily buildings.
These new provisions would have required the gas pipe at ConAgra to be purged outdoors, away from personnel and ignition sources. Under the new requirements, purging must be monitored using appropriate detection equipment to prevent a significant release of flammable gas. The new requirements are similar to new safety procedures developed and implemented by both ConAgra and the State of North Carolina in the months following the tragedy.
Outdoor purging is inherently safer than venting gas into a building. Had the gas pipe at ConAgra been safely purged outdoors, the explosion and resulting deaths and injuries could have been avoided.
I encourage all companies to study the new code recommendations and to purge flammable gases outdoors whenever possible. I urge the NFPA to ensure that a prohibition on indoor purging and other safeguards are permanently incorporated into the National Fuel Gas Code, and I thank the NFPA leadership and members for their positive actions to promote worker safety.
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Was poor area classification to blame for explosion at Veolia ES Technical Solutions Hazardous Waste Facility?
July 21, 2010, Washington DC- The US Chemical Safety Board (CSB) has come out with its investigation report on the 2009 explosion and fire at the Veolia ES Technical Solutions L.L.C. facility in West Carrollton, Ohio. It calls on the waste management industry the industry to improve safety standards covering
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hazardous waste processing, handling, and storage facilities. The Board also recommended that fire protection codes be revised to require companies to determine safe distances between occupied buildings and potentially hazardous areas.
This is because in the accident, flammable and explosive vapors of a solvent Tetrahydrafuran (THF) leaked and traveled some distance away from the processing area to an area that apparently was not classified as a hazardous area. These flammable vapors found anignition source and exploded, devastating the facility and the neighborhood too.
Read the entire report here (given below).
The accident occurred on May 4, 2009, when flammable vapor was released from a waste recycling process, ignited, and violently exploded. The blast seriously injured two workers and damaged 20 nearby residences and five businesses. CSB investigators found that the north wall of the lab and operations building – where the victims were injured – was less than 30 feet from the waste recycling processing area where the flammable vapor was released.
CSB Chairman Rafael Moure-Eraso said, “This accident should not have happened. Our report notes that OSHA cited the company for inadequate attention to process safety management practices in the handling of flammable liquids. But in case of an accident, I believe it is absolutely critical that buildings at chemical facilities be sited safe distances from process equipment to maximize the safety of workers. We are making recommendations that would help ensure that operating areas with occupied buildings such as control rooms be sufficiently separated from process areas containing flammable liquids and gases that have the potential to explode.”
The Board issued a recommendation to the National Fire Protection Association (NFPA), which develops codes and standards for industry, urging NFPA to require companies to perform engineering analyses to determine safe separation distances between buildings occupied by administrative and other personnel not essential to process operations, and buildings housing the potentially hazardous process equipment.
The Board also revised a previous recommendation to the Environmental Technology Council, a hazardous waste industry trade group, to petition the NFPA to develop a standard specific to hazardous waste treatment, storage and disposal facilities. This would include guidance on reducing the likelihood of fires, explosions, and releases of hazardous waste.
Dr. Moure noted, “The Environmental Technology Council did not respond adequately to our 2007 recommendation, which we issued following an explosion and massive fire at the Environmental Quality hazardous waste facility in Apex, North Carolina, to work for more stringent standards in the hazardous waste industry. I strongly urge the industry to act now. These facilities, by their nature, contain wide varieties of flammable and toxic materials that can cause significant injury to workers and threaten the well being of nearby communities. Facility owners and operators need stricter technical requirements to improve the safety of life and property.”
The report notes that after a normal run of the tetrahydrafuran (THF) solvent recovery process at the Veolia facility, the unit operator began a routine shutdown. Completing the process required blowing nitrogen back through the circulation piping to clean it, prior to closing valves.
CSB lead investigator Johnnie Banks said, “At the time of the shutdown, witnesses reported hearing the sound of a sudden, loud vapor release and smelling a very strong odor of THF solvent which knocked several employees to their knees. It was a matter of just a couple of minutes until the highly flammable vapor ignited.”
The vapor drifted to the laboratory and operations building and found an ignition source inside the building. A worker in the control room reported being enveloped in a fireball that went through the building. The first explosion knocked over a bank of lockers, severely injuring an employee and pinning him underneath.
Because of the extensive fire damage, the CSB was unable to conclusively determine the exact initiating event for the vapor release, concluding one of two possible scenarios likely occurred. In the first scenario, air may have been drawn into a tank containing THF residue and peroxides, causing increased pressure in the tank and forcing flammable vapor from the tank to escape through a manway cover or a vacuum breaker.
In the second possible scenario, CSB investigators believe a line hose, intended to send pressurized nitrogen into a different tank, may have instead been connected to a tank containing unprocessed, flammable liquid. When the nitrogen was applied, it forced flammable vapor out through the tank vent. In either scenario, the vapor drifted to the operations building and ignited, causing the injuries.
In addition to issuing recommendations to NFPA and the hazardous waste industry, the Board also issued recommendations to Veolia, which is rebuilding the plant. The CSB called on the company to restrict occupancy in buildings in close proximity to the operating plant to personnel trained in the safe operation and orderly shutdown of the plant. The Board also called on the Center for Chemical Process Safety, a division of the American Institute of Chemical Engineers, to revise control room siting guidelines to address the characteristics of all Class 1B flammable liquids.
Yet Another Hot Work Accident in Colorado-CSB chief expresses regret
Washington, DC, July 9, 2010 — Dr. Rafael Moure-Eraso, chairperson and CEO of the U.S. Chemical Safety Board (CSB) said today he was saddened by news of the death of a Colorado welder yesterday while performing what is called “hot work” on a storage tank containing flammables at an environmental remediation company in Englewood, Colorado.
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Hot work is defined as welding, cutting, grinding, or other spark-producing activities that can ignite flammable substances. To date in 2010, the CSB has learned of 15 serious hot work-related fires and explosions that caused six reported fatalities and numerous injuries.
Dr. Moure said, “I am saddened by this accident and disturbed that such fatalities continue to occur. The CSB is vitally concerned about hot work accidents and this was expressed in our important safety bulletin and safety video, both issued within the past few months.”
According to information gathered by the CSB from the fire department and the company, a worker was standing on a ladder, welding on the side of a tank partially filled with a mixture of water and flammable hydrocarbons. Sparks ignited flammable vapor and the worker was thrown off the ladder, suffering fatal injuries.
The company stated that although it has a hot work permit system and had provided safety training to the victim, there was no monitoring for a flammable atmosphere before or during the welding. ( What a joke-how can anybody issue a permit when they haven’t measured the flammable gas concentration in the area-do they expect a piece of paper will actually prevent an accident?!). While current OSHA standards prohibit hot work in an explosive atmosphere, OSHA does not explicitly require the use of combustible gas detectors.
There have been more than 60 fatalities since 1990 due to explosions and fires from hot work activities on tanks. In seven of the 11 accidents discussed in the bulletin, no gas testing was performed prior to or during the hot work activities. In the remaining cases, monitoring was conducted improperly.
Dr. Moure said, “There is no secret to preventing these accidents. Companies should require effective monitoring of the atmosphere before and during all welding or other spark-producing activities near tanks that may contain flammable liquids or gases. Monitoring should be frequent or continuous and performed at multiple locations to assure that no flammable vapor is present which could be ignited. Monitoring the atmosphere and following the other six key lessons in our bulletin can help avoid these tragedies.”
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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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
