Bayer Cropscience Accident at Institute- CSB issues final report
Institute, West Virginia, January 20, 2011 – The U.S. Chemical Safety Board (CSB) today released its final report on the August 28, 2008, Bayer CropScience pesticide manufacturing unit explosion that killed two workers and injured eight others. In a report scheduled for Board consideration at a public meeting this evening in Institute, the CSB found multiple deficiencies during a lengthy startup process that resulted in a runaway chemical reaction inside a residue treater pressure vessel. The vessel ultimately over pressurized and exploded. The vessel careened into the methomyl pesticide manufacturing unit leaving a huge fireball in its wake.
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The report found that had the trajectory of the exploding vessel taken it in a different direction, pieces of it could have impinged upon and possibly caused a release from piping at the top of a tank of highly toxic methyl isocyanate (MIC).
(Editors Note: MIC is the same chemical that has killed thousands of people in the infamous Bhopal gas disaster. To think that it could have happened even 25 years later in the US is telling)
The accident occurred during the startup of the methomyl unit, following a lengthy period of maintenance. The CSB found the startup was begun prematurely, a result of pressures to resume production of the pesticides methomyl and Larvin, and took place before valve lineups, equipment checkouts, a pre-startup safety review, and computer calibration were complete. CSB investigators also found the company failed to perform a thorough Process Hazard Analysis, or PHA, as required by regulation.
This resulted in numerous critical omissions, including an overly complex Standard Operating Procedure (SOP) that was not reviewed and approved, incomplete operator training on a new computer control system, and inadequate control of process safeguards. A principal cause of the accident, the report states, was the intentional overriding of an interlock system that was designed to prevent adding methomyl process residue into the residue treater vessel before filling the vessel with clean solvent and heating it to the minimum safe operating temperature.
Furthermore, the investigation found that critical operating equipment and instruments were not installed before the restart, and were discovered to be missing after the startup began. Bayer’s Methomyl-Larvin unit MIC gas monitoring system was not in service as the startup ensued, yet Bayer emergency personnel presumed it was functioning and claimed no MIC was released during the incident.
Here is an animated video of the likely sequence of events that occured.
CSB Chairperson Dr. Rafael Moure-Eraso said, “The deaths of the workers as a result of this accident were all the more tragic because it could have been prevented had Bayer CropScience provided adequate training, and required a comprehensive pre-startup equipment checkout and strict conformance with appropriate startup procedures. This would have revealed multiple dangerous conditions and procedures that were occurring at a time when the company wanted to restart production of a key pesticide product. Startups are always a potentially hazardous operation, but to begin with computer control systems that have not been checked, while bypassing safety interlocks, is unacceptable.”
The investigation report makes recommendations to the company and its Institute plant, to the Occupational Safety and Health Administration (OSHA), the Environmental Protection Agency (EPA), and several West Virginia agencies. Citing a highly successful county program to ensure refinery and chemical plant safety in Contra Costa County, California, the CSB report recommends the West Virginia Department of Health and Human Resources establish a “Hazardous Chemical Release Prevention Program” that would have the authority to inspect and regulate such plants, and make public its ongoing findings.
Dr. Moure-Eraso said, “I believe a state and county-run program like this would go a long way to making chemical operations safer in places like the Kanawha Valley. OSHA and EPA, have limited resources and cannot be everywhere at once. However, local jurisdictions can put together highly effective and targeted inspection and enforcement programs, funded by levies on the plants themselves. The accident rate in Contra Costa County has dropped dramatically, and last year in fact they had no significant accidents, thanks, in my view, to this program.”
CSB Investigations Manager John Vorderbrueggen noted that a major contributing factor to the accident was a series of equipment malfunctions that continually distracted operators. “Human factors played a big part in this accident, and the absence of enforced, workable standard operating procedures and adequate safety systems meant that mistakes could prove fatal. For example, operators were troubleshooting several equipment problems and during the startup, inadvertently failed to prefill the residue treater vessel with solvent. A safety interlock was designed to stop workers from introducing highly-reactive methomyl, but it was bypassed as had been done in previous operations with managers’ knowledge. Once the chemical reaction of the highly concentrated methomyl started, it could not be stopped, and the temperature and pressure inside rose rapidly, finally causing an explosion.”
Board Member John Bresland, who was CSB chairman at the time of the Bayer accident, noted the confusion that resulted in the community’s emergency response following the explosion at 10:33 p.m. “The Bayer fire brigade was at the scene in minutes, but Bayer management withheld information from the county emergency response agencies that were desperate for information about what happened, what chemicals were possibly involved,” Mr. Bresland said. “The Bayer incident commander, inside the plant, recommended a shelter in place; but this was never communicated to 911 operators. After an hour of being refused critical information, local authorities ordered a shelter-in-place, as a precaution.”
“Proper communication between companies and emergency responders during an accident is critical,” said Mr. Bresland, adding, “The community deserved better, especially considering the amounts of hazardous chemicals, in use and being stored at various chemical facilities in the Kanawha River valley.
The CSB report notes that two workers and four volunteer firefighters required examination for possible exposure to toxic chemicals.
The investigation examined the potential consequences of a hypothetical trajectory of the careening residue treater vessel that would result in its hitting the heavy steel mesh ballistic shield surrounding the above-ground MIC tank. The analysis – using blast pressure and impact energy calculations – concluded that the shield would have protected the MIC tank from a residue treater vessel hit. However, the CSB found, had the residue treater struck the shield structure near the top of the frame, the displaced frame could have contacted an MIC pipe, which might have resulted in an MIC release into the atmosphere.
