Case StudyU.S. Chemical Safety and Hazard Investigation Board Key Lessons for Preventing Inadvertent Mixing During Chemical Unloading Operations Chemical Reaction and Release in Atchison, Kansas MGPI Processing, Inc. Incident Date: October 21, 2016 Over 140 Sought Medical Attention, 6 Hospitalized No. 2017-01-I-KS Published December, 2017 KEY ISSUES: • Design of Chemical Transfer Equipment • Automated and Remote Emergency Shut-offs • Pipe Markings • Chemical Unloading Procedures • Human Factors • Emergency Planning The U.S. Chemical Safety and Hazard Investigation Board (CSB) is an independent Federal agency whose mission is to drive chemical safety change through independent investigations to protect people and the environment. The CSB is a scientific investigative organization; it is not an enforcement or regulatory body. Established by the Clean Air Act Amendments of 1990, the CSB is responsible for determining the root and contributing causes of accidents, issuing safety recommendations, studying chemical safety issues, and evaluating the effectiveness of other government agencies involved in chemical safety. More information about the CSB is available at www.csb.gov. The CSB makes public its actions and decisions through investigative publications, all of which may include safety recommendations when appropriate. Examples of the types of publications include: CSB Investigation Reports: formal, detailed reports on significant chemical accidents and include key findings, root causes, and safety recommendations. CSB Investigation Digests: plain-language summaries of Investigation Reports. CSB Case Studies: examine fewer issues than a full investigative report, case studies present investigative information from specific accidents and include a discussion of relevant prevention practices. CSB Safety Bulletins: short, general-interest publications that provide new or timely information intended to facilitate the prevention of chemical accidents. CSB Hazard Investigations: broader studies of significant chemical hazards. Safety Videos: high-quality outreach products that support the agency’s mission to improve worker and environmental protection. CSB publications can be downloaded at www.csb.gov or obtained by contacting: U.S. Chemical Safety and Hazard Investigation Board Office of Congressional, Public, and Board Affairs 1750 Pennsylvania Ave NW, Suite 910 Washington, DC 20006 (202) 261-7600 No part of the conclusions, findings, or recommendations of the CSB relating to any chemical accident or the investigation thereof may be admitted as evidence or used in any action or suit for damages. See 42 U.S.C. § 7412(r)(6)(G). 2 CSB MGPI Processing Case Study GLOSSARY Motor carrier: a general term for chemical distributors that deliver Acid: a substance capable of donating a hydrogen ion (e.g., sulfuric chemicals via highway. acid). A solution of acid and water has a pH less than 7. Mod B area: where the incident took place at MGPI. It includes the Base: a substance capable of accepting a hydrogen ion from a transfer equipment, tank farm, process area, and control room. proton donor (e.g., sodium hypochlorite). An aqueous solution of a base, or alkali, has a pH greater than 7. A base reacts with an acid to Mod B building: the building within the Mod B area that contains produce a salt. the indoor chemical processes, a locker room, laboratory, and the control room. Bill of Lading: a document issued by a carrier that details the type, quantity, and destination of the goods being transported. Plume: a continuous release of a gas cloud. Cargo tank: a tank intended primarily for the carriage of liquids, Split rings: metal rings with a split around the circumference used to gases, solids or semi-solids that is attached to or forms part of a motor attach two objects; also known as key rings. vehicle; also referred to as a “tanker” in this Case Study. Transfer equipment: a general term for the fill lines, valves and Cargo tank motor vehicle: a motor vehicle with one or more cargo piping used to unload and transfer chemicals from cargo tank motor tanks permanently attached to or forming an integral part of the vehicles to storage tanks. motor vehicle.1 ACRONYMS AND ABBREVIATIONS Cam lever dust cap: a metal or plastic cap that attaches to the fill AAR & IP After-Action Report and Improvement Plan line connection point to prevent debris and access to the fill line. These caps contain levers that, when in the closed position, prevent the ACDEM Atchison County Department of removal of the cap. The levers can be locked in the closed position to Emergency Management prevent unauthorized access. AFD Atchison Fire Department Connection point: the point at which a hose connects to a fill line. ANSI American National Standards Institute Day tank: a tank that contains enough chemical inventory to be used in one day or a short period of time; day tanks are typically refilled daily API American Petroleum Institute or as needed by transferring chemicals from larger bulk storage tanks. ASHRAE American Society of Heating, Refrigeration, Discharge hose: the hose from the cargo tank motor vehicle and Air Conditioning Engineers connected to the fill line. Fill lines: facility piping where hoses are connected to unload ATSDR Agency for Toxic Substances and Disease Registry chemicals from cargo tank motor vehicles. CCPS Center for Chemical Process Safety Heating, ventilation and air conditioning: systems that provide thermal comfort and air quality in indoor spaces. CEPR Commission on Emergency Planning and Response CI Chlorine Institute 1 49 C.F.R. § 171.8 (2017). CSB MGPI Processing Case Study 3 CIA Chemical Industry Association NEP National Emphasis Program Cl chlorine NIOSH National Institute for Occupational Safety and Health CSB U.S. Chemical Safety and Hazard Investigation Board NPRM Notice of Proposed Rulemaking CTMV cargo tank motor vehicle NRC National Response Center DOT U.S. Department of Transportation NSSP National Syndromic Surveillance Program EMS Emergency Medical Services OSHA U.S. Occupational Safety and Health Administration EPA U.S. Environmental Protection Agency pH potential of hydrogen EPCRA Emergency Planning and Community PHA process hazard analysis Right-to-Know Act PHMSA U.S. Pipeline and Hazardous Materials ERPG Emergency Response Planning Guidelines Safety Administration FMCSA U.S. Federal Motor Carrier Safety Administration PO propylene oxide H2SO4 sulfuric acid PPE personal protective equipment hazmat hazardous materials ppm parts per million HMEP Hazardous Materials Emergency Preparedness PSM Process Safety Management of Highly Hazardous Chemicals HMR Hazardous Materials Regulation RMP Risk Management Program HOCl hypochlorous acid SDS Safety Data Sheet HVAC heating, ventilation and air conditioning SERC State Emergency Response Commission KDEM Kansas Department of Emergency Management SO2 sulfur dioxide KDHE Kansas Department of Health and Environment VOC volatile organic compound LEPC Local Emergency Planning Committee WWTP Wastewater Treatment Plant NACD National Association of Chemical Distributors NaClO sodium hypochlorite 4 CSB MGPI Processing Case Study MGPI has two operating segments at than 39. facility management must alcohol. September 2015 https://www. sulfuric acid and sodium hypochlorite (better known 3. which consists of specialty and commodity wheat transfer equipment by applying the hierarchy of controls and starches and proteins for food and non-food applications.0 Recommendations shelter-in-place and other community members to evacuate Appendix A – Simplified Logic Tree in some areas.0 Regulatory Oversight and Guidance cargo tank motor vehicle (CTMV) at the MGPI facility tank farm.0 Conclusion (ACDEM) ordered thousands of community members to 12. and a Harcros employee. responsibility between the chemical distribution company and 2. and office buildings event occur. warehousing.0 Incident Description in its less concentrated form as bleach). Case Study examines the factors that contributed to the incident at MGPI and includes key lessons for preventing similar incidents for While two specific substances were involved in this incident.0 Industry Associations and Guidance delivery of sulfuric acid from a Harcros Chemicals (Harcros) 8. inadvertent 1. is an operating subsidiary of the National Association of Chemical Distributors (NACD).0 MGPI and Harcros Post-Incident Changes 10. 2017). The mixture of the two chemicals. Missouri. including members Appendix B – Recommended Practices of the public. (MGPI) facility in Atchison. Therefore. originally established the consequences of an incident may be severe.aiche.0 Similar Incidents During Unloading Operations community. In addition. more MGP Ingredients. distillers feed.1 MGPI PROCESSING. sought medical attention. laboratories. INC. 2016. produced a cloud 4. 9. by considering human factors to reduce the opportunity for The Atchison facility contains grain processing. in situations where CTMV drivers are and employs 140 personnel. The incident occurred during a routine chemical 7. there must be shared the United Food and Commercial Workers Union Local 74D. but because these the city of Atchison. Kansas.0 Key Lessons The Atchison County Department of Emergency Management 11. including food-grade every 8.0 Incident Analysis workers onsite and members of the public in the surrounding 6. Chemical 2. The company. MGPI employees. The cloud impacted 5. facilities receiving chemicals and the companies delivering them. This of exposure to the cloud produced by the reaction.1.0 BACKGROUND activities can lead to potentially dangerous reactions. 2.0 Background Inc. about 50 miles northwest of operations can involve extremely large quantities of chemicals. the accidental mixing of many acids and bases or other incompatible chemicals during unloading operations and other 2.2 HARCROS CHEMICALS 2 Center for Chemical Process Safety. Inc. Kansas.0 Introduction mixing of incompatible chemicals at the MGPI Processing. and pay careful attention to the design and operation of chemical ingredients.0 INTRODUCTION TABLE OF CONTENTS This Case Study examines the October 21. Kansas City. fuel-grade alcohol and corn oil. CSB MGPI Processing Case Study 5 . one MGPI employee and five members of the public required hospitalization as a result facility management to ensure chemicals are unloaded safely.org/sites/default/ chemicals and blends to a broad range of industrial customers files/cep/20150920. unloading operations from CTMVs may be perceived as simple The MGPI facility is located near a primarily urban part of compared to other processes in fixed facilities.9 million tons of product were delivered to customers the Atchison plant: distilled products.pdf (accessed September 12.4 seconds in 2016. distilling inadvertent mixing and to mitigate consequences should an operations. Unloading and Loading Hazardous Materials Harcros manufactures and distributes industrial and specialty Process Safety Beacon [Online]. Over 140 individuals.2 According to as a small distillery in 1941.0 Chemical Analysis containing chlorine and other compounds. of which 100 are represented by directly involved in unloading chemicals. modify starch through pH adjustment. MGPI’s Mod B facility in Atchison. and propylene oxide and commodity starches.Figure 1. different chemicals are material CTMVs for chemical deliveries.3 In 2016. At Mod B.3 PROCESS DESCRIPTION Southeast. The Mod B area. Kansas. operates two chemical manufacturing facilities and 29 where specialty wheat starches are manufactured to customer distribution locations.fmcsa. Harcros utilized to satisfy various desired characteristics of the specialty supplied sulfuric acid. and the use of sodium 3 Federal Motor Carrier Safety Administration. Headquartered in Kansas City. primarily in the Midwest and 2.gov/SMS/Carrier/980774/CompleteProfile. Safety Measurement Profile for Harcros hypochlorite to oxidize starch. Kansas (Source: MGPI). 2017). including the use of sulfuric acid to to the process area where the incident at MGPI occurred. separated from Chemicals Inc. is located on an access road (accessed September 12. sodium hydroxide. Figure 2. Harcros operates about 50 hazardous specifications (Figure 1). Harcros The October 2016 incident occurred at MGPI’s Mod B area. throughout the United States.dot. https://ai. 6 CSB MGPI Processing Case Study . MGPI and surrounding area (Source: Google).aspx the main plant by railroad tracks. and acetic anhydride.F. propylene oxide. The building also contains a locker room. or process vessels for production inside the Mod B building. and stored at atmospheric pressure.R § 1910. and is adjacent to MGPI’s Wastewater Treatment Plant (WWTP) (Figure 2). Chemical unloading operations at the and the control room where operators perform most of their time of the incident (Source: MGPI). Mod B chemical unloading area and tank farm (left) and Mod B building (right) (Source: CSB). Operators then to two chemicals stored above threshold quantities at Mod B: propylene oxide (a flammable liquid received at the unloading area) and phosphorous oxychloride (not received at the unloading area). where it is transferred by piping to an outdoor 6.500-gallon 5 The U. From there. The Mod B building contains an indoor process area where chemicals are combined to manufacture product.5 CTMV drivers transfer chemicals by connecting discharge hoses Among the chemicals delivered to Mod B is 12. laboratory.Figure 3. sodium hydroxide.S. chemicals hypochlorite.4 sulfuric acid. The two chemicals involved in this incident are not 6 MGPI took this photo of the Harcros CTMV connected to the fill line shortly after the covered under the standard.6 duties. Occupational Safety and Health Administration’s Process Safety Management of High Hazardous Chemicals standard (29 C. The Mod B area comprises the Mod B building and an adjacent outdoor tank farm (Figure 3). which include monitoring process conditions. CSB MGPI Processing Case Study 7 . as needed. Figure 4. into day tanks and/ quantities of five chemicals: sodium hypochlorite. Deluge systems were on at this time to mitigate the release. incident. MGPI receives sodium hypochlorite at the chemical unloading area 4 Sodium hydroxide is also referred to as “caustic” in this Case Study. Operators then transfer smaller through which CTMVs from various companies deliver bulk quantities of the chemicals.119) applies bulk tank. flow through piping to several large bulk storage tanks in On the perimeter of the tank farm is the unloading area the tank farm (Figure 4). called Gasoline Alley. a more concentrated version of bleach.5% sodium from the cargo tanks to the fill lines. (driver)7 exited the cab and began to pressurize the cargo tank for unloading. MGPI receives 30% sulfuric acid at the chemical arrived at the MGPI Atchison facility to complete a scheduled unloading area in an outdoor 8.3.500-gallon day tank. The driver checked 7 The Harcros driver is one of multiple Harcros drivers who made sulfuric acid deliveries to Mod B in 2016. handed it After completing delivery. Operators delivery of 30% sulfuric acid. The driver removed the dust cap from the first unlocked fill line that he saw at the facility. rubber gloves. as this chemical was delivered by another chemical distribution company. which he assumed to be the sulfuric acid fill line.0 INCIDENT DESCRIPTION tank in the Mod B building. the paperwork prepared by the shipper. operators first unlock operator on duty reviewed and signed the paperwork for accepting a barbed wire gate that encloses the tank farm area and five fill a delivery. When they reached the when they are not in use. operators return to acid fill line. the driver. CTMV drivers rely on operators his personal protective equipment (PPE). a Harcros CTMV is sulfuric acid. 2016. From there. No Harcros driver was involved in any delivery of sodium hypochlorite. It was. The driver connected the hose to the fill line and then connected the hose to the truck. 9 Seals are placed on the trailer valves and caps of cargo tanks to prevent tampering with the contents and so that those receiving deliveries can ensure that the contents of the trailer match what is stated on the bill of lading and other paperwork. begin the connections. The operator then returned to the Mod B building at approximately 7:47 AM before he saw the driver connect the discharge hose to the fill line. Harcros had made many deliveries of sulfuric acid in the previous year. 8 CSB MGPI Processing Case Study . and is.8 During this time. A locked cam lever dust cap on a fill line at Mod B are designed to be broken to ensure that they cannot be removed and placed back on a cargo tank. the night shift operator accepted the delivery. the driver took the 2. Upon arrival. and safety glasses.1 THE INCIDENT process vessel as needed. The seals Figure 5.1 PRE-INCIDENT CHEMICAL UNLOADING OPERATIONS bills of lading to the Mod B building where the MGPI night shift To access the fill lines for a chemical delivery. The driver their chemical discharge hose from the cargo tank to the fill line. unlock the padlock on the cam lever dust cap that secures the fill line for the chemical being delivered. and then retrieved the hose from the CTMV to fill line and re-secure it by locking the padlock. At approximately 7:42 AM. it is transferred into a 3. The operator placed the lock from the sulfuric acid the control room. the driver set his paperwork on the back of the are secured by engaging two levers and locking them in place cargo tank and walked down the passenger side to finish donning with a padlock and two split rings. Operators then show drivers the appropriate and removed the lock on the cam lever dust cap for the sulfuric fill line. the operator escorted the driver from the Mod B prevent access to fill lines by capping the end of the fill lines building to the chemical unloading area. reports that the operator did not point out the fill line. the Harcros employee transfer sulfuric acid from the day tank directly into the process. a hard hat with a face shield. however.transfer sodium hypochlorite by piping into a smaller day 3. As seen in Figure 5. the to unlock and identify the fill line designated for the chemical operator unlocked the gate in front of the transfer equipment being transferred. The numbers on the seals are supposed to match the numbers on (Source: CSB). 8 The driver donned a chemical resistant coat. operators the start of dayshift. drivers place the dust cap back on the to the operator. removed the seal9 from the back of the cargo tank. Next. The operator reports that he pointed out MGPI’s practice to unlock fill line dust caps only for delivery. Because the driver arrived at MGPI at 7:35 AM. Another chemical delivered to Mod B At approximately 7:35 AM on October 21. Once the equipment is unlocked. cam lever dust caps rear of the CTMV. Drivers then remove the dust cap and connect fill line on the angle iron above the fill line (Figure 6). the location of the sulfuric acid fill line to the driver and that the driver acknowledged the location. of which the driver made six. Cam lever dust caps At 7:44 AM. prior to lines designated for each chemical (Figure 4). The driver connected the sulfuric acid discharge hose to line padlock (circled) placed on angle iron. the CSB found that the sodium hypochlorite fill line was also accessible to the driver (Figure Figure 6. which resulted in the inadvertent mixing of approximately Shortly before 8:00 AM a greenish-yellow gas began emitting 4. operators ran northeast on the cargo tank to begin discharging sulfuric acid. and set his paperwork down. The WWTP manager brought the driver inside the WWTP control room.10 checked for leaks. one of the operators used inside. Sulfuric acid fill 7).4). At this point. length of pipe between the truck and tank. The driver (Figure 2) through the cloud until they reached fresh air near the returned to his cab. temperature and humidity. During this time. The bottles. The face pieces connect to 5-minute escape Figure 7. The WWTP manager also alerted MGPI management of the release by phone and radio. 