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.”
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.”
Will CSB investigate the BP Transocean Deepwater Horizon accident?
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June 9, 2010- The US Chemical Safety Board (CSB) which is an important agency in the government that investigates accidents in the chemicals, oil & gas and similar industries, is being urged to investigate the BP/ Transocean oil rig (Deepwater Horizon) fire and sinking. Chairman John Bresland of the CSB issued the following release given below
Statement from CSB Chairman John Bresland Regarding
House Committee Request to Investigate BP Deepwater Horizon
I have received the letter from Chairmen Waxman and Stupak of the of the House Committee on Energy and Commerce, requesting that the CSB investigate the BP Deepwater Horizon blowout. It is my desire that the CSB do everything it can to facilitate the request and to undertake the investigation and determine what factors led to the explosion and failure of the blowout prevention system.
The CSB, a small agency, is currently engaged in numerous investigations consuming all of our investigation staff. However, I will be consulting immediately with the rest of the board and with key staff to determine how we may put together a high-performing investigation team.
The CSB thoroughly investigated the BP Texas City refinery explosion of 2005 and issued a lengthy report and hour-long CSB Safety Video following our investigation, and as the letter from the committee chairmen states, we would be in a unique position to address numerous questions about BP’s safety culture and practices, and to answer the questions outlined in the House committee letter today. The CSB investigation report and safety video may be viewed at www.CSB.gov.
In addition, at the CSB’s urgent recommendation in 2005, BP convened a special panel under the leadership of former Secretary of State James Baker to evaluate the safety culture at BP’s North American refineries. That report was published in January 2007.
We will be making key decisions on the matter in the next few days and we thank the Committee on Energy and Commerce for its interest in and support of CSB investigation activities
Deepwater Horizon Oil Rig Explosion in the Gulf of Mexico Oil spill gets worse
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April 29, 2010- The oil rig explosion and fire that occured in the Gulf of Mexico last week is now thought to be leaking out five times the oil than originally estimated. The new estimate is 42,000 gallons per day of crude. This can cause large scale damage to the marine environment in the area. The US Coast Guard has now stepped in to contain the slick and now plans are afoot to burn off the oil spill.
The original Deepwater Horizon accident can be found in this blog post here.
This seems to have a bad impact on the share price of BP, which saw continued weakness in the markets on the news. Upto now the shares have dropped more than 11%, resulting in a loss of market cap of about $20 billion. This shows how important Safety, health and the environment is to a companies financial health too. This issue is often not understood by some company managements, who see no value in spending on good and safe engineering practices and maintenance.
The video below (posted on YouTube) shows the problem with great visuals.