Chairperson Moure-Eraso said, “Any significant MIC release into the atmosphere along the Kanawha valley could have proven deadly, and that concern has been legitimately expressed for decades in the community. This potential was reduced when Bayer announced last year it would no longer store MIC above ground; it will be reduced to zero in approximately 18 months when the company has announced it will end MIC production and use at the Institute facility – the only place in the country still storing large quantities of MIC.”
Dr. Moure-Eraso continued, “Bayer’s decision to end pesticide production using MIC was, I understand, done for its own business reasons. But for whatever reasons, the eventual elimination of this chemical will enhance safety in the Kanawha Valley, for workers and residents alike, and is a positive development in my view.”
Offshore Oil and Gas Regulation-CSB to hold hearing
CSB to Hold Hearing in Washington DC to Hear Expert Testimony on Regulation of Offshore Oil and Gas Safety Practices
Washington, DC, November 23, 2010 – The U.S. Chemical Safety Board (CSB) today announced that it will be holding a daylong public hearing entitled “Regulatory Approaches to Offshore Oil and Gas Safety” on Wednesday, December 15, 2010, in Washington DC. The meeting is part of the CSB’s ongoing investigation into the April 20, 2010, fire and explosion on the Deepwater Horizon that killed 11 workers. The hearing will bring together international regulators, union representatives and industry groups to discuss approaches to regulating the safety of offshore oil and gas exploration and production.
The meeting will be held from 8:30 am – 4:30 pm at the Embassy Suites Ballroom located at 1250 22nd Street Northwest in Washington D.C. The meeting is free and open to the public.
The CSB’s board members and Deepwater Horizon investigation team will hear testimony from leading safety experts involved in offshore drilling activities from the United Kingdom, Australia and Norway. Members of the audience will have an opportunity to comment and to submit questions for the panel participants.
The meeting will be available via webcast. All proceedings will be videotaped and an official transcript will be published.
CSB Board Member Mark Griffon Calls on American Society of Mechanical Engineers to Adopt CSB Recommendation Prohibiting Natural Gas Blows at Power Plants
Phoenix, Arizona, September 21, 2010—U.S. Chemical Safety Board (CSB) Member Mark Griffon today called on the American Society of Mechanical Engineers (ASME) to adopt a CSB recommendation calling for natural gas blows to be prohibited during power plant construction.
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The recommendation was one of 18 urgent recommendations issued in June 2010 following a CSB investigation into a powerful natural gas explosion that killed six workers and injured dozens of others at the Kleen Energy plant in Middletown, Connecticut on February 7, 2010, which was under construction. Workers used hundreds of thousands of cubic feet of natural gas to clean debris from gas pipes used to fuel electricity-producing turbines. The gas accumulated in and around the buildings, was ignited by an unknown ignition source, and exploded.
Speaking to a meeting of ASME members in Phoenix who are considering changes to the ASME Code for Pressure Piping Systems, Mr. Griffon said, “The CSB believes that using natural gas or other flammable gases to clean fuel gas piping is inherently unsafe and should be prohibited.” He cited other accidents to show that explosions resulting from flammable gas blows have the potential of causing death, serious injuries, and costly property damage.
Mr. Griffon noted that the practice of using gas blows, or forcing large volumes of flammable gas through piping to clear out debris, was common in construction of electric generating facilities. The CSB investigation of Kleen Energy, resulting in 18 urgent recommendations, states “From a fire and explosion perspective, releasing large volumes of natural gas in the vicinity of workers or ignition sources is inherently unsafe.”
In remarks prepared for the ASME, which is considering the CSB recommendation to prohibit gas blows and use inherently safer methodologies to clean piping, Board Member Griffon said, “It has been argued that the gas blow at Kleen Energy was not conducted properly to ensure the dispersion of the released natural gas and to prevent the gas from encountering ignition sources. This point overlooks the simple fact that cleaning piping with flammable gases presents an inherent explosion hazard. Cleaning piping with flammable gases presents an explosion hazard that cannot be wholly eliminated.”
Even if every effort is made to eliminate ignition sources, such as welding, or electrical equipment not rated for a hazardous environment, he noted, the friction of the gas flowing through the piping can cause an accumulation of static electricity and cause ignition; in addition, sparks from impacts of metal debris striking surfaces when the gas exits the piping can also ignite the gas.
Mr. Griffon noted the CSB investigation found ample alternatives to gas blows which are safer. These methods include blowing air or nitrogen through piping, or by “pigging,” in which a cleaning device is propelled through the pipe using air.
Board Member Griffon noted that that some in industry have already eliminated gas blows. He said that a representative of General Electric, a major gas turbine manufacturer, stated at the CSB public meeting in June that his company greatly discourages gas blows and did not know of any situation where using gas to clean pipes was necessary. The company official said GE wants to “make gas blows something that will not happen again under GE’s watch.” GE also expressly prohibits its own employees from being on site if one of its customers chooses to conduct a blow with natural gas.
Since the public meeting, several other major turbine manufacturers also have reported to the CSB that they already have, or intend to soon develop, guidance that strongly advises their clients away from the practice of natural gas blows.
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.”
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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