10 Drivers check the air pressure using the air gauge and pressure regulator. This mixture of incompatible materials resulted The cloud grew. gave him water. climbed railroad tracks. who was in the cab of the truck. The driver turned around and attempted the same from the passenger side but again was overwhelmed by the gas. chlorine gas and other compounds (Section 4. the unsecured fill line for the sodium hypochlorite bulk tank. and then migrated offsite in a northeast direction. Although the sulfuric acid dust cap was unlocked immediately prior to unloading. opened the facility’s valve and then the valve respiratory protection.the air pressure in the cargo tank. He tried to get to the connection area at the rear of the truck by running down the driver side. another company employee contacted 911 at 7:59 AM. Following day shift operator and a trainee were in the Mod B building this alert. checked his air pressure on the way. CSB MGPI Processing Case Study 9 . hypochlorite. After exiting. The three operators inside the Mod B control room at the time of the release quickly became aware of the reaction by the odd smell of gas that entered the building.0). but were unable to do so because the respirator face pieces were not stored in a readily accessible location or had been moved.000 gallons of sulfuric acid and 5. and radioed MGPI employees that the driver was inside and out of the cloud. however.11 As a result. padlock (Source: CSB).850 gallons of sodium from the sodium hypochlorite bulk tank. forming a cloud. The driver. the MGPI his radio to alert MGPI employees of the emergency. the manager of the adjacent WWTP saw the release and shouted for the driver to run in his direction. Sodium hypochlorite dust cap on ground beneath fill lines (Source: CSB). Sodium hypochlorite dust cap with missing split ring. but the gas overwhelmed him. and air supply at the customer’s site. discussing plant operating status with the night shift operator. 11 The night and day shift operators attempted to retrieve their respirator face pieces from their respective lockers but were unable to do so. the previous shift moved it because they needed counter space (Section 5. They immediately attempted to access their emergency escape respirator face pieces. As-found state of connection area post-incident. covering the Harcros truck and the Mod B in a reaction that promoted the release of a cloud containing building. At the railroad tracks. equipment parameters. and upon all three operators were forced to evacuate the building without not finding any. first noticed the gas cloud in his rearview mirror. The amount of pressure applied depends on several variables that must be considered for each load. such as viscosity and other physical properties of the product. The missing split ring prevented the dust cap from being secured by the trainee normally kept his respirator on a counter in the control room. The trainee did not have a locker because MGPI does not assign lockers to trainees. while a few left prior to any examination. tend emergency responders. and exposed the two 14 The CSB collected patient information from nearby hospitals and clinics for firefighters. Minutes later. due to the wind.pdf (accessed November 27. both of whom were transported to the hospital. safer location. coughing. atsdr. the plume shifted. transferred 800 middle and high school students upwind to northeast. By 8:10 AM. When and respiratory tract. The wind shift presented challenges to experience more severe effects than healthy subjects or nonsmokers. and some evacuated the area. https://emergency. Responders were able to safely close the discharge valve on the Consistent with acute exposure to chlorine. requiring emergency responders to evacuate to a exposed to the toxic cloud and was released three days later.17 a motor vehicle accident near the plant required assistance from the two firefighters. https://emergency.cdc. route. it began to migrate towards the WWTP where the WWTP manager. was likely caused by a reaction when sulfuric acid and sodium hypochlorite were inadvertently mixed.gov/agent/chlorine/basics/facts. In general. ACDEM communicated an all clear and lifted informed emergency responders that a “chlorine-like” plume the shelter-in-place and evacuation orders. or plume. While treating the vehicle accident 13 The closest weather station. 3. 12 employees. 2016. An Emergency Medical Services (EMS) symptoms are delayed (Table 1). Around that same time. was estimated to extend a few hundred residents to the north who were not in the plume. 15 Centers for Disease Control and Prevention.asp (accessed September 12. and throat irritation. Of those not admitted to a hospital. it slowed due to low chemical release at 8:02 AM and units arrived on scene at 8:05 wind speed. or who are heavy smokers. the Kansas Highway Patrol monitored the size 16 According to the ATSDR. the plume shifted to the employee was admitted to a hospital after being directly northwest. the concentrations listed above are approximate. skin. Due to the time of day. Joseph. At the same time. MGPI after the incident. many who visited a cargo tank and turn off the truck engine.15 The extent of symptoms varies with they saw that the plume was heading in their direction. cdc. At 11:00 AM. By 8:43 AM. 2017). a hazardous materials (hazmat) trailer Five citizens were admitted to the hospital. they the concentration. the and movement of the plume throughout the morning to assist effects will depend also on exposure duration. a majority were sent home after examination. Agency for Toxic Substances and Disease Registry. As the plume shifted to the west of Mod B. there was a significant amount the south side of Atchison. and duration of exposure.16 Most long-term health vehicle then transported the driver to the hospital for treatment effects from acute exposures are typically associated with of his symptoms from exposure to the cloud.3. as the plume began to move The Atchison Fire Department (AFD) received notification of the toward the north and west of the city. and the Chlorine is a yellow-green gas that can irritate the eyes. individuals who sought medical attention as a result of the release.000 Atchison citizens to shelter-in-place. two firefighters who attended to the driver were located. one MGPI mitigate the release.14 Of these. the Harcros driver. By approximately 10:30 AM. Facts about Chlorine. They also set up a water hospital or medical center reported general respiratory issues spray and manually activated the Mod B deluge (sprinkler) system including shortness of breath. From a helicopter. driver. reported calm winds until 10:53 AM on October 21.gov/agent/chlorine/basics/facts. complications developed after exposure to high concentrations.asp (accessed September 12. Toxicological Profile for Chlorine. radio. 2017). to suppress the plume generated by the chemical reaction.3 CONSEQUENCES the Atchison County Department of Emergency Management Because of the chemical reaction and release. in St. 17 Centers for Disease Control and Prevention. and social media to alert the community of the shelter-in. released within two days and one was released five days later. 12 ACDEM used TV. 2017). victims. place and evacuation orders. approximately 3 hours were en route to the hospital and at about the same time. Buses safely feet high and to be slowly migrating on the ground to the north. the of traffic in the immediate vicinity of the plant and the fire Kansas Highway Patrol reported to emergency responders department blocked nearby intersections to restrict and re-direct that the plume was on the north and west outskirts of the drivers from entering the plume. of which four were arrived with additional emergency responders and equipment.2 EMERGENCY RESPONSE for emergency responders and. and over 140 community MGPI worked with the fire department to develop a plan to members sought medical attention.13 ACDEM issued evacuation orders to schools and AM. the Mod B operators city and dissipating rapidly.gov/toxprofiles/tp172. 10 CSB MGPI Processing Case Study . MO. four MGPI (ACDEM) advised 11. Facts about Chlorine. people who suffer from respiratory conditions such as allergies or hay fever. The cloud. cdc. https://www. the downstream sodium hypochlorite amount of mixing that occurred as sulfuric acid was introduced to day tank. containing sodium hypochlorite (10-16%). Reed. Reed. aqueous solution.html (accessed 1. Contractors evaluated the effect (pulmonary edema) of meteorological conditions on both the generation of reaction products 430 ppm for Death and the behavior of the plume in the atmosphere.5% sodium hypochlorite has a pH range of 11. 2017). based organic or other chlorinating compounds. Chlorine Institute: Arlington. consistent with the density of 30% sulfuric acid. 19 Case Forensics. Laboratory testing confirmed that a sodium hypochlorite may have occurred.csb.gov/assets/1/19/2445003_Report.25 The liquid that was added to the tank and the gases that The CSB commissioned a chemical analysis to characterize evolved from the reaction were released through a 3-inch diameter the contents of the tanks and truck involved in the incident. 19 atmospheric vent and an 18-inch lid on the roof of the bulk tank. The sodium hypochlorite (NaClO) used at MGPI is supplied as a diluted • hydrogen chloride (HCl(g)) or hydrochloric acid (HCl(aq)). and odor. The products of the initiating reactions likely solution and 30% sulfuric acid were involved. ionic species. 4th ed.22 Sulfuric acid (H2SO4) Concentration Potential health effects18 is a strong acid that violently reacts with bases (alkalis) and is corrosive 1-3 ppm Mild nose irritation to most metals.pdf (accessed September 12. The [Online] 2017.cdc. 4. the on animal and human studies (Source: ATSDR). Investigators collected samples from the sodium hypochlorite bulk tank. These may have included: of the samples revealed no evidence of elements other than those found in sodium hypochlorite and sulfuric acid. the sodium hypochlorite and sulfuric acid immediately initiated a highly exothermic. Case Forensics. Washington.csb. MGPI Investigation Support – Chemical Reactions and Air Characterization of Reactants MGPI Processing Inc. 2017. • chlorine gas (Cl2(g)). sodium hydroxide (4%) and water (balance). while the precise chemistry cannot be definitively determined. The sodium hypochlorite from the downstream day tank had a pH of 12. • chlorine dioxide (ClO2(g)). and • oxygen (O2(g)) 18 Agency for Toxic Substances and Disease Registry. sodium • sodium sulfate (Na2SO4(aq)).TABLE 1. September 12. MGPI Investigation Support – Chemical Reactions and Air September 12.. M. Washington.0 CHEMICAL ANALYSIS reaction. Technical Report for CSB. the 1. and the remaining liquid in the CTMV after the the sodium hypochlorite tank. E.21 When mixed with acids.23 5-15 ppm Throat irritation 30 ppm Immediate chest pain. 2017. respectively. in Atchison Kansas. consistent with further reacted to generate additional toxic gas (g) products the expected contents of the bulk tank and truck. 2017). It can react violently with water and other organic 5 ppm Eye irritation materials.24 Upon mixing. several different series of reactions incident._Redacted. Pamphlet 96.5. or heat-producing. 24 Peterson. E. Characterization of Reactants MGPI Processing Inc. It is a strong base that can react with acids and ammonia. 2017).18 hypochlorite ion is known to form chlorine gas. The CSB also commissioned an analysis to fully understand the potential changes in breathing rate and cough reaction pathways on the day of the incident to determine what products 40-60 ppm Lung injury and fluid in lungs might have been created and released..227 gm/cm3. https://www.000 ppm for Death primary toxic reaction products were likely chlorine and other chlorine- a few minutes containing compounds. Pocket Guide to Chemical 20 The sulfuric acid density of the two Harcros CTMV samples was 1. Analysis 20 and aqueous (aq). 2017. The analysis concluded 30 minutes that. 4th ed. Pamphlet 96. CSB MGPI Processing Case Study 11 . chloride (12%). 21 The Chlorine Institute.pdf Chlorine Institute: Arlington.cdc. VA. resulting in the evolution of heat and irritating gases.gov/assets/1/19/2445003_Report. 23 National Institute of Occupational Safety and Health. Technical Report for CSB. where the suspected mixing of sodium hypochlorite Depending on the temperature and pH of the mixture. hypochlorite solution is a clear yellow liquid with a characteristic bleach • water. [Online] Modeling._Redacted. M.gov/niosh/npg/npgd0577. (accessed September 12. The sodium • sodium bisulfate (NaHSO4(aq)).228 g/cm3 and Hazards.atsdr. 22 The Chlorine Institute.3 post incident. Sodium Hypochlorite Manual. Potential health effects of short-term chlorine exposure. in Atchison Kansas. October 2011.gov/toxprofiles/tp172. 2017).. http://www..pdf (accessed 25 Peterson. 12. vomiting.5 to 13. Sulfuric Acid. which evolves from the solution. Modeling. and can cause a serious chlorine release. October 2011. DC. The https://www. http://www. DC. Sodium Hypochlorite Manual. and the and sulfuric acid occurred. VA. Toxicological Profile for Chlorine. .2 ppm of sulfur dioxide present cloroxregular-bleach12015-06-12. CA.28 The mixture of the two resulted in the formation of small chlorine gas bubbles (left) collected in a distillation apparatus (right) software to understand the characteristics of a chlorine gas cloud (Source: CSB). onsite in 3 of 62 samples.1 to 11. MGPI Investigation Support – Chemical Reactions and Air Modeling. 2017.. Though the and surrounding atmosphere. Reed. pH. the U. Environmental Protection Agency (EPA) arrived at 1:00 PM and began on-site and perimeter air monitoring with handheld detectors equipped with chlorine sensors. Washington. 2017). DC. Chlorine dioxide can itself decompose to form chlorine gas and There was no real-time air monitoring data available during the oxygen gas. E.S. contractors conservatively assumed that combined with the heat produced by the reaction.com/wp-content/uploads/ 32 Air monitoring instruments also detected 0.32 At the time of the monitoring. Reed. M. Technical Report for CSB. MGPI Investigation Support – Chemical Reactions and Air Modeling. June 12. accelerated the the sodium hypochlorite might have completely decomposed rate of sodium hypochlorite decomposition. Technical Report for CSB. Additionally.26 A likely assuming that no chlorine further reacted or was otherwise removed reaction pathway between sulfuric acid and sodium hypochlorite from the plume.27 These around the Mod B area.29 The maximum theoretical quantity of chlorine major and minor reactions may have occurred.30 A reaction between chlorine and water in the produced hypochlorous acid and sodium sulfate.7 parts per million (ppm) in the immediate vicinity of Mod B. DC. 26 Peterson. Technical Report for CSB. several during the incident. Reed. Reed. the plume concentrations and distance 29 Peterson. chlorine concentrations were below detectable limits in the community. Figure 8. MGPI had stationary air monitors in and to 70 degrees Celsius (104 to 158 degrees Fahrenheit). M.. the series of reactions produced by mathematical calculations to predict how chemicals disperse the inadvertent mixing created toxic products that can cause in the atmosphere. temperature. Chemical reaction approximately 1 minute after Harcros sulfuric acid sample was added to fresh Clorox® bleach (5-10% sodium Contractors also modeled a hypothetical release using PHASTTM hypochlorite). 2017. 2015. Chlorine dioxide will also react with hydrochloric incident that would have detected the concentrations of chemicals acid to form chlorine gas and water at temperatures around 40 present in the plume. See the CSB Contractor’s Report the truck.1-0. the day of the incident. Technical Report for CSB. concentration. The hypochlorous plume would likely reduce the overall amount of chlorine gas. MGPI Investigation Support – Chemical Reactions and Air Modeling. E. The Clorox Company: Oakland. 31 Peterson. Washington.). Washington.. E. 30 Peterson. The PHAST software uses As discussed in Section 3.thecloroxcompany. These health effects largely depend on the largely dependent on the characteristics of the release source concentration of the toxic products yielded as a result. MGPI Investigation Support – Chemical Reactions and Air Modeling.The sulfuric acid lowered the pH of the sodium hypochlorite. approximately 5 hours after much of the cloud had dissipated. involving both the gas produced by the reaction was estimated to be 3.. air quality was safe in the building and immediate area where the incident occurred.1. M. E. The results of the dispersion models are adverse health effects.pdf (accessed September 12. Though the plume modeling reactions and the quantity of the reaction products are dependent provides some of the basic characteristics of the cloud present on on source conditions and the environment (e. Washington.31 acid further decomposed to form chlorine and chlorine dioxide. 2017. Reed. 27 Peterson. M. reactants and products formed by their decomposition. https://www. Monitoring results were negative for chlorine. 12 CSB MGPI Processing Case Study . Environmental consultants hired on behalf of MGPI also conducted real-time air monitoring using a variety of instruments at 3:30 PM and detected levels of chlorine from 0. 2017 28 Safety Data Sheet for Clorox Regular Bleach. propylene oxide and phosphorous oxychloride. they conducted air quality monitoring and determined the for a technical summary of the potential chemical reactions. E. Technical Report for CSB. Washington. etc.3.g. but these were to detect concentrations of chlorine-containing compounds have a greenish-yellow tint. 2017. DC. DC. which. M. under similar atmospheric conditions..490 pounds. DC. Shortly after emergency Several MGPI employees described the cloud as yellow-green responders mitigated the reaction by closing the discharge valve on to CSB investigators (Figure 8). As a result. MGPI Investigation Support – Chemical Reactions and Air Modeling. such as fluctuations. http://app.knovel. Center for Chemical Process Safety/AIChE: New Hanna. and the systems under which work is carried out.. worker stress chlorine and other compounds on the day of the incident. such as procedures. Technical Report for CSB.34 Under these conditions. http://www. [Online]. the atmosphere is considered stable. 41 A Human Factors Roadmap for the Management of Major Accident Hazard. The exothermic reaction provided the role of human factors to reduce or eliminate opportunities buoyancy to the relatively hot gases. Center for Chemical Process Safety/AIChE: New Warwickshire UK.knovel. M.41 For improved conditions on the day of the incident because the air all processes and equipment that require human interaction. Britter. E. to fog with slight winds from the south. using less hazardous 33 Peterson. R. D. Reed. E. which ultimately led to the incident. 2007. NY. labeling. 2017). 