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.”
CSB approves urgent recommendations to OSHA NFPA and others to prevent Kleen energy type natural gas explosions
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June 28, 2010 Middletown, CT On a 4-1 vote, the U.S. Chemical Safety Board tonight approved urgent safety recommendations to OSHA, NFPA and others. The draft recommendations, which were approved without amendments at a public meeting in Portland, CT, aim to prevent deadly explosions and fires during pipe cleaning and purging operations.
The recommendations – directed to the Occupational Safety and Health Administration (OSHA), the National Fire Protection Association (NFPA) and others, result from extensive CSB investigations into the February 7, 2010, explosion at the Kleen Energy power plant in Middletown that caused six deaths and multiple injuries, and the June 9, 2009, explosion at the ConAgra Foods Slim Jim plant in Garner, North Carolina, that killed four workers and injured 67.
The accident at Kleen Energy occurred during the planned cleaning of natural gas piping during the commissioning and startup phase of construction. Natural gas was forced through large piping that was to fuel the plant’s large electricity-generating gas turbines, in an operation called a “natural gas blow.” This gas was vented directly to the atmosphere from open pipe ends that were less than 20 feet off the ground and were located in congested areas adjacent to the power generation building.
CSB investigators obtained gas company records showing some two million standard cubic feet of natural gas were released to the atmosphere during gas blows on February 7—enough, the CSB calculated, to provide heating and cooking fuel to a typical American home every day for more than 25 years!! The gas found an ignition source and exploded.
In the CSB proposed recommendations, OSHA is urged to pass regulations that would prohibit the use of natural gas for pipe cleaning, the cause of the explosion at Kleen Energy, and would prohibit the venting or purging of fuel gas indoors, the cause of the explosion at the ConAgra Slim Jim plant. Both explosions resulted from releases of natural gas during the installation and commissioning of new piping that led to gas-fired appliances.
OSHA is also urged to require that companies involve their workers and contractors in developing safe procedures and training for handling fuel gas.
In testimony this morning at a field hearing before a subcommittee of the U.S House of Representatives Committee on Education and Labor, held in Middletown, CSB Board Member John Bresland said there is a “significant gap” in the current gas safety standards for general industry and construction, “a gap that threatens the continued safety of workers at facilities that handle flammable natural gas.”
An urgent recommendation directed at the NFPA urges the code-development organization to enact a tentative interim amendment as well as permanent changes to the National Fuel Gas Code that addresses the safe conduct of fuel gas piping cleaning operations. Under the draft recommendation, NFPA would be asked to remove key exemptions in the code for natural gas power plants and for high-pressure gas piping and to require the use of inherently safer alternatives to natural gas blows. CSB investigators determined that compressed air is a feasible and economical alternative to using natural gas for pipe cleaning and is already used by many companies.
Mr. Bresland told the House Committee, “At our CSB public meeting later this evening, I intend to vote for and support new urgent safety recommendations that we have developed, calling for OSHA to enact new regulations to control this hazard, and I will encourage the other Board members to do the same.”
Other draft recommendations would seek related safety improvements from the State of Connecticut and other states, the leading gas turbine manufacturers, the American Society of Mechanical Engineers, and the Electric Power Research Institute.
At the public meeting, newly appointed CSB Chairman Dr. Rafael Moure-Eraso will preside; Dr. Moure and Mr. Mark Griffon were confirmed by the Senate on Wednesday June 23 and were commissioned by President Obama the following day.
The CSB public meeting begins at 6:30 p.m. at the Saint Clements Castle conference facility, 1931 Portland-Cobalt Road, Portland, Connecticut, (860) 342-0593. The public is invited; no prior arrangements are needed. Attendance is free and there will be ample seating and free parking.
The CSB investigation team, headed by Investigations Supervisor Don Holmstrom, will present a report on the Kleen Energy accident as well as a review of existing regulations applying to the practice of gas blows at power plants and general industry.
The Board will hear from two witness panels, including –
· Professor Paul Amyotte – Dalhousie University (Canada)
· Ervin Patterson – Commissioning Management Services, Inc.
· Larry Danner – GE Energy
· Representative Matthew Lesser – Connecticut House of Representatives
· Professor Glenn Corbett – John Jay College of Criminal Justice (New York)
· Michael Rosario – Local 777, United Association of Plumbers and Pipefitters
· Steven Schrag – Connecticut Council for Occupational Safety and Health
Following a public comment period in which any interested person may speak, the Board will vote on the recommendations. The CSB staff is expected to propose (subject to Board approval) that upon passage of the urgent recommendations, the Kleen Energy and ConAgra investigations would be concluded. Although no additional written report is planned beyond the statement of more than 60 factual findings, the CSB plans to develop a computer-animated safety video describing the two accidents and the recommendations for safety change.
Mr. Bresland told the House committee, “We believe that the 18 urgent recommendations proposed today – together with the two urgent recommendations we issued on February 4 – address all of the principal root causes of these two tragic accidents. If adopted by the recipients, I have no doubt that future accidents will be avoided and lives will be saved as a result.”
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
Deepwater Horizon Oil Rig Explosion in the Gulf of Mexico Oil spill gets worse
You can now download the Safety Instrumented Systems e-learning course demo from here. Covers Safety Integrity Level (SIL), IEC 61508 and related topics in detail.
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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.
Sulfur Trioxide leak at BASF plant in Missouri
Mar 23, 2010- A BASF facility in Northeast Missouri had a leakage of Sulfur Trioxide, a highly toxic gas that can cause severe injuries if inhaled or ingested. Contact with water results in the formation of Sulfuric Acid.
The Missouri Department of Natural Resources were trying to estimate how much of the gas was released at the plant. A large section of the Mississipi river was shut down by the Coast Guard to boat traffic for hours . Reports say that people at BASF and other facilities in the vicinity had to be evacuated to safety. The cloud of gas is now traveling towards Illinois, but it was unclear as to how it could be dispersed in a safe way. As of now, no injuries have been reported.
The release apparently occured to a mechanical failure in the plant that resulted in the gas being vented through a stack. The BASF facility produces agrochemical products. German origin BASF, that owns the facility is supposed to be the largest chemical company in the world with nearly a hundred thousand employees worldwide.