2017). S. NY. facility management must carefully examine severity of the incident at MGPI. Reed. weather includes a broad range of areas that can influence safety. CCPS.pdf (accessed September 12. Human Factors Methods for Improving Performance in the Process direction. 34 Peterson. was saturated with moisture.0 INCIDENT ANALYSIS 5. NY.knovel. Center for Chemical Process Safety/AIChE: New York. physical and mental capabilities. pp 14.gov.com/hotlink/toc/ methods/introduction (accessed September 12. id:kt002YJLVL/wind-flow-vapor-cloud/definitions-concepts (accessed December 6. 2007. Washington. Washington. CCPS/AIChE: New York. 2017). Center for Chemical Process Safety/AIChE: New equipment.43 For example. 1997. http://app. and fatigue.com/hotlink/pdf/id:kt004MHZ41/human-factors- methods/introduction (accessed September 12.traveled do not reflect actual conditions. 2017. [Online]. or other conditions that may have diluted the the design and physical characteristics of a work area. IChemE: Rugby. Modeling. methods/introduction (accessed September 12.com/hotlink/toc/id:kt00A7EN31/ York. pp 33. Center for action. D. Industries--Introduction [Online]. training. equipment. however. 40 Inherently safer approaches eliminate hazards by.uk/humanfactors/resources/ Modeling. 2017). color schemes. United Kingdom. and provides additional layers of protection. Human Factors Methods for Improving Performance in the Process Industries--Introduction [Online]. This is because the environment among workers. 2007. and processes37 and model does not account for potential side reactions. may have kept the greatest concentrations of of equipment. NY.. plume dispersion is slow because safer approaches. and chlorine and other chemicals at higher elevations in the community. the air transitioned from the hierarchy of controls—from design to administrative controls fog and calm winds. 2007. http://app. equipment 5. Industries--Introduction [Online]. D.knovel. M. http://app. http://app. Major Hazards and their Management [Online]. Technical Report for CSB. 2017).com/hotlink/pdf/id:kt004MHZ41/human-factors- Sites [Online].knovel. which likely caused the plume for failures when identifying process hazards and evaluating to rise above the bulk tank and then disperse downwind. and how applying safer design 39 The hierarchy of controls is the concept of applying a hierarchical order of controls strategies could have reduced reliance on operator and driver to eliminate or reduce hazards and their consequences. and communication. describes these deficiencies.38 Because workers An analysis of the atmospheric conditions and hypothetical release must often interact with equipment to operate and maintain modeling concluded that weather played a significant role in the process plants. DC. G. size. with little or no wind or When the risks associated with hazardous chemicals cannot atmospheric turbulence (or mixing). hf-roadmap. should be configured by considering human thereby lessening the potential impact at ground level.1 HUMAN FACTORS 37 Crowl.39 within the first hour of the incident. 43 Crowl. This section York. According 33 safeguards. Wind flow and Vapor Cloud Dispersion at Industrial and Urban York. 2nd ed. Human Factors Methods for Improving Performance in the Process Industries--Introduction [Online]. MGPI Investigation Support – Chemical Reactions and Air HSE: Merseyside. for example.com/hotlink/ pdf/id:kt00A68RS1/guidelines-engineering/inherent (accessed September 12.com/hotlink/pdf/id:kt004MHZ41/human-factors- The CSB identified several human factors issues that affected how methods/introduction (accessed September 12. 2012. 2017). such as accessibility. DC. shape. 2017. This condition allows for an increased mixing of chemicals within the atmosphere. to PPE—to ensure controls are effective and can be understood.com/hotlink/pdf/id:kt004MHZ41/human-factors- major-hazards-their-management/wind-dispersion (accessed December 6. CSB MGPI Processing Case Study 13 . 2017). NY. 2017). Human factors must be integrated into all levels of to data from the closest weather station..hse. MGPI Investigation Support – Chemical Reactions and Air materials and process conditions. D. “Human factors” addresses the interactions in a work Chemical Process Safety/AIChE: New York.knovel. Guidelines for Engineering Design for Process Safety--Introduction. When the atmosphere is 35 be eliminated through substitution or other inherently stable during a chemical release.40 the next best approach is to design a chemicals do not readily mix or dilute in the atmosphere. may have interactions.knovel. 35 Atmospheric turbulence is irregular air motion or wind that fluctuates in both speed and 42 Crowl. which may have dissolved chlorine facilities must apply human factors to understand how within the developing and existing plume.36 The system that meets the limitations of human and machine presence of fog and high humidity in the air.42 Key attributes plume. The buoyancy of the workers interface with and use equipment. the operator and the driver interacted with the chemical transfer 38 Crowl. Human Factors Methods for Improving Performance in the Process 36 Wells. http://app. http://app. 2002. however. 2 IDENTICAL CONNECTIONS AND LOCKS ed. amines. 5. Pocket Guide that the sodium hypochlorite and the acetic anhydride dust to Chemical Hazards. VA. Guidelines for Process Safety in Batch Reaction Systems--Table 3: Chemical Process Safety/AIChE: New York. October 2011. 2nd ed. the fill line proximity increased the include spacing and using incompatible hose couplings. A post-incident examination of the unloading area revealed 46 Acetic anhydride reacts violently with alcohols. Center for 49 CCPS. October 2011.noaa. unsafe combinations designated by X (Source: CSB). CDC: Atlanta. 4th 5. Mod B fill line chemical incompatibilities. Sodium Hypochlorite Incompatibility Chart.49 Physical separation is or leaks from chemical containers. the sodium hypochlorite fill line was about 18 inches from the sulfuric acid Figure 9.1 [Online]. edu/fas/fsr/rm/EHS/Documents/chemical%20compatibility%20chart. Engineering Design for Process Safety--Introduction. significantly. p 11. The Chlorine Institute. and water. 4th ed. when receiving various classes and types of chemicals. 2017). VA. http://app. 15.knovel. restoration.knovel.com/hotlink/pdf/id:kt003JMGR1/guidelines-process-safety/ September 12.1. 45 The Chlorine Institute. In addition to SDS. Guidelines for likelihood of the inadvertent connection in this incident.gov/reactivityworksheet.1 DESIGN OF CHEMICAL TRANSFER EQUIPMENT 5.44 Sulfuric Sodium Sodium Acetic Propylene 44 Acid Hypochlorite Hydroxide Anhydride Oxide Sulfuric Acid X X X X Sodium Hypochlorite 45 X X X Sodium Hydroxide X X X Acetic Anhydride 46 X X X X Propylene Oxide 47 X X X X must be designed so that it is suitable for the designated task.1. Pamphlet 96. oxidants. and its components must be recognizable and consistent with user training and experience. The Chlorine Institute: Arlington. 48 The CSB determined that the chemical fill lines were first installed with this same 50 A passive control minimizes the hazard through process and design strategies without configuration at Mod B in 1996. The Chlorine Institute: Arlington. https://www. 33. 47 Central Michigan University.1.com/hotlink/ Equipment Configuration and Layout [Online].cmich. Acetic Anhydride [Online]. Chemical Incompatibility Chart. CCPS. Laboratories and the transportation industry apply physical Physically isolating or using distance to separate fill lines can separation to chemical storage to prevent mixing during spills lower the risk of incorrect connections. Refer the risk of an unintended reaction because a CTMV driver to the chemical manufacturers’ Safety Data Sheet (SDS) for information regarding incompatibly and reactivity. 2012. 5. 2017).48 In addition to the incompatibility of sodium hypochlorite and sulfuric acid. (accessed September 12. strong bases. NY. the other chemicals delivered considered a passive control50 and can be especially important to Mod B presented reactivity hazards if mixed (Table 2). one can result when chemicals are combined under certain conditions.1. 2017).html (accessed November 27. Distance between fill lines (Source: CSB).pdf (accessed http://app.1 FILL LINE PROXIMITY The CSB found that the proximity of the sulfuric acid fill line to the sodium hypochlorite fill line at Mod B increased the likelihood for an incorrect connection during chemical unloading. GA. Unloading acids in an area 44 Although a violent reaction is not expected for some of the chemical combinations in located away from the unloading area for bases decreases Table 2. fill line (Figure 9). equipment--configuration.gov/niosh/ipcsneng/neng0209.1. Examples of passive controls incidents associated with incorrect corrections. the chemical to an incorrect and incompatible fill line. 14 CSB MGPI Processing Case Study . 1999. avoids unnecessary complexity. Although the CSB did not identify any previous active functioning of a device or human interaction. The five chemical fill lines in the Mod B chemical transfer area were all located near each other.cdc. pdf/id:kt00A68RS1/guidelines-engineering/inherent (accessed September 12. https:// caps were not secured on the fill lines at the time the operator www. July 2015. National Institute for Occupational Safety and Health (NIOSH). 2017). the CSB also used the EPA Chemical would have to drive to a different area of a facility to unload Reactivity Worksheet for reactive combinations of chemicals: http://response.1. Pamphlet 96.TABLE 2. Sodium Hypochlorite Incompatibility Chart. On the acetic wrong hose and inadvertently transferring material (Figure 10). 51 driver could connect fill line connections Physically isolating The CSB was unable the sulfuric acid hose with uniquely or using distance to determine why the to the incorrect.. a chain was attached to a split ring on only one cam lever and wrapped around the empty lever. but shaped and color- to separate fill sodium hypochlorite unlocked. Though and fill line connectors is another example of a passive control not causal. sodium dust cap was missing a hypochlorite fill line. Inherently Safer Chemical Processes-.g. 2. The use of uniquely sized or shaped hose couplings the split ring to deteriorate and fall off the dust cap. Center for Chemical Process Safety/AIChE New cap on the fill line using only the padlock and one split ring (e. coded fittings for lines can lower the split ring nor how long each chemical or risk of incorrect it was left unsecured Chemical process class of chemicals connections during on the fill line prior plants and chemical bulk unloading to the incident. At the time of transfer equipment for sulfuric acid to make it impossible for the incident. Because operators had a practice of keeping 9. 2009. missing a split ring on one lever. it was the only physical barrier receive chemicals from multiple distributors. hose manufacturers. Since the incident. Mod B operators reported that the split rings a particular hose can be connected only to a fitting mated to experienced chemical corrosion and this could have caused receive it. the CSB found that the size and orientation of the fill lines used at Mod B are consistent with common MGPI started using dust caps to prevent product contamination industry practice.0). it also provides preventing drivers from incorrectly connecting to the wrong fill the opportunity for a wrong connection. The sodium fill line before they hypochlorite dust cap was unable to be locked because it was made a connection. MGPI had no design or engineering controls preventing Harcros has worked with MGPI to select uniquely shaped the driver from making an incorrect connection. by inserting the York. http://app.5.knovel. Without the split ring on one Since both fill lines Work with motor of the cam levers. line. drivers distributors to determine what size and shape hose couplings typically relied on operators to unlock the dust cap for the correct are feasible and modify unloading equipment accordingly. [Online].com/hotlink/pdf/id:kt0068GQQ3/inherently-safer- padlock through the lever that was missing the split ring).10 Limitation cap and single split ring. It distributors can operations is possible that the reduce the likelihood of an incorrect connection by designing sodium hypochlorite and selecting equipment so that connections or manual dust cap was not secured by the driver of the last sodium configurations of components are difficult or impossible to hypochlorite delivery nine days prior. anhydride dust cap. chemical/limitation-available (accessed September 12.unlocked the sulfuric acid dust cap for the delivery. it was impossible to secure the dust cap on the had the same diameter carriers to select fill line with the padlock and orientation. CSB MGPI Processing Case Study 15 . giving it In reviewing the range of fitting diameters offered by various the appearance of being secured on the fill line (Figure 6). Though the practice of locking dust caps fill line receivers are most common for this type of service. the CSB determined there was no other way to lock the dust of Available Energy 2nd ed. 51 Through mechanical functionality testing of the as-found sodium hypochlorite dust 52 CCPS. NY. and this went unnoticed perform in error.. is not a specific requirement for process safety or environmental Though the identical size of the fill lines allows facilities to reasons. the hose couplings and (Figures 5 and 7). Based on information from the chemical or tampering issues on all receiving lines in response to a 2010 distribution industry. 2017).A Life Cycle Approach: 4. the CSB observed that the acetic anhydride dust that eliminates or reduces the possibility of connecting the cap was also missing a split ring on one lever. the Mod B fill lines were similar in appearance and drivers to connect another delivery hose to that line (Section identically sized. when executed properly.and 3-inch round hose couplings and food safety inspection.52 This includes designing fill lines so that by MGPI. Facilities that receive multiple chemicals should work with the fill lines locked with dust caps when not in use. 16 CSB MGPI Processing Case Study . as a result. urea. Contrary to Mod B. Neither sodium hypochlorite nor sulfuric acid fill lines had identical padlocks on the sodium hypochlorite and sulfuric acid pipe markers or identification tags affixed at connection points. and tags are extremely important in process plants and all facilities that handle hazardous chemicals to ensure that workers can identify equipment that requires manipulation and to Pipe markings on communicate hazards that cannot be controlled transfer equipment by other means.1. by using the wrong control or entering the wrong value. intended to be secured and locked on the end of the fill line through the cam levers. fill lines and transfer piping.53 For example.55 Using different padlocks and keys for each valve prevents operators from unlocking the incorrect valve with another key. Color coding can also assist in ensuring proper connections. uses a different padlock and key for each fill line. 5. the onsite WWTP. similar to the Mod B fill lines. 55 MGPI had locks on the transfer valves for three of the four fill lines at the WWTP. which caustic line contained a cap. could unlock the wrong and ferric chloride. The dust cap in error.1. Scheme for the Identification of Pipes. 53 The American Society of Mechanical Engineers (ASME) Standard A13. the facility and chemical distributor could select orange hexagon shaped couplings and fill line receivers for acids and square purple couplings and receivers for bases. unlock both chemicals and.2 PIPE MARKING Pipe markings. labels. The CSB also evaluated whether MGPI’s practice of placing Figure 11. Colors associated with each class of chemicals can be used for pipe markers. sodium hydroxide (caustic). it was not locked at the time of the incident. The CSB observed that though the cap was on the end of the caustic fill line. MGPI did have a pipe marker on the propylene oxide (PO) fill line near the dust caps increased the likelihood of an incorrect connection. includes a color chart that defines color schemes for six 56 An error of commission is typically associated with performing a task out of sequence categories of chemicals and four user-defined color options for other chemicals. receives four chemicals54 via CTMV about 200 feet from the Mod B transfer area. Though not causal. Proper and piping should be equipment identification accurate and legible. connection point (circled) (Source: CSB). couplings. Combination of fill line shapes and sizes to avoid incorrect connections during deliveries (Source: CSB). reduces errors of Pipe markers should commission56 with be placed as close to using the wrong piece of the fill line as possible equipment or performing Sodium Hypochlorite Sulfuric Acid Fill Line Fill Line Figure 10. as one lever also appeared to be missing a split ring. the CSB found that this method could result in an incorrect connection because the same key could 54 The MGPI onsite WWTP receives phosphoric acid. effective 59 incorrectly identified as “hydrochloric acid” from a prior placement allows the pipes to be “traced. connection point) to finish (e. Labeling [Online].” The CSB observed pipe service (Figure 12.g. the CSB noted that the WWTP has a much and fill line (Figure 12..60 MGPI selected a sleeve or wrap marked with labels above each connection point (Figure 13).1 Scheme for the Identification of 62 Prior to the incident. 60 American Society of Mechanical Engineers. the text of the pipe marker appeared upside down from the vantage point of the fill line area (Figure 12. A13. 2017). tank). http://app. from start and elbow (right) (Source: CSB).1 Scheme for the Identification of 61 The transfer system was modified in 2009 when MGPI permanently replaced Pipes. around marker for the sodium hypochlorite piping that attached loosely to the pipe. 58 American Society of Mechanical Engineers. CSB MGPI Processing Case Study 17 . only propylene oxide had a pipe marker at its connection point (Figure 11). with tape directly on top of the hydrochloric acid marker from the previous service. 2007. 2007.g. The piping immediately downstream not be determined whether this pipe marker was adhered of all the Mod B fill lines changed direction at a 90-degree elbow to the sulfuric acid fill line prior to the incident. (e. 2007.11. top). it could connection points as possible. A13.62 (Figure 12. Both pipe markers are located several feet from the fill line markers to be placed at multiple points along piping. The recommended industry practice simpler design and identification scheme than Mod B. The CSB also found that the placement and orientation of the pipe markings downstream of some of the Mod B fill lines made it difficult Figure 12. It is common practice for pipe service (top). 57 Crowl. the adhesive pipe marker was affixed to the sulfuric acid line Pipes. Center for Chemical Process Safety/AIChE: New York. D.1 Scheme for the Identification of According to MGPI. emergency response actions removed the pipe marker during the incident.the wrong action. right). the sulfuric acid fill line was found to be and visually accessible from a normal line of vision . ASME: New York. hydrochloric acid with sulfuric acid for the modified starch process. the chemical fill lines at the WWTP are more clearly adjacent to changes in direction. the water deluge system or water spray from the firetrucks and Pipes. 59 American Society of Mechanical Engineers.com/hotlink/pdf/id:kt004MI1B3/human-factors-methods/ Figure 13. MGPI’s placement and orientation of the sodium hypochlorite pipe marker likely decreased its visibility and readability to the driver when he connected the sulfuric acid hose to the fill line.. right).knovel. it might have been immediately obvious to the driver that he was connecting the discharge hose to the incorrect fill line. Had MGPI placed pipe markers or identification tags on all the fill line connection points (or at the very least. For for piping identification states that pipe markers shall be placed instance.57 The CSB found several key deficiencies in the pipe marking system at the Mod B unloading area that likely contributed to the incorrect connection. labeling (accessed September 12. of the five fill lines in the area. Sodium hypochlorite pipe marker appearing upside down for drivers less familiar with the piping arrangement to confirm (left) and sulfuric acid piping mislabeled “hydrochloric acid” from a prior that they made a correct connection.58 These pipe markers must be strategically placed so that they can be easily followed After the incident. Both the sodium hypochlorite and sulfuric acid pipe markers were located several feet downstream of the pipe elbow By comparison. ASME: New York. 2007. The CSB noted that. left). on the sodium hypochlorite fill line connection point).61 Although the CSB found a damaged markers along the sulfuric acid and sodium hypochlorite piping and sulfuric acid pipe marker on the ground approximately 3 found that MGPI did not place pipe markers as close to the fill line feet south of the unloading station and fill lines. WWTP chemical fill lines (Source: CSB). NY. Human Factors Methods for Improving Performance in the Process Industries . In addition. ASME: New York. A13. Since the operator was more indicate what should be done. They reasoned that it was safer for truck drivers paperwork with the driver in the control room.1.knovel. reports that the operator did not monitoring process to determine if these were factors which led point out the location. Operators 5. were current with all MGPI training requirements on the sulfuric 64 CCPS. In addition.1.3. First. annually.3.knovel. if they unlocked only one fill line (i. including training on unloading states that operators must verify the connection: they are cargo tanks. after the operator signed the procedures.4 Error Prevention [Online]. the operator to open the fill line valve because they had the appropriate escorted the driver out to the unloading area.65 Training must be given at least once every three supposed to “have DOT-approved driver hook unloading hose years after the initial training. Accordingly.3. 18 CSB MGPI Processing Case Study . are conducted regularly Prevention [Online]. such as checklists. the driver. the procedure as function-specific training. careful attention to human factors sulfuric acid fill line valve. into procedures can help connected to the sodium hypochlorite line when he verified ensure critical steps are adhered to.R. The operator reports that he pointed out 5. and that the company lacked a procedure did not state that a correct connection be verified. when the driver is ready and the hose is connected. including those for unloading.R. as well unloading procedure in two critical ways.1.704(a) (2017).5. not the truck driver.1 MGPI also reported that it was their practice to have truck drivers 5. With respect to training. If the design and layout of procedures do not clearly the discharge hose and fill line.com/hotlink/pdf/id:kt0068GRV3/inherently-safer-chemical/error- prevention (accessed September 12. in contrast to all other Mod B unloading As discussed in Section 3. the resulting confusion can aware of the location of the sulfuric acid fill line valve than increase the potential for error. MGPI requires Mod B operators to review hose to any other connection.704(c)(2) (2017). Center for Chemical Process Safety/AIChE: New York.2 Training and Active Monitoring the fill line to the driver and that the driver acknowledged the The CSB reviewed both MGPI’s training program and active location.64 The CSB found that some operators were unfamiliar with these The CSB found that MGPI’s unloading procedures were not two steps in the unloading procedure. 66 49 C. Adherence to either step would is necessary for procedures. NY.66 The CSB found that. http://app. The extent to which facility the correct connection or attempted to open the valve.e. MGPI asserts that “Toolbox Talks. NY. An operator reported to CSB investigators that procedures did not align with work practices and attributes it seemed logical. observations about the chemical 63 CCPS. 2007). § 172.com/hotlink/pdf/id:kt0068GRV3/inherently-safer-chemical/error. that the truck driver would only be able to hook up to and discharge contents into that line. operator pointed out the safety shower and then unlocked the sulfuric acid fill line. operators train their personnel on procedures. The operator then returned the control directly to the incident. and verify knowledge and skills. 2007). 2009. the those deficiencies. the inclusion 63 the truck driver. addition. On the way. as part of to tank unloading station” and “not allow driver to connect its training program.1.1.4 Error deliveries and any changes necessary. he likely would have noticed that the driver of job aides. can also affect the potential for error..1. rigorous process to ensure operators understood and could even though all Mod B unloading procedures include a step safely follow them. 65 49 C. Inherently Safer Chemical Processes--A Life Cycle Approach: 6. 2009.1. as well as others. This work practice did not align with the Mod B sulfuric acid be provided general awareness/familiarization training. DOT regulations room before the driver made the connection and opened the provide requirements for hazardous materials (hazmat) chemical transfer valve to discharge contents from the cargo employees.” where operators discuss. correct fill line).” Second. Center for Chemical Process Safety/AIChE: New York.3 CHEMICAL UNLOADING PROCEDURES the operator. to inadequate training. These regulations require that each hazmat employee tank.F.F.1 Procedures and Work Practices Not Aligned open the fill line valve. § 172. the PPE on in the event of a spill or leak from the fill line. http://app. however. among other things. the CSB found that Harcros’ for verification. just as it is for design and pipe have required the operator to observe the connection between markings. Inherently Safer Chemical Processes--A Life Cycle Approach: 6. Mod B operators present on the day of the incident prevention (accessed September 12. They indicated that the aligned with work practices. In procedure. according to the all procedures. at Mod B. is supposed to open the To make processes safer. gov/ Noetic Group (Risk): Canberra. and appropriate management update the procedures.gov/ assets/1/7/Wilkinson_Active_Monitoring.acid unloading procedure. 2017). Australia and Washington. The Mod did not call for verification of the correct fill line and some B supervisor was off duty on the day of the incident. Such records or their routine practice was to ensure that dust caps were locked. When proactively ensure that barriers and risk controls are effective.1.csb. http://www.. The CSB found these gaps to training to properly oversee transfers.1. P. accounts might have proven vital for active monitoring as they Unloading procedures should always include measures to ensure likely would have informed management how best to improve that fill lines are properly locked after delivery.71 With meaningful employee activities carried out by line managers (i. DC. Active monitoring 69 without operator verification. P. who can training. not truck the CSB found that MGPI did not provide him with the necessary drivers. despite the existence of an active monitoring as instructed in procedures.3. although it could not be determined whether the exposure by allowing the driver to open the facility transfer sodium hypochlorite fill line dust cap was locked after the last valve. Had MGPI conducted effective had a record been created for the operators’ deviance from the active monitoring for its unloading procedures.67 Yet some stated that the procedure and adjusted the practice and/or procedure accordingly. Australia and Washington. however. assets/1/7/Wilkinson_Active_Monitoring. CSB MGPI Processing Case Study 19 . operators. B sodium hypochlorite and WWTP chemical unloading procedures.gov/ assets/1/7/Wilkinson_Active_Monitoring. correcting instances of nonconformance on a case-by-case basis. [Online]. management requirement that operators.gov/ chemical unloading procedures for comparison. then supervisory instruction. Although not causal. http://www. procedures can be written or updated to align directly overseeing those performing the work in the field) to with actual operator performance.csb. P. more effectively implement safety systems that work. Although the Mod B for verifying that dust caps on fill lines were locked after delivery. to open the fill line valve. Noetic Group (Risk): Canberra. operators reported to the CSB that no records or accounts of operator deviations. 70 Wilkinson.csb. DC. management can incorporate these process at Mod B for unloading operations. Noetic Group (Risk): Canberra. [Online]. not identify that operators were not performing procedures as The CSB found this aspect of active monitoring to be important written. removed a crucial barrier that shipment. it is critical for companies to regularly and effectively examine Active monitoring refers to all formal and informal checking them through active monitoring. [Online].pdf (accessed September 12. http://www. supervisor monitors the unloading practice by participating in Despite the fact that two fill lines were incapable of being and overseeing the majority of unloading transfers.68 actual practice is found to deviate from procedures in an unsafe In contrast. The role of “Active Monitoring” in Preventing Major Accidents. where appropriate. 2017). Noetic Group (Risk): Canberra. the process did actions into updated procedures and provide training on them. the CSB also found Because systems and procedures do not always work as intended. The role of “Active Monitoring” in Preventing Major Accidents. 2017). and train operators accordingly. including the Mod assets/1/7/Wilkinson_Active_Monitoring. supervisors.pdf (accessed September 12. The role of “Active Monitoring” in Preventing Major Accidents. 69 Wilkinson. 71 Wilkinson. the CSB nonetheless reviewed other MGPI 68 Wilkinson.pdf (accessed September 12.e. Australia and Washington.pdf (accessed September 12. and verification to adhere to the procedures is needed. DC. such as having truck drivers perform hose line hook-ups independence from line management. For example. 2017). Australia and Washington. P. instead focuses responsibility on line management. personnel could have assessed the safety risks of such a deviance. 5. valve. a practice that upon the unloading practices and/or procedures. none of the Mod B unloading procedures provided prevented drivers from mixing chemicals. not drivers. the CSB found locked before the incident. personnel participation. where actual operator practice may be safer than The CSB found that. were unaware that the procedure required operators.csb. http://www.70 Alternatively. even so. This deviation. Operators deviated from the procedure to avoid chemical because. open the facility transfer might have been able to note instances of nonalignment. auditing is typically carried out with a degree of way. [Online]. it necessary to examine MGPI’s active monitoring process. DC. should be checked periodically. In assessing MGPI’s training program. The role of “Active Monitoring” in Preventing Major Accidents. which requires more than be indicative of the inadequacy of MGPI’s training program.3 Comparison to Other Chemical 67 Mod B operators had most recently completed their sulfuric acid unloading Unloading Procedures at MGPI procedure training in June/July 2016. ensures that they are easy to follow and demands the use of. use. For example. the sulfuric are secured. standard.5. http://app. The CSB reviewed the Harcros CTMV unloading procedure and 73 CCPS. the sodium correct connections [ .2. state. and local governments. and found that they lacked consistency. inaccuracy.F. Guidelines for Writing Effective Operating and Maintenance Procedures found that work practices did not align with the procedure in [Online]. .2 HARCROS 72 CCPS. states. effective formatting and page Substance” under the EPA’s Emergency Planning and Community layout.1. § 355 app.” Compared to the Mod B sulfuric acid procedure step with respect to ensuring that truck driver actions aligned with for verification. 5. Furthermore. knovel. The procedure also calls the procedure. the acid and sodium hypochlorite and found an inconsistent approach. For more information on EPCRA. Part of the Mod B sodium hypochlorite unloading procedure (left) and sulfuric acid unloading procedure (right) (Source: MGPI). WWTP caustic unloading procedures states.72 Procedures must also be complete and accurate and Right-to-Know Act (EPCRA). a chemical The CSB examined the unloading procedures at Mod B for sulfuric delivered to Mod B.2. see Section 5.com/hotlink/pdf/id:kt0068GRV3/inherently-safer-chemical/error. in the WWTP’s unloading procedure for caustic. 40 prevention (accessed September 12.1 Procedures and Work Practices Not Aligned knovel. 2007). the truck driver writing-effective (accessed September 20. Center for Chemical Process Safety/AIChE: New York. NY. especially since sulfuric acid is classified as an “Extremely Hazardous among other things. “Verify the truck driver While the sodium hypochlorite procedure included space for has his hose hooked to the correct fill line and that all connections the operator to sign. Sign the truck driver[’]s paper work that you verif[ied] acid procedure did not (Figure 14). Center for Chemical Process Safety/AIChE: New York. NY. ] and then allow the driver to start unloading hypochlorite procedure was more detailed and direct. Critical steps or difficulty in implementation often present safety risks. including critical verification steps valve. Procedures that The CSB also found that the WWTP procedures employs a much are not followed due to obsolescence. 2007).3. substances to federal. two critical ways. http://app. unloading procedure should have at least matched (or preferably 5. On the day of the incident. of Extremely Hazardous Substances.75 include the appropriate level of detail. A (2017). .1. for example. 1996. this is much more specific.knovel. Inherently Safer Chemical Processes--A Life Cycle Approach: 6. unavailability.000 pounds. The CSB notes that the rigor applied to the sulfuric acid increases the likelihood that such steps are not overlooked. approach to chemical unloading. date. In terms of verifying a correct connection. 2009. 20 CSB MGPI Processing Case Study . Sulfuric acid is on EPCRA’s list http://app.com/hotlink/toc/id:kpGWEOMP01/guidelines-writing-effective/guidelines. and timestamp each step.73 This is particularly true for procedures involving critical tasks or activities. 2007). and release of hazardous Prevention [Online].com/hotlink/toc/id:kpGWEOMP01/guidelines-writing-effective/guidelines- writing-effective (accessed September 20. Guidelines for Writing Effective Operating and Maintenance Procedures [Online]. especially the caustic.4 Error 75 EPCRA requires industry to report on the storage. while sodium hypochlorite is not. Center for Chemical Process Safety/AIChE: New York.74 missing in the sulfuric acid unloading procedure are included. “Have supplier slowly open vehicle transfer valve.3.Figure 14.” while While including such steps in a procedure does not guarantee the sulfuric acid procedure does not mention the vehicle transfer that the steps will be followed.R. Consistency in procedures been greater than) that of the sodium hypochlorite procedure. different. 1996. 74 CCPS. NY. the sodium hypochlorite procedure for WWTP personnel to ensure the cap is locked after delivery. more specific. with a reportable quantity of 1. C. Attendance requires that (1) the the Department of Transportation cited the delivery company for violating the qualified person is within 25 feet of the cargo tank. as a result.Figure 15. In fact. 77 49 C. (2) the qualified person observes by means to enter the cab of the truck while unloading.F. “A motor carrier who transports hazardous materials by a cargo tank must ensure that the cargo tank is attended by a qualified person at all times during unloading. even from inside the either the fill line or truck valve to stop the flow of sulfuric acid. Harcros asserts that the driver could have continuously back of the truck. thereby allowing him to immediately close monitored the unloading operations.0). 49 C.S. the truck driver did not continuously monitor was the one and only. to the Harcros driver during the incident at MGPI. in 2015 (Section 6.77 Had this second step other fill lines were properly secured. showing sodium hypochlorite tank and cab of CTMV (Source: MGPI). he could not safely do so because the material to be transferred will be going into the correct vessel. § 177. and correct. it is go into the correct vessel. the procedure of the incident. 49 C.F.834(i)(2) 78 The Department of Transportation’s Pipeline and Hazardous Materials Safety (2017). Although the truck driver attempted to shut states that drivers must “carefully check to make certain that off the truck valve. and has an unobstructed attendance requirement because the company’s procedures required the truck driver view of the cargo tank and delivery hose. or (3) the hoses used in the loading or unloading are able to stop the cargo tank and delivery hose and would not provide an unobstructed view of the the flow of product from both source and receiving tank within 1 second without hose and activities occurring back there.834(i)(3) (2017) gives the conditions for which a qualified person including one in Holly Hill.F. is alert.” 49 C. however. in part. the driver likely would have reported to the CSB that he entered the cab to put away his monitored the unloading operations from an area closer to the paperwork. CSB MGPI Processing Case Study 21 . the correct one).” cloud had developed and he was surrounded by toxic gas.R § 177. Post-incident photograph of Harcros CTMV connected to sodium hypochlorite fill line at Mod B unloading area.834(i) (2017).834(i)(2) (2017) states.R § 177. as he was in the cab of the truck facing away MGPI operator assumed.R.R. the procedure states that drivers must “continuously monitor transfer. Department of Transportation regulation. connected his discharge hose to the first fill line he saw unlocked This in turn might have caused the chemical reaction to slow or after the operator left the unloading area. the driver in the procedure been followed. cab. He then opened the stop much sooner and. “attends” the loading or unloading of a cargo tank. fill line to connect to. Furthermore.. As the the transfer. In the Holly Hill incident. First.F. Similar circumstances occurred with respect human intervention.834(i)(3) (2017). the truck driver also assumed that all from the unloading area (Figure 15).e.78 76 This step is a requirement of a U. mitigated the consequences valves and returned to the cab of the truck.F. the fill line that the driver saw unlocked Furthermore. § 177. Second. The investigative team found that of video cameras and the loading or unloading system is equipped with various sitting in the cab of the tractor put the operator some 40 feet away from the rear of safety safeguards. Administration has investigated numerous incidents similar to the one at MGPI.”76 The CSB found. by maintaining an unobstructed view of the discharge hose and cargo truck through the truck’s side view mirrors. such as by tracing the fill line with likely that the truck driver did not confirm a correct connection the operator or requesting confirmation of a correct connection because he reasoned that if the operator unlocked only one fill from the operator before the operator left the unloading area. Florida. that the truck The CSB found that the driver was likely unfamiliar with these driver did not check to ensure the material in the truck would two steps in the tank truck unloading procedure. line (i. 49 C.R § 177. the roles actuation and of being remotely actuated.1. and 49 C. This action conflicted with Harcros’ procedure. The CSB also found that the driver was current with his Had the procedures been Commercial Driver’s License hazmat and tanker endorsements. For example.R.3.R.2. 79 The driver had most recently completed his training in 2016.F.R. training include “operation of emergency control that responsibilities are clearly defined. § 177. 5.”82 This training day of the incident. the driver’s trainer must observe and initial that they have been completed. mention when interviewed by the CSB that the procedure called for checking to ensure a correct connection.S. Department of Transportation (DOT) regulations for driver distributors to identify and assess risks associated with unloading training require. rather than attempt to close the of the location of a pneumatic emergency shutoff switch 80 valve at the back of the trailer. (3) the pneumatic emergency shut off at the front of the cargo tank. and (4) a manual upon.F. he did not 79 (Sources: Harcros and CSB). as indicated on the tanker training log.704(c)(2). 82 49 C. or agree switched.000 gallons procedures that address those risks. Harcros requires drivers to complete various tasks included on a tanker training log.2 Training The CSB also examined Harcros’ training program and determined that it was deficient in effectively communicating the importance of the critical safety steps that did not align with work practices on the day of the incident. Accordingly.F. § 172. drivers should be Nor did he mention that he was responsible for intimately familiar with the location of emergency remote continuously monitoring the unloading process. as well as with how they function. Procedures of the cargo tank. Harcros CTMV (right) and emergency shutoff switch (left) was current on all Harcros training requirements. 80 Pneumatic means containing or operated by air or gas under pressure.R. (2) a manual internal valve located at the rear of the cargo tank. procedures for should also establish valve on top of the cargo tank. § 177. chemical unloading a process that requires 22 CSB MGPI Processing Case Study .3. according to MGPI’s procedures. in part.5. Without adequate training. the truck driver opened the valve to the fill must occur once every three years per 49 C.816(b)(1) (2017).” Although training records indicate that the truck driver Figure 16. As part of its training program.348 (2017). Facilities and or agreed upon by 81 The Harcros tank trailer was a Department of Transportation 412 version. the driver might have attempted to trigger the the tanker training log indicated that the driver was aware emergency shutoff switch. on the features of the cargo tank or portable tank. despite being in the cab at the time of the incident (Figure 16).345 and 178. driver did not trigger the emergency shutoff switch. developed together. § 178.1. the CSB found that the the appropriate response reliably in a real emergency. 49 C. that for the operation of cargo tanks operations and collaborate to develop and/or agree upon or vehicles with portable tanks with a capacity of 1. shutoffs. at amount of reading or checking would be likely to produce the front of the trailer 81. the CSB identified practice locating and triggering the emergency remote shutoff another area that may have contributed to the incident: in simulations. which is chemical distributors required to have stop valves capable of closing the tank outlet within 30 seconds of both parties. no for the internal valve that would stop the flow of product. Such collaboration ensures or more.F. Two of these tasks include ensuring “customer’s piping is to the correct storage vessel” and “constant monitoring of the connections and tanker during the unloading process to abate leaks or any other malfunction that might arise.816(d) line although. four devices on the Harcros cargo tank could have stopped the flow of material from the trailer: (1) a manual external main valve located at the rear to develop. such as by requiring its drivers to In reviewing Harcros’ training documentation.3 COLLABORATION IN PROCEDURE DEVELOPMENT The CSB determined it is critical for facilities and chemical U. near the dome. should collaborate might not have been According to Harcros. Had Harcros provided adequate training. however. the operator was supposed to. http://app. Center for Chemical Process Safety/AIChE: New viewerType:toc/root_slug:guidelines-for-writing-effective-operating-and. NY. omissions. but would Alarms and interlocks are active safeguards that. chemical unloading area to the bulk tank. NY. as MGPI did not configure the critical when coordinating a multi-person procedure to prevent system to do that. should verify a correct connection before transferring chemicals. At 7:59 AM on the day of the incident. an interlock on a pressure from activating the activities or level indicator would have signaled the transfer valve to emergency stop buttons automatically close. MGPI did not have instrumentation help suppress the cloud interlocks and in the Mod B process control system that would have produced by the reaction. http://app. the sodium hypochlorite tank to the day tank. MGPI has a sodium hypochlorite tank level indicator that signals an As this incident demonstrates.4 Procedure Checklist Elements [Online].com/hotlink/pdf/id:kt00A68RY1/guidelines- maintenance-procedures (accessed September 12.knovel. pressure.1. Center for Chemical Process Safety/ 84 CCPS.facility personnel to be physically present during deliveries monitor process variables and function to eliminate or mitigate because they are more familiar with their equipment. On the day of the incident. not have mitigated the reaction. the driver did not recall hearing that information. as there was no remote shutdown capability for the chemical unloading area. that correct connection. 83 CCPS. [Online]. neither verbal nor visual verification was given MGPI had two emergency stop buttons for the Mod B process. where feasible. York.v/cid:kpGWEOMP01/ Stewardship.knovel. such as tips and reminders. Guidelines for Engineering Design for Process Safety .5. In addition. area. may also be employed. engineering/safeguard-stewardship (accessed September 12. MGPI had a deluge Finally. Activating the emergency stop buttons would have halted the processes. In addition. through the control system. such as a pressure increase. without requiring action from operators.com/web/toc. is automatically shut down the transfer. management and supervisory personnel must actively monitor system to mitigate propylene oxide releases in the unloading procedures for conformance. for the chemical processes. though the operator reported that he pointed out the in the control room. or level The cloud entering operations during exceedance. which emergency responders were able 5. operators could connection point to storage tank with drivers. management of facilities and chemical One of the emergency stop buttons could stop the flow from distributors should provide effective training on unloading procedures. the level the omission of steps. mitigation measures automatically shut down the transfer of chemicals in the event to maintain safe of a process deviation. including his understanding of what is happening. 2nd ed. in the sodium hypochlorite bulk tank. but not from the both periodically and when equipment or chemicals are modified. it only notifies operators of the high level and does not Using a checklist or other means. or signal operators to remotely mitigate a process concerns and increases the likelihood for safe execution. 83 indicator in the sodium hypochlorite bulk tank triggered an alarm Verifying a proper connection should be both verbal and visual. both facility personnel and CTMV drivers alarm in the control system when the level approaches tank capacity. where operators walk down fill lines from of the chemical unloading area. especially if the steps are critical to safety. 2017). and the other in the indoor process area. one nor requested. The after the sulfuric acid began flowing into the tank. such as a temperature. could remotely shut down equipment and processes downstream Equipment walk-downs. however.84 Process plants can configure instrumentation to Having both facility personnel and CTMV drivers monitor the automatically modify or shut down process equipment. Guidelines for Writing Effective Operating and Maintenance Procedures--5. and update them as necessary. Based on operator combination of verbal and visual confirmation is important because interviews. this was likely about the same time operators became it makes it more likely that an individual will catch his own errors or aware of the reaction and began to evacuate the control building. without chemical unloading process allows either party to identify operator action.7 Safeguard AIChE: New York. a hazard. Because the control room chemical unloading the reaction generated significant pressure and the tank prevented operators was 90% full prior to the delivery. 2012. remotely shut down equipment through the control system. 2017). CSB MGPI Processing Case Study 23 . when activated. 1996. deviation.2 AUTOMATION AND REMOTE SHUTDOWN to manually activate to Install or configure At the time of the incident. which forced operators toxic gas alarms that would have warned operators to don escape to evacuate. the outside air. monitors near the Mod B tank farm to detect concentrations of propylene oxide only. the CSB observed holes and gaps in the HVAC intake Because MGPI received and stored a number of hazardous ducts located on the roof.Designing and installing automated systems for chemical unloading Other than a particulate filter.csb. an alarm alerts operators to evacuate. ventilation.3 MOD B VENTILATION a predefined set point. and bulk chemical transfer area. At Honeywell.5-mile radius. entered an occupied process area from entering the control room. If the propylene oxide concentrations reached 5. (Honeywell) chemical plant in Baton associated with even higher chemical concentrations outside. flow of sulfuric acid that was reacting with the sodium hypochlorite the cloud had entered through the Mod B building intake before in the bulk tank long before emergency responders closed the operators became aware of the release. The HVAC intake system had no the cloud produced by the reaction. which resulted in injuries to seven workers and the issuance of a shelter-in-place advisory for residents within The Mod B building has a positive pressure control room. 24 CSB MGPI Processing Case Study . the Honeywell control any vapors from tank trucks unloading or from any vents or pressure release devices on the tanks could enter the control 85 CSB. However. If the pressure in the control room drops below room was designed to maintain a higher pressure than the outside that in the production area. which only maintained positive compares the air pressure inside the control room to that in the pressure relative to the production area. such an automatic shutoff device would have stopped the toxic release can the reduce impact on control room occupants. investigations/completed-investigations/?F_InvestigationId=54 (accessed October 3. Because Honeywell attempted to prevent vapors from outside entering the control room. the Honeywell control room was positive pressure and located on the first level of the structure. One of these intakes is As with MGPI.gov/ room through any doors. http://www. Rouge. which allowed chlorine to be drawn into chemicals in the chemical unloading area and tank farm. an alarm would sound in the control room The CSB found that the pre-incident design of the Mod B and operators were required to shut down the ventilation system building and ventilation system allowed for the intake of per the emergency action plan. from harmful gases or vapors from outside the building. the building during the release. and operators were forced to evacuate the area before they could air conditioning (HVAC) system for Mod B has a 4-ton air handler diagnose the problem and isolate the source of the leak. In addition. open crevices. with a high-speed motor that draws air from two intakes located on the exterior of the Mod B building. CSB found. The occupants from harmful vapors inside the production area. August 8. Positive pressure is control room through the ventilation system. the Honeywell control production area. MGPI had outdoor air discharge valve on the Harcros truck nearly 45 minutes later. Inc. however. Because the gases produced by the reaction respirators before the gases could enter through the vents. Though shutting off ventilation systems during a At MGPI. The CSB found achieved by maintaining a higher air pressure in the control room that the Honeywell release lasted 3.5 hours.85 The chlorine was released from a failed designed only to prevent harmful gases from the adjacent indoor coolant system and. atmosphere. 2005. partly because than in the indoor process area. they were forced to evacuate and did not have time to retrieve their emergency In 2003 the CSB investigated a release of chlorine gas from the escape respirators to protect them from respiratory hazards Honeywell International. MGPI’s heating. or air intakes. the ventilation system intakes Although MGPI designed the control room to protect were located at the highest point of the plant to pull in fresh air. 2017). as in the MGPI incident. adjacent to the tank farm designed to prevent the infiltration of hazardous gases. Honeywell Chemical Incidents. found that the positive pressure control system design considerations did not include protecting occupants did not protect personnel or equipment during the 2003 release. a 0. the fresh air intake that supplies areas provides additional safeguards to unloading processes as the air to the control room does not include filtration or cleaning systems automatically shut down valves supplying chemicals to bulk systems to effectively remove the chlorine gas or other gases from or day tanks in the event of an unintended reaction or tank overflow. A gauge constantly reads and unlike the Mod B building at MGPI. Louisiana. overwhelmed the operators in the control room. In addition. Chlorine is a chemical that falls under the PSM impact of a release on building occupants. the U. The Chlorine Institute (CI) also control the hazards involved in the process.1). CSB MGPI Processing Case Study 25 . other processes and chemicals at Mod B are trigger ventilation system shutdown and filtration equipment covered by the PSM standard.kuehnecompany. Administration (OSHA) Process Safety Management of Highly 89 29 C. The Chlorine 94 OSHA and MGPI entered an Informal Settlement Agreement on May 10. ventilation systems to protect occupants in buildings at facilities flammable. Pamphlet 64 recommends chlorine monitors with alarms that automatically However.90 PSM requires employers to perform provide direction around positive pressure control rooms that an initial PHA on covered processes to identify. reactive.R.F.4). Emergency Response Plans for Chlor-Alkali.1).F. Pamphlet 64.119(e) (2017). 2017). among other things. reduced the number of violations and penalty.1) covers emergency response plans for failing to accurately address the ingress of chlorine gas for sodium hypochlorite and suggests that facilities consider due to a catastrophic release from chlorine lines into the designing building and ventilation systems to minimize the control room. § 1910. the provides guidance on designing building and ventilation systems PHA shall address. VA. 2017. Sodium Hypochlorite and Hydrogen Chlorite Facilities. 93 Kuehne Company. cited Kuehne Chemical. The Chlorine Institute: Arlington. § 1910. and 752 threshold quantities. facility siting.F.1. New Jersey.91 Specifically. Although chlorine elevated air intakes. November 2014. The intakes on 87 B building on the day of the MGPI incident. Without these controls.88 PSM is a performance-based standard 5. The American the standard (Section 8. in the case of MGPI.119(a)(1) (2017).R.92 When for facilities handling sodium hypochlorite. given that the the MGPI incident.3.S.119(e)(1) (2017). 12 violations.119 (2017). 7th ed. including two chemicals to remove chlorine from supply air to keep building occupants stored above threshold quantities at Mod B: propylene safe during a chlorine release. Emergency Response Plans for Chlor-Alkali.com/history/ (accessed November 27. the chlorine the first floor of the Mod B building likely allowed for greater was a byproduct of a reaction between sulfuric acid and concentrations of chlorine in the cloud to enter the building sodium hypochlorite.. perform a process hazard analysis (PHA) on processes covered by the PSM standard. Although MGPI is evaluating siting.94 One was for not appropriately performing a PHA that addressed the hazard of toxic and flammable Although it does not include specific design requirements for control rooms. OSHA. because chlorine gas is heavier than air gas in addition to other toxic compounds entered the Mod and tends to accumulate at lower elevations.1 GUIDANCE AND STANDARDS that includes requirements for preventing or minimizing Standards and industry guidance for designing buildings and the consequences of catastrophic releases of toxic.93 Pamphlet 64 (Section 7. OSHA initially issued citations to MGPI for cloud entered the control room without warning (Section 5.R. neither of which is covered by PSM.room ventilation system intake was not equipped with toxic gas Hazardous Chemicals standard (PSM) requires facilities to alarms or an automatic shutoff. http://www. shortly after the chemical reaction began. November 2014. 7th ed.R. Occupational Safety and Health 88 29 C. § 1910. Pamphlet 64. Pamphlet 64 provides flammable gases from releases are able to enter control rooms. oxychloride (not received at the unloading area).F. a chlor-alkali plant in South Kearney. Because of was not readily accessible during the release. In 2008.F. Sodium 92 29 C.89 The PSM standard applies to Petroleum Institute (API) develops standards for petroleum processes that involve certain chemicals at or above specified refineries and API Recommended Practices 550. facilities should consider whether toxic or not a member of the CI (Section 7. and may be helpful to other industries. evaluate. or explosive chemicals that are covered under handling hazardous chemicals are limited. guidance on designing ventilation systems. under the PSM standard. but with a manual shutoff device. 551. VA. § 1910. 86 The Chlorine Institute. 90 19 C. operators oxide (received at the unloading area) and phosphorous must rely on respiratory protection that. § 1910. 91 29 C.. which Institute: Arlington. Hypochlorite and Hydrogen Chlorite Facilities. 87 The Chlorine Institute. See Section 8. 119(e)(3)(v) (2017).86 This includes standard if held in sufficient quantities. which can be useful to industries and facilities that handle sodium hypochlorite.R. 6. S. The CSB recommended that ASHRAE “Develop guidance for the time necessary to shut the plant down. MA. Safety/AIChE: New York. mitigation measures. fire and health hazards leading farm and the lack of access to appropriate respirators. This violation was amended in the plant hazard and control building design.knovel. Refrigeration. 2017). per API RP 752 be conducted to address potential toxic positive pressure requirements. on the effective design and maintenance of HVAC systems and CIA acknowledges that it may be possible for ducted air to be other necessary control room components designed to protect supplied from a sufficient distance “that it is uncontaminated employees and equipment in the event of a release of hazardous 99 Chemical Industry Association. 1979. or shutdown. Informal Settlement Agreement and combined with the general PHA violation. Elsevier: Waltham. London. http://app. operators likely would Evaluate building design must be capable have had more time to safely shut down processes. 100 CCPS..2 PREVIOUS RECOMMENDATION TO ASHRAE Design (1979). London.4 of this Case Study. R22)__O-ARAR1. the ventilation system at Mod Facility Siting and Layout (2003) discusses control building siting B may have been modified or designed to prevent ingress.S. 2003. 2012.”99 air handling equipment. England.com/hotlink/toc/id:kpGFSL0005/ 96 Mannan. Mod B operators were forced to evacuate the building without OSHA reasoned that “Employees were exposed to [a] release shutting down any other processes due to the toxic gas entering of volatile organic compounds (VOC)s to atmosphere that the building through the vents directly adjacent to the tank historically result in explosion. 2003-13-I-LA-R22. 102 Recommendation Status Change Summary. liable to prevent the infiltration of. http://www. Appendix III. 1979.1 and Section 5.100 CCPS also suggests that consequence analyses Industries (4th Edition) discusses the need for an airtight design. http://app. plant hazard and control building design. NY.”98 Alternatively. not adequately addressing hazards related to facility siting. and Air Conditioning Engineers or alternatively (ASHRAE).com/hotlink/toc/id:kpGFSL0005/ 97 Chemical Industry Association. 2017). 2017). and the possible use of toxic impacts to control buildings.com/hotlink/toc/id:kpLLPPIVH2/lees- 101 CCPS. Safety/AIChE: New York. 2017). (1979). 98 Chemical Industry Association. such as supplied air.knovel. Appendix III. 1-3. Guidelines for Facility Siting and Layout. NY. and evacuate. 4th ed. at the conclusion of the Honeywell investigation. 1979. Vols.96 Design of control rooms for protection HVAC pressurization. http://app. 2003.vapors entering the control room through the pressurized under the wind condition that put the building itself at risk. the CSB in the event of a spill or clean air for the length issued recommendation 2003-13-I-LA-R22102 to the American chemical reaction of the emergency Society of Heating.6. An approach to the categorization of process gov/assets/recommendation/Status_Change_Summary__ASHRAE_(Honeywell_ plant hazard and control building design. If the control building is shown gas detectors and alarms in the control building that shut off to be impacted. and placement of building HVAC intakes. Lees’ Loss Prevention in the Process Industries. MGPI was also specifically cited for As explained in Section 3. An approach to the categorization of process guidelines-facility-siting/guidelines-facility-siting (accessed September 13. CCPS recommends that vents and relief vents on equipment be located to vent to Commonly referenced texts briefly cover positive pressure control a safe location. Citation 1 Item 7. normal ventilation air. London. to injury and death to employees in the workplace. specifically a safe distance from building HVAC rooms and ventilation systems. should be provided. An approach to the categorization of process 95 OSHA Inspection 1186824. “Normal external ventilation Had the Mod B building and ventilation system been designed air supplies. to be contaminated. England. [Online] Center for Chemical Process loss-prevention/lees-loss-prevention (accessed September 13. (1979). or automatically respond to. retrieve and ventilation systems of being sealed their emergency escape respirators. [Online] Center for Chemical Process Citation 1 Item 6. [Online].csb.knovel.” 95 Had the hazard of toxic vapors entering the control room been The Center for Chemical Process Safety (CCPS) Guidelines for recognized prior to the incident.3. releases from the outdoor tank farm.101 against toxic releases is also discussed in the Chemical Industry Association’s (CIA) Process Plant Hazard and Control Building 5. in occupants are protected an emergency with 2005. standards and guidance for how to specifically stations to ensure building occupants design building ventilation systems to protect against different must be supplied in types of potentially hazardous chemicals from various sources. 26 CSB MGPI Processing Case Study . England.pdf (accessed September 13. Because of near chemical unloading off… [and] control the lack of U. guidelines-facility-siting/guidelines-facility-siting (accessed September 13. Lees’ Loss Prevention in the Process intakes.97 Specifically it states. Guidelines for Facility Siting and Layout. (1979). About ASHRAE.” proposed as either an ASHRAE handbook chapter or sources. The rest of the standard or chapter will help facilities select and install the correct equipment to protect occupants. combined and publishes voluntary consensus standards for the HVAC sources. ASHRAE also indicated that it planned the occupants of the Mod B building from internal sources to begin drafting the guidance document in February 2016. and filtration.org/standards-research-. and combined sources. In 2014. 2017).materials.ashrae. As described cause death or serious physical harm.g. pressurization equipment. and 4) there was a feasible means available that would eliminate or materially reduce the hazard. standards for purposes of identifying recognized hazards Ventilation is further outlined under the principles of protection that do not have a specific OSHA standard and thus fall under section. more specifically. 2016. containment. Standards and Guidelines. Other sections provide guidance on. as the performance. when evaluating the effectiveness of their engineering controls technology/standards--guidelines (accessed September 13.” 103 At that topics. ASHRAE had expressed support for the recommendation relation to work spaces. This provision affords OSHA the ability to issue citations when the four components of this provision 5. sources of hazards in time. ASHRAE issues this guidance. facilities can apply it to the design 105 ASHRAE. however.2.1 Energy Standard for Buildings Except Low-Rise Residential down the transfer from a safe location because the toxic cloud Buildings. 107 Section 5(A)(1) of the Occupational Safety and Health Act requires that employers to handle contaminants from inside or outside sources. and equipment and provided the CSB with an outline of a new guidance selection and installation. 3) the recognized hazard was causing or was likely to of a release if safe to do so and evacuating the area. information for designing and maintaining HVAC systems 104 ASHRAE. The CSB found that existing standards and guidance for 103 An “Open--Acceptable Response or Alternate Response” designation means a response by a recipient that indicates a planned action that would satisfy the addressing building ventilation at chemical facilities lack specific objective of the recommendation when implemented. and applicable standards and the eleventh provides developing the dedicated guidance as proposed to the CSB in 2014. principles of protection.” The outline is broken standard or chapter nor a timetable for its completion. Additionally. isolation and removal.107 In addition. The into eleven sections. model building and ventilation. Ventilation & Air ASHRAE has not yet provided the CSB with a draft of the Conditioning of Hazardous Spaces. Ventilation & Air Conditioning of Hazardous relation to work spaces. CSB MGPI Processing Case Study 27 . scope. the section on hazards covers hazardous industry. under sources of hazards in document. https://www. 105 ASHRAE is accredited by the American National Standards Institute (ANSI) and follows ANSI requirements for The section on equipment selection proposes to cover. both ANSI and ASHRAE standards as national consensus ventilation equipment.ashrae. and required to be strictly adhered to in some jurisdictions. among other to “Open—Acceptable Response or Alternate Response. It also covers other principles of protection such energy codes have adopted some ASHRAE standards and are as pressurization. https://www. performance. ASHRAE: Atlanta. whereas its other documents encourage enhanced result of a release from an inadvertent chemical reaction). 2017). which distinguishes between positive and negative the General Duty Clause.106 OSHA recognizes among other things and in conjunction with other standards.” In 2015 the CSB updated the Recommendations Status references. including a written timetable for completion. 108 filtration. Standards and Guidelines. internal sources. incident at MGPI highlights the need for ASHRAE to continue definitions. provide employment and place of employment free from recognized hazards that are causing or are likely to cause death or serious physical harm. or 106 ASHRAE.4 ACCESS TO EMERGENCY ESCAPE RESPIRATORS are met: 1) the employer failed to keep his/her workplace free of a “hazard.104 The standards define minimum values for acceptable conditions normally and abnormally present (e. ASHRAE distinguishes among external Spaces. that were in the processing area inside the Mod B building. MGPI protected standard or design guide. ASHRAE provided the CSB a proposed draft outline for a chapter or standard titled “Heating. operators could not stop the release by shutting 108 ASHRAE Standard 90. 2017).org/about-ashrae (accessed September to control hazards from a variety of chemicals and sources. the first few cover the purpose. or modification of occupied buildings and chemical processes.ashrae. If 13. https://www. applicable hazardous substances. the toxic cloud that entered the Mod B building was ASHRAE is a global. “Heating. nonprofit organization that develops the result of external sources and.org/standards-research-- technology/standards--guidelines (accessed September 13.. Of note. due process and standards development.” 2) the hazard was “recognized” either by the cited employer individually or by the MGPI’s Emergency Response Plan calls for shutting off the source employer’s industry generally. in Section 5. GA. The CSB also found that Harcros’ tanker training log the company instructs employees to properly store respirators states that all proper PPE must be donned according to the SDS for when not in use to prevent damage. the oncoming day MGPI to wear respirators. § 177. provided during the shipment of CTMVs for certain chemicals. operators immediately respiratory protection during the incident. 114 49 C. the respirator face pieces made for such a requirement when receiving verbal delivery that attached to them were not. never be secured such that immediate access is impeded.S. As such.F. Further complicating acid Safety Data Sheet (SDS). that the sulfuric shift operator’s respirator remained locked. in their trucks. emergency egress in hazardous atmospheres but. produced by Harcros. the Mod B area was not equipped with Hazardous Materials Safety Administration (PHMSA) Hazardous automatic controls to immediately stop the transfer of sulfuric Materials Regulations (HMR)s require respiratory protection be acid or shut down the building’s ventilation system. respirators at Mod B post-incident.109 Mod B did have mobile escape bottles with them. respirators should respirator was not provided to the driver on the day of the incident. Harcros drivers are generally not trained breathing air. therefore. See Section 9. cryogenic liquid must provide thereby reducing the severity of the injuries they suffered. § 1910. Harcros did not provide evacuated the building. such requirements establish that it is critical for chemical distribution companies to provide drivers 109 Escape respirators are hoods or face pieces attached to a supply of breathing air and are intended to be used only for emergency exit.840(k) (2017). Also. pieces be worn for individual protection. while they were MGPI did not have a respirator requirement. drivers with self-contained air breathing apparatuses that are approved by NIOSH. compartments or covers that are clearly marked as containing which might have allowed him to escape with less severe injuries. For had MGPI provided Mod B operators with easily accessible example. 29 C.840(e) (2017). 110 Although proper storage the chemical being delivered. As such. including face pieces with a gas mask of a type approved by the National Institute of and mobile escape bottles. According to Mod B operators. provides that matters is that these lockers are equipped with combination locks.F. Respiratory Protection Standard.113 been able to don their escape respirators before evacuating. diatomaceous Earth to one customer. however. carriers of carbon monoxide.112 Because of this.111 Immediate accessibility was vitally important at MGPI where operators had to rely on respiratory In reviewing regulations regarding the provision of respiratory protection to protect themselves from an outdoor chemical protection on CTMVs. MGPI operated under the assumption that Harcros drivers had access to respirators According to records from MGPI’s respiratory training program. § 177. Accordingly. emergency respirators. The Although a chemical respirator with organic vapor cartridge and full OSHA Respiratory Protection Standard requires that emergency face piece would not have provided the driver with clean breathing respirators be kept accessible in the work area and stored in air. intended to be used for a short duration during under the Respiratory Protection Standard. Pipeline and release. the CSB found that Mod B a respirator for the truck driver because Harcros does not require operators did not have immediate access to escape respirators delivery drivers to wear respirators unless its customers require for the evacuation.134(h)(2)(ii) (2017). other.0 for a description of post-incident changes. chlorine CTMVs must be shipped only when equipped storage areas for respiratory equipment. however. chemical respirators with organic vapor cartridges and full face requiring additional time in an emergency to attempt to unlock. MGPI immediately addressed this issue by ensuring the accessibility of emergency 113 49 C. it would have afforded the driver at least some protection. 28 CSB MGPI Processing Case Study . the CSB found that the U. According to Harcros. The CSB found.R. the Mod B operators might have Occupational Safety and Health (NIOSH) for chlorine service. Harcros operated under operators’ practice was to lock respirator face pieces in their lockers the assumption that MGPI did not have known workplace hazards at the end of each shift and remove them at the start of shift.R. and caustic soda and caustic potash to the 111 OSHA.entered the control room. As discussed. no indication was readily accessible during the incident. the instructions from the company.F.114 Although there is no similar regulation for The CSB also found that the truck driver did not have access to the shipment of sulfuric acid.R. Harcros delivers completed respiratory protection training in April 2016. 112 Harcros indicated that two of its customers require Harcros drivers to have respiratory protection readily accessible when making deliveries to their sites 110 The operators inside the control room on the day of the incident had most recently because of potential respiratory hazards that could be encountered. The CSB determined that this type of is key to prevent damage to this equipment. that would have caused Harcros drivers delivering chemicals to Because the incident occurred at shift change. Both require air purifying respirators. drivers can access emergency responders utilized social media and local radio and television to respirators to safely escape in the event of an accidental release. Furthermore. communicate details about the emergency. 2017). parties do not actively establish who is responsible for making the communication. the CSB recommends that Harcros establish a largely unknown throughout the incident. as described. As part of the after- process whereby the respiratory hazards associated with chemical action review.5 EMERGENCY PLANNING AND RESPONSE ANALYSIS with local hospitals to have a representative at the emergency 5. depending on the size Following the October 2016 incident. issued by the Atchison County 115 Onsolve Code Red Product Description. the equipment should be to hospital transport.5.1 INCIDENT AFTER ACTION REVIEW AND IMPROVEMENTS operations center or command post. city and county emergency of the event. As identified by ACDEM in the AAR & IP. it set up a plan 5. Harcros relies on to CodeRED since the incident. in addition to voice. so as to avoid triage stations in town to evaluate members of the public prior the problems faced by MGPI operators. informed of the status of potential victims and decontamination The evaluations should determine whether drivers might need procedures for the chemicals. ACDEM has completed additional communications made by its customers to determine workplace training on the CodeRED system to ensure it will work correctly hazards. This is meant to ensure that the representative is responders conducted a post-incident critique to examine issues up-to-date on all information to relay back to the hospital. Equipment and training for chemicals to the hospitals until about 1 and a half to 2 hours such protection should be provided. the exact chemicals be shared responsibility between chemical distribution companies and concentration of chemicals contained in the cloud. The emergency responders set up with OSHA’s Respiratory Protection Standard. an omission on the part of one may be Though some emergency responders quickly became aware interpreted as a commission by the other. CodeRED is a mass should ensure that drivers have access to. According to ACDEM. Most responders to determine the need to train drivers to don appropriate PPE and agreed that interagency communication and coordination respond to chemical spills or releases during unloading operations. there must of the chemicals involved in the reaction. text. though overwhelmed stored in an area of the CTMV that allows for immediate access. Such reliance may prove misplaced. CodeRED. Accordingly. As Department of Emergency Management (ACDEM). hospital staff reported that they were not kept unloading at each customer’s site are proactively evaluated. Though the response was largely viewed as a success by responders. Progress has been made with respect to be inadequate in part because. notifications did not go out at the time of the incident. In facilities can also store emergency respiratory protection near the absence of CodeRED functioning. after the incident. chemical distributors CodeRED® community notification system. As described. in accordance after the incident began. The report identified issues with the Where mitigating incidents is not feasible. and are properly notification system provider that can alert and inform subscribers of trained to wear. evacuate in the event of an incident. CodeRED notifications did not go out due to a lack The CSB found Harcros’ respiratory protection policy for drivers of training on the system.onsolve.115 Although Atchison County uses chemical distribution companies supplying respirators on CTMVs. chemical distributors challenges communicating the incident to the public as well as should provide the appropriate PPE for doing so on CTMVs. CSB MGPI Processing Case Study 29 . but they identified some Where mitigating incidents is feasible. emergency escape respirators on CTMVs to safely emergencies or severe weather through a variety of methods (e.com/solutions/products/ codered/ (accessed October 30. was able to decontaminate and treat all arriving patients. as appropriate. Atchison Hospital. remained safely. updating the local hospital. If properly trained. chemical distribution companies should conduct evaluations several issues and areas for improvement. mobile alerts).with respiratory protection when the circumstances warrant it. went well on the day of the incident. identified during the response. however. incident command did emergency escape respirators in the event of an accidental not directly communicate information regarding the released reaction and/or release of chemicals. where and has increased efforts to publicize the notification system. In addition. https://www. the After-Action Report and Improvement Plan (AAR & IP). identified such. ACDEM and local emergency unloading areas. initially. email.g.. Finally. as and facility management to ensure chemicals are unloaded well as the exposure effects on the community. gov/sites/production/files/2015-05/documents/epcra_fact_sheet. the AAR & IP identified the for receiving and processing public requests for information. gov/sites/production/files/2015-05/documents/epcra_fact_sheet. 121 EPA. The Emergency Planning and Community Right-to-Know Act.pdf&usg=AO 124 EPA.5. https://www. transportation.pdf&usg=AO vVaw2QLzSqlBWPlTpKez3akXCg (accessed October 30. fire. LEPCs. onsite Intended to address concerns about local preparedness for and offsite.S. (4) outline emergency the Emergency Planning and Community Right-to-Know Act notification procedures. establish procedures Following the incident. The Emergency Planning and Community Right-to-Know Act. and effects associated with the chemicals involved in the reaction environmental professionals.cdc. Sharing Information Across Sites. and provide information to the public.126 The plans must (1) identify facilities and transportation routes of extremely hazardous 5. MGPI annually. 2017).pdf (accessed emergency-planning-committees (accessed November 2.C. 2017). CDC February 2017.S. CDC February 2017.1). gov%2Fnssp%2Fdocuments%2Fsuccess-story-chemical-spill-20170201. and the media. began sharing information subject to EPCRA emergency planning requirements. https%3A%2F%2Fwww.epa. 120 EPA. (5) explain the means to determine the (EPCRA) of 1986. 119 EPA. (3) hazardous chemical (8) provide a training program for emergency responders inventory reporting (§§ 311-312). 2017). (7) outline evacuation plans.epa. need for more operational coordination and a liaison and review local emergency response plans.pdf (accessed 125 EPA. each of which communicate and share health information to increase must have a Local Emergency Planning Committee (LEPC). Epidemiologists at KDHE used the system to search the health police. and respond to. established a framework for states to organize probable area and population affected by chemical releases. 2017). The Emergency Planning and Community Right-to-Know Act. https://www. 118 community groups.124 While SERCs supervise and coordinate the activities of LEPCs. Chemical Spill in Kansas: Importance of 123 42 U. 117 https://www. Less than two months after the incident. public health. 2017). 116 The NSSP expertise in emergency response.119 EPCRA is divided (6) describe local emergency equipment and facilities and the into four parts: (1) emergency planning (§§ 301-303). 2017).gov/epcra/local- November 2.123 awareness of.epa. including a representative from Atchison Hospital. to discuss the Community emergency response plans are developed by LEPCs hazards of the chemicals used at Mod B (Section 5. October 31. Chemical Spill in Kansas: Importance of Sharing Information across Sites. the Kansas Department of Health and EPCRA Section 301 requires each state to create a State Emergency Environment (KDHE) initiated syndromic surveillance through the Response Commission (SERC) composed of individuals with National Syndromic Surveillance Program (NSSP). https://www.5. hazardous events and outbreaks. LEPCs develop to communicate exposure information during similar community emergency response plans.127 Facilities covered EPCRA are different.2. gov/sites/production/files/2015-05/documents/epcra_fact_sheet.2 STATE AND LOCAL EMERGENCY PLANNING substances. 127 EPA.epa.pdf (accessed November 2.During the incident.epa. 2017). 30 CSB MGPI Processing Case Study . 118 National Syndromic Surveillance Program.125 hosted training with local emergency responders. https://www. 2017). § 11001 (1986). as are the quantities that trigger reporting. within two hours of the incident. and (9) detail methods and schedules reporting (§ 313). gov%2Fnssp%2Fdocuments%2Fsuccess-story-chemical-spill-20170201.121 by Section 311 must also submit Emergency and Hazardous Chemical Inventory forms to their SERCs. (2) describe emergency response procedures.117 LEPCs must be composed of elected state and local officials. coordinators to implement the plan. resources to pre-plan for chemical accidents. review the plans incidents. The Emergency Planning and Community Right-to-Know Act. representatives of facilities and. emergency release notification (§ 304). emergency-planning-committees (accessed November 2.html 122 42 U.122 It also requires each system enables public health agencies at all levels to immediately SERC to set forth emergency planning districts.gov/nssp/overview. (3) designate a community coordinator and facility chemical emergencies and to ensure public access to information. with state and local health departments and hospitals.C. November 2. with stakeholder participation. 2017). § 11001 (1986). https%3A%2F%2Fwww. The Emergency Planning and Community Right-to-Know Act.epa. vVaw2QLzSqlBWPlTpKez3akXCg (accessed October 30. and (4) toxic chemical release (including schedules).pdf (accessed November 2. https://www.cdc. gov/sites/production/files/2015-05/documents/epcra_fact_sheet. Local Emergency Planning Committee. (2) people responsible for them. https://www. and local fire 116 National Syndromic Surveillance Program. Local Emergency Planning Committee.gov/epcra/local- gov/sites/production/files/2015-05/documents/epcra_fact_sheet.pdf (accessed 126 EPA.epa.120 The chemicals covered by each section of for exercising emergency response plans. https://www. civil defense.cdc. 2008 Nationwide Survey of Local Emergency Planning Committees (LEPCs): apr%2014.gov/KDEM.pdf (accessed December 5. https://www.kansastag. 2017). 131 Information submitted under Sections 311 and coordinates proposals for training grant funds.gov/sites/production/files/2013-08/documents/2008_ lepcsurv.epa. funding deficiencies have often these organizations work to provide information and training caused shortfalls.2.asp?PageID=408 132 EPA. 2017). 2008 Nationwide Survey of Local Emergency Planning Committees (LEPCs): (accessed December 4. hazard category).epa.kansastag.asp?PageID=408 133 EPA.gov/KDEM.pdf (accessed December 5. the CSB found that AFD had conducted annual tours gov/sites/production/files/2015-05/documents/epcra_fact_sheet. https://www. although a majority of them responsibilities as well as example activities. 2017). and together.135 This is achieved preceding calendar year. The Emergency Planning and Community Right-to-Know Act.gov/sites/production/files/2013-08/documents/2008_ lepcsurv. gov/sites/production/files/2015-05/documents/epcra_fact_sheet. 2017). emergency October 31. http:// kansastag. A 2008 survey by EPA found that the majority to LEPCs within the state. (2) an estimate (in ranges) of the by assisting with the development of local hazard mitigation average daily amount of hazardous chemicals in each category. 135 Kansas Department of Emergency Management.pdf (accessed October 31. 129 EPA. oversees 105 LEPCs within the state. https://www. neither the city nor the county trained for such an event.134 Accordingly. http://www. though there were no issues with the response that LEPCs take advantage of grants and resources. The CEPR and KDEM published an of LEPCs were not receiving technical assistance or guidance LEPC handbook to provide information on LEPC duties and from the federal government. https://www. the CSB submissions or are unfunded. The CEPR implements federal EPCRA (in ranges) of the maximum amount of hazardous chemicals provisions and works to enhance state and local emergency for each category present at the facility at any time during the response and preparedness capabilities. Final Report.128 Facilities provide either Tier I or Tier II In the state of Kansas.asp?PageID=408 131 EPA. 2017). In terms of the Atchison County LEPC. when available.133 Although grants are occasionally the CEPR has multiple resources available to LEPCs including made for LEPC activity with federal funding such as the conference presentations and regional training activities. The Emergency Planning and Community Right-to-Know Act. 2017). With respect to the Atchison Fire Department 128 EPA.departments annually. or members of the public.138 In addition.epa. The Emergency Planning and Community Right-to-Know Act. 137 Kansas Department of Emergency Management.pdf (accessed October 31. gov/sites/production/files/2015-05/documents/epcra_fact_sheet.5. 2017). Commission on Emergency Planning and Response. 2017). 138 Kansas Department of Emergency Management. (accessed December 4. directing their activities. the Commission on Emergency inventory forms. 136 Kansas Department of Emergency Management. The Emergency Planning and Community Right-to-Know Act. but list the information by chemical (rather than by planning districts.pdf (accessed facility’s sprinklers. http://www.epa. it is critical that noted that.139 gov/sites/production/files/2015-05/documents/epcra_fact_sheet.136 category. lighting. many LEPCs only 5.epa. Final Report. Commission on Emergency Planning and Response. Commission on Emergency Planning and Response.137 and 312 is available to the public from SERCs and LEPCs.1 ATCHISON COUNTY LEPC receive direct funding through state fees from EPCRA report When examining emergency planning and response. 2017). resulted in additional consequences to emergency responders in order to ensure the full success of their capabilities. https://www.pdf (accessed October 31. (accessed December 4.gov/AdvHTML_doc_upload/2014%20LEPC%20Handbook%209%20 134 EPA. exercises and reported that federal support “plays a significant role” in potential sources for additional LEPC funding.kansastag. 2017). planning and management. among other duties. plans. 129 Tier I inventory forms include the following Planning and Response (CEPR) serves as the state emergency information for each applicable hazard category: (1) an estimate response commission. Department of Transportation (DOT) Hazardous Materials Emergency Preparedness (HMEP) Grants. employees. https://www. safety showers/eye wash stations. and reviewing responses and (3) the general location of hazardous chemicals in each to emergencies and recommending improvements.epa. The Emergency Planning and Community Right-to-Know Act. Kansas LEPC Handbook. AFD performs annual inspections of the gov/sites/production/files/2015-05/documents/epcra_fact_sheet. 130 EPA.130 Tier II inventory forms contain much of the same The CEPR. 139 The Atchison County LEPC is administered by ACDEM. CSB MGPI Processing Case Study 31 .epa.gov/KDEM.132 The Kansas Department of Emergency Management (KDEM) While EPCRA provides an essential function to emergency provides administrative support to the CEPR. http://www.pdf (accessed October 30. (AFD). training and exercises.pdf (accessed of MGPI as well as annual fire extinguisher training for MGPI October 31. https://www. designates emergency information. and hydrants. 2017). In addition. under EPCRA. chemicals to be covered under the EPA Risk Management These training exercises did not include incidents at chemical Program (RMP). https://www. https://www. States. In 140 Kansas Department of Emergency Management.gov/AdvHTML_ representatives from law enforcement/EMS/firefighting and MGPI. More recent exercises. hazmat/hazardous-materials-grants-program (accessed October 31.gov/AdvHTML_doc_upload/2014%20LEPC%20Handbook%209%20 recent LEPC roster from March 2017 lists 26 members. The LEPC organizes full-scale exercises produce or store extremely hazardous chemicals. How LEPCs can use RMP tools when planning for chemical accidents. 2017. or train training and table-top exercises for area emergency responders on.dot. MGPI has increased its involvement sodium hypochlorite and sulfuric acid as those chemicals are with local emergency planners and responders. where a chlorine gas release resulting allocations: planning and training. Kansas LEPC Handbook. https:// the events of that day. and Atchison 5. and August 2017. improve. KDEM July 2016 http://kansastag. The most http://kansastag.dot. 2008 Nationwide Survey of LEPCs. as well as successes and improvements www. hazards of those chemicals. however. 2017).epa. emergency responders and facilities Kansas. pp26.142 The HMEP comprises two facilitated by KDEM. During not covered under the EPA RMP. provides financial and sessions. however. Three separate sessions were held. MGPI invited emergency that LEPCs can gain useful information by reviewing facility responders to Mod B for training on the chemicals used and Risk Management Plans and training for offsite releases stored there. on October 6. incidents involving accidental facility Risk Management Plans from the state for preplanning releases of unknown chemicals in the community. PHMSA Hazardous Materials Grants Program. 2017). its Emergency Response state fees or other private sources. Atchison County LEPC. including the locations of all advantage of federal grant opportunities to support and enhance bulk tanks and chemicals stored therein. the week of December 12. active shooter situations. territories and tribal nations Just as MGPI increased its involvement with local emergency can designate an agency to receive HMEP grant funds.pdf (accessed October 31. and implement emergency plans Atchison County LEPC also participated in that exercise. doc_upload/Risk%20Management%20Program-EPA%20Ndiaye%20and%20Brewer. there are four other facilities focused on infectious diseases.140 Atchison County. 144 PHMSA Hazardous Materials Grants Program. KDEM requests project proposals from active and eligible have also increased participation in the Atchison County LEPC. 2017. pdf (accessed October 31. 2017). 2017) During an LEPC meeting held on March 22. committee 141 EPA. holds The CSB found that the Atchison LEPC does not review. MGPI provided copies of a non-compatible chemical Because LEPCs generally only receive funding through the matrix for all chemicals used at Mod B. https://www. It also demonstrated their emergency planning and training programs. The CSB still found. Further.143 The purpose of the planning from a railcar derailment was simulated.144 In planners and responders. or review Risk Management Plans prior to the incident.phmsa. 2017). offered by PHMSA. The LEPCs are encouraged by KDEM to request facilities. EPA Risk Management Plans submitted by facilities that throughout the year.gov/grants/ Emergency Response Plan be discussed at the end of each year.gov/sites/production/ members conducted a tabletop exercise of the incident that files/2013-08/documents/2008_lepcsurv. with attendees from AFD. the every three years. April 2016. were largely CSB concluded that besides MGPI. 20 members were listed on the LEPC roster. A functional and training.phmsa. 32 CSB MGPI Processing Case Study . that could be made in the future. and in Atchison County that store sufficient quantities of hazardous severe weather events prior to the October 2016 incident. Additionally. LEPC meetings were also held in May.gov/grants/ hazmat/hazardous-materials-grants-program (accessed October 31.gov/grants/hazmat/hazardous-materials-grants-program (accessed October 31. July. 2017). together with ACDEM.5.3 THE HMEP GRANT PROGRAM Hospital. The training allocation funds public sector employee training for hazmat incidents. pp 35. or more specifically. 2016. Local emergency response departments discussed 142 The Hazard Grants Programs are funded by registration fees collected by DOT from hazmat shippers and carriers.pdf (accessed November 1. and maps of its facility.phmsa. occurred at MGPI. including apr%2014. as well as for a discussion on the properties and involving chemicals processed and stored at those sites. LEPCs and SERCs must take Plan. however did not obtain hazmat exercise is scheduled for the second quarter of 2019. MGPI attended technical assistance and guidance to enhance hazardous materials and participated in a Tabletop Exercise in Hiawatha. MGPI also requested that its 143 PHMSA Hazardous Materials Grants Program.the CSB found that the LEPC. The Risk Management Plan submitted for MGPI did not include Following the incident. Kansas.141 The HMEP new PPE installed at Mod B since the incident during these grant program. Members of the grant is to develop.dot. emergency planning and training. 15 (2017). 148 Kansas HMEP Grant Guideline. and work planning to prevent hazmat transportation incidents. 2017).16 (2017) and mandate immediate November 1.F.pdf (accessed The CSB reviewed PHMSA incident data from 2014 through November 1.gov/ 154 PHMSA’s regulations require detailed written reports for hazardous materials AdvHTML_doc_upload/HMEP%202015-2016%20Grant%20Guide%20. and conducting drills and exercises to test pre-planning and training with chemical facilities in the county county emergency response capabilities and identify gaps in to ensure the community is prepared for future incidents. awards the grants. The CSB learned that the Atchison County LEPC has not 2003-2007 and found that a significant number of highway directly applied for or received HMEP grant funding for planning incidents153 subject to mandatory reporting154 occurred or training since 2007. pp 7. http://www.152 The CSB found that over the years a number of injuries have occurred as a result of similar incidents involving inadvertent Funding is provided to the Atchison County LEPC from local tax mixing during unloading.000 in grant funding. 148 The HMEP Atchison LEPC should better utilize the training and information grant program designates funding priorities for training and resources available at a state and regional level. 2017).1 PHMSA Guidance for further discussion of PHMSA data and November 1.pdf (accessed (3) unloading incidental to movement of a hazardous material. the CSB found that the Atchison Country LEPC can to LEPCs. 17. http://www. KDEM: 2016. KDEM: 2016. 146 In FY 2014-2015.1(c) (2017). and (4) storage November 1. PHMSA reviewed incident data from dollars.gov/ commonly involve compatible materials and result in tank AdvHTML_doc_upload/HMEP%202015-2016%20Grant%20Guide%20. incidental to movement of a hazardous material.2. http://www.kansastag.0 SIMILAR INCIDENTS DURING release. AdvHTML_doc_upload/HMEP%202015-2016%20Grant%20Guide%20.kansastag. 146 Kansas HMEP Grant Guideline.gov/ 153 PHMSA’s regulations apply to the transportation of hazardous materials in AdvHTML_doc_upload/HMEP%202015-2016%20Grant%20Guide%20.gov/ AdvHTML_doc_upload/HMEP%202015-2016%20Grant%20Guide%20. training and planning.kansastag.pdf (accessed incidents as described in 49 C.LEPCs.pdf (accessed overfills. pp 3. which separates transportation functions into four 150 Kansas HMEP Grant Guideline. 145 Kansas HMEP Grant Guideline. http://www. 2017). was included in an application submitted by another county to information regarding similar incidents from PHMSA. Less common are incidents similar to the MGPI November 1.151 Planning activities can include hazmat tabletop UNLOADING OPERATIONS exercises and hazmat preparedness activities for fixed facilities. 152 Kansas HMEP Grant Guideline. unloading. 2017). was similar to the MGPI incident and involved a carrier delivering sodium hypochlorite. reporting for serious incidents that meet thresholds described in 49 C. KDEM distributes grant awards and monitors Though KDEM uses HMEP grant funds for state and regional how award funds are used. One such conduct a 12-county regional commodity flow study to identify event in Holly Hill.kansastag. 5. since November 1. Therefore. 2017). Florida.gov/ 2017 and found that unloading incidents involving hose AdvHTML_doc_upload/HMEP%202015-2016%20Grant%20Guide%20. and storage incidental to transportation. KDEM: 2016.gov/ areas: (1) movement.147 KDEM can distribute funds directly participate. CSB MGPI Processing Case Study 33 .kansastag. or fund state and regional hazardous materials and training activities. it hazardous material. http://www. However. KDEM: 2016.gov/ AdvHTML_doc_upload/HMEP%202015-2016%20Grant%20Guide%20. In 2007. pp 5.R. See 49 C. the program includes conducting appropriate specifically directed at preparing for emergencies involving hazard assessments to determine the level of hazmat risks hazardous materials. 150 Eligible training activities can include chemical specific response training.kansastag. pp 9.149 Among with the state to apply for grants that will provide funding other priorities.gov/ incident where two incompatible materials are inadvertently AdvHTML_doc_upload/HMEP%202015-2016%20Grant%20Guide%20. 2017). In addition the LEPC should conduct more within a jurisdiction. 147 Kansas HMEP Grant Guideline. http://www. such as a toxic chemical 6. fund exercise and training initiatives that benefit local benefit from applying for grants to fund additional planning responders. § 171. 2017).pdf (accessed mixed due to incorrect tank connections. the LEPC received grant funds during loading and unloading incident to movement of a to update the county emergency operations plan. pp 5. guidance. § 171. KDEM: 2016.pdf (accessed commerce. http://www.kansastag. KDEM: 2016.145 Once PHMSA hazmat transportation flow patterns throughout the state.155 The CSB requested and received. (2) loading incidental to movement of a hazardous material.pdf (accessed 155 See Section 8. pp 10-11. § 171. November 1. 151 Kansas HMEP Grant Guideline. KDEM: 2016. Kansas received activities through which LEPCs and emergency responders can $368. pp 5.F. 2017).R.R. pp 5. including loading. KDEM: 2016. http://www.kansastag.F. the CSB concludes that the training through universities and training institutes. In 2013.pdf (accessed connections to incorrect tanks occur frequently but most November 1. 149 Kansas HMEP Grant Guideline. and submits grant applications to PHMSA. https://www. These incidents can lead to injuries and evacuations begin flow of liquid then leave the rear of the cargo tank due to potentially violent chemical reactions and harmful gases to climb into the cab of the tractor to start the engine and entering the air. alkali 157 chemicals. https://www.org/about-us/ (accessed 159 The Chlorine Institute. The that sitting in the cab of the tractor put the operator some CSB concludes that adopting key lessons and recommendations 40 feet away from the rear of the cargo tank and delivery resulting from this Case Study.159 Additionally. which include safety its members that produce. and suppliers. the CI has developed many safety 156 Up to and including June 9. sodium hydroxide. generation plants. and other information for the chlor- sodium hypochlorite. recommended practices. 2017. in that the process is public and private swimming pools. 158 CI members include chlorine producers. and hydrochloric acid collectively. 34 CSB MGPI Processing Case Study . Individuals Evacuated: 846 The DOT investigative team found that the “company’s Analysis of the data reveals that these incidents occur periodically SOP and related training for unloading of cargo tanks and are not tied to specific industries. distribution. 2017) hose from a truck filled with sodium hypochlorite to a Incidents: 8 fill line to two storage tanks containing sulfuric acid. Florida.1 CHLORINE INSTITUTE returned. As a result. distribute. the driver apparently The Chlorine Institute (CI) is a technical trade association that walked into the chemical gas cloud when returning to the focuses on the production. the CI requires and comply with stewardship policies. § 177. Inadvertent mixing during unloading can occur build up air pressure.R. users. anhydrous hydrogen chloride. in addition to recognized industry hose and would not have provided an unobstructed and regulatory guidance. In the Holly Hill incident.chlorineinstitute. for instance. or use chlorine to sign and security audits and hazard evaluations of chlor-alkali operations. These incidents resulted in 44 injuries and the evacuation of 846 individuals (Table 3).chlorineinstitute.” The DOT investigative team found at any facility that receives more than one type of chemical. and use of chlor.org/hess/hess-overview/ September 12. packagers. Holly Hill Incident The Pipeline and Hazardous Materials Safety Administration Table 3. 2014. 2017). Incidents involving inadvertent mixing from PHMSA Database (PHMSA) investigated a similar incident to the MGPI (Source: CSB).F. stipulated by 49 C. (accessed November 15.834(i). rear of the vehicle after the situation was out of control. resources and technical pamphlets that provide guidelines. The Injuries: 44 mixture of the two materials caused a release of gas that Hospitalizations: 2 overcame the operator and several local residents. and its North American producer members account for a majority of the total a Member Safety and Security Commitment and Pamphlet chlorine production capacity of the United States and Canada. incident in 2015 that occurred in Holly Hill. certifying that they will promote and demonstrate safety and security and that they have implemented As part of its chlorine stewardship program. as well as at other industrial to open valves on the cargo tank and fixed storage tanks to facilities. 158 The Chlorine Institute. can prevent similar incidents. the operator would be unaware of 7. potassium hydroxide. 2014 found that the driver of the tank truck connected a delivery through June 9. 2017).0 INDUSTRY ASSOCIATIONS AND GUIDANCE any abnormalities occurring at the connection until he 7. 157 Chlor-alkali products refer to chlorine. view of the hose and activities during the unloading operation. distributors.January 1. Certification annually. incidents violated the attendance requirement during unloading as have occurred at water treatment plants. PHMSA PHMSA Totals: (January 1.156 eight incidents similar to the MGPI incident have occurred involving incompatible materials and resulting in a chemical reaction. 4th ed. Pamphlet 64. and market It was not placed at the connection point or immediately adjacent to the downstream elbow. Emergency Response Plans for Chlor-Alkali. Pamphlet 96. as connections. And.” a new Sodium Hypochlorite.. 7. although concluded that voluntary adherence to the information in these MGPI used padlocks and keys to open the caps on the fill lines pamphlets could have prevented or mitigated the incident. Sodium 160 The Chlorine Institute. Pamphlet 64. the CSB avoid any compatibility issues. “Sodium Hypochlorite Manual. transportation and uses. the CI advises that employers provide escape routing. VA. and Hydrogen Chloride Facilities. Pamphlet 96.3. packaging. although the The National Association of Chemical Distributors (NACD) is chemicals are incompatible.4. and the regulations affecting these areas. steps for unloading in Appendix D include “verify[ing] that during an accidental release of chlor-alkali products. for example.163 As described in Section 5. visible. October 2011. MGPI’s sodium hypochlorite fill line was located CHEMICAL DISTRIBUTORS only 18 inches from the sulfuric acid fill line. 163 The Chlorine Institute. the can trace the product piping from the connection severity of consequences that followed the inadvertent mixture point to the receiving tank. transport. In addition. system did not protect occupants from the plume.” is a guidance Harcros verified that the connection was correct.. Institute: Arlington.164 Members consist of companies that loosely attached to the line and appeared to be upside down.”161 Appendix D also recommends: of the building ventilation system. Furthermore. October 2011.alkali industry and emergency responders. ease of access to escape respirators became an issue for • Locating sodium hypochlorite unloading connections operators during the incident. (accessed December 4.com/about/about/ Chlorine Institute: Arlington. The 164 National Association of Chemical Distributors. Sodium Hypochlorite Manual. re-package. VA. November 2014. which meant that operators had away from incompatible product loading/unloading to evacuate without respiratory protection. neither the sodium hypochlorite fill line Institute: Arlington. Had MGPI and marked as best as possible so that the unloader voluntarily followed Pamphlet 64 before the incident. 7th ed. the Mod B control room ventilation • Ensuring sodium hypochlorite piping is short. safe handling. incident might have been prevented or the likelihood reduced. VA.” provides addition to the prior edition. The Chlorine by Pamphlet 96. while not identified 162 The Chlorine Institute. The CSB reviewed connection point nor the CTMV hose receptacle had a unique pamphlets related to the equipment and processes at MGPI and size or shape to prevent incorrect connections. might have been lessened. https://www. its properties.) [. and intends to work with the CI to communicate the key lessons • Considering the use of lockout systems to prevent from this Case Study at the completion of its investigation. Furthermore. in the unloading area. the sodium hypochlorite fill line was unlocked at the time of the incident. November 2014. 2017). The Hypochlorite and Hydrogen Chlorite Facilities. store. Recommended procedural the basics of an emergency response plan to be used. Emergency Response Plans for Chlor-Alkali. etc.160 A critical part of Pamphlet 96 is CI Pamphlet 64. 4th ed. CSB MGPI Processing Case Study 35 . the closest sodium an international association of chemical distributors and their hypochlorite pipe marker to the fill line connection point was supply-chain partners. respirators and consider steps to minimize the consequences of [and] follow[ing] applicable regulations for monitoring/ a release on a building’s occupants in the design and operation attendance. formulate. “Emergency Response Plans for Chlor-Alkali. Finally. VA.162 Among the unloading connections/piping are correct (check labels. manufacture. The Chlorine Chlorine Institute: Arlington.. the hypochlorite. neither MGPI nor CI Pamphlet 96.] verify[ing] connections by a second person. unloading into tanks prior to proper verification. Had MGPI document intended to provide information about sodium voluntarily followed Pamphlet 96 before the incident. blend. 7th ed. Because sodium hypochlorite is one • Dedicating sodium hypochlorite unloading lines to of the chemicals handled by CI member companies. process. other things.nacd. which would have made the line much easier to trace. Sodium Hypochlorite and Hydrogen Chlorite Facilities. described in Section 5. 161 The Chlorine Institute. Appendix D.2 NATIONAL ASSOCIATION OF As discussed.. “Guidance to Avoid Accidental Mixing. Sodium Hypochlorite Manual. and the environment. and downstream users that participate in NACD activities. the CSB found that.174 to the member companies and their chemical handler affiliates Therefore. As part of that verification process.173 Harcros Chemicals Inc. to ensure lessons and recommended practices are shared with nacd. Improving Reactive Hazard Management.com/distribution (accessed December 4.nacd. 2017). 174 Harcros Distribution. Distribution Program. https://www. NACD holds various events. nacd. the Harcros unloading procedure required document based on the Responsible Distribution Program’s Guiding verifications to ensure correct connections to minimize the risk Principles and a Code of Management Practice. member companies must describe how guidance and information 165 National Association of Chemical Distributors. subject to Responsible Distribution on-site verification. Responsible Distribution.nacd.pdf (accessed September 19. such as the facilities that receive chemicals. 171 On-site program verification is conducted inadvertent mixing of incompatible chemicals. 2017). 169 NACD’s Management Practice in 2003 to ensure procedures for loading Responsible Distribution Program verification is required of each and unloading chemicals at member company facilities include. at least once every three years.com/distribution (accessed December 4. 2017). safety. the CSB issued a recommendation to NACD following its customers. 36 CSB MGPI Processing Case Study . As such. 2017). http://harcros.168 NACD of incompatible chemicals. health. iveHazardInvestigationReport.172 Successful of inadvertent mixing from improper loading and unloading. such as customers. http://harcros. https://www. 2017). an increased awareness of hazards from the of company facilities. 168 National Association of Chemical Distributors. 175 also modified the Code of Management Practice to verify member companies have a process in place to ensure that In 2002. of the 167 serious incidents involving mixing hazards. more than 50% of the 450 members and affiliate companies represent more than 85% incidents involved chemicals not covered under existing OSHA and of the chemical distribution capacity in the United States. http://www.nacd. webinars through which downstream users can also benefit from 170 Examples of CHAs include public warehouses and carriers. are shared with downstream 166 National Association of Chemical Distributors. 2017).com/rd/about/verification/ (accessed December 4. and 30% occurred at facilities that use or consume bulk quantities of chemicals. users.177 As a result.csb. the CSB To become a member company of NACD. http://www. safety & security program.pdf (accessed September 19.nacd. information sharing and lessons learned.000 customers. 167 National Association of Chemical Distributors.com/about/about/ Though downstream users are not subject to the Responsible (accessed December 4. https://www. Third Party Verification. companies must recommended NACD “Expand the existing Responsible Distribution meet certain requirements. however. nacd. At the time of the by an independent. NACD member and chemical handler affiliate170 at a 20% sampling among other things. 2017). Improving Reactive Hazard Management. third-party verifier(s) against a specifications 2016 incident at MGPI. Harcros manufacturing and distribution facilities are within the Responsible Distribution Program.176 In receive information to increase awareness of inadvertent the study. ensure that the revisions address requires members to work continuously to improve performance storage and handling.csb. http://www. 2017).com/about/about/ regarding loading and unloading.com/about/about/ (accessed December 4. to work with NACD following the publication of this Case Study nacd. and 169 National Association of Chemical Distributors. NACD member companies.com/rd/about/verification/ (accessed December 4. 177 CSB.”178 In response to the recommendation. is a NACD’s modifications to procedural verification only extended verified member of the NACD Responsible Distribution Program.com/rd/about/verification/ (accessed December 4. 2017).gov/assets/1/19/React iveHazardInvestigationReport. 2017). “at a minimum.com/about/about/ (accessed December 4. 166 EPA process safety standards. one of which is participation in Process to include reactive hazard management as an area of NACD’s Responsible Distribution® Program. is a condition of continued membership in NACD.gov/assets/1/19/React 175 Harcros Distribution. 176 CSB. 2017).pdf (accessed September 19. NACD. the CSB intends 171 National Association of Chemical Distributors. hazards of incompatible mixtures. 2017).gov/assets/1/19/React 178 CSB. https://www. https://www. iveHazardInvestigationReport.com/rd/about/ (accessed December 4.csb. https://www. https://www. meetings. as well as non-member distributors 173 National Association of Chemical Distributors. Improving Reactive Hazard Management. warehouses and carriers.chemical products for over 750. 167 The program emphasis” and. also Improving Reactive Hazard Management investigation study. and the (accessed December 4. chemical storage. 2017). https://www. completion. 172 National Association of Chemical Distributors. including the hazards of inadvertent mixing in protecting health. accomplishes this through a mandatory third-party verified NACD updated its Responsible Distribution Program Code of environmental. Third Party Verification.165 NACD’s nearly reactive hazards between 1980 and 2001. Third Party Verification. Accordingly. On April 19. whereby certain phosphorous oxychloride. propylene oxide and entered an Informal Settlement Agreement. as MGPI hazardous materials handled or stored in the workplace. For more information on OSHA’s PSM standard: https://www. as well OSHA’s National Emphasis Program (NEP) for PSM Covered as relevant PHMSA guidance. and found them to be pertinent. The at Mod B. www. they are included here because they provide the October 2016 incident as described in this Case Study. OSHA’s PSM applies to two chemicals stored above threshold elements to the entire Mod B process. MGPI identified the potential for the wrong an investigation that arose out of this incident.gov/pls/oshaweb/ owadisp. to prevent the transfer of a involve chemicals other than 30% sulfuric acid and sodium wrong chemical. as well as the application of PSM for covered chemicals because the chemicals are not covered under the standard. one of the PSM violations pertained to a PHA requirement for facility 8.180 communication training to follow standard operating procedures to unload sulfuric acid.1200(h)(3)(ii) 1910.3.1200(h). but Though OSHA does not have a specific standard for bulk not limited to. OSHA inspected MGPI for compliance with under OSHA’s PSM standard.osha. such as reactivity. OSHA and PHMSA. PSM standard. which are covered under the OSHA citations and penalties were amended and/or withdrawn. most of which failed to prevent or mitigate hypochlorite. OSHA and MGPI The Mod B process uses two chemicals. which requires employees to to determine their applicability to this incident. 179 This operators were unable to retrieve respirators per the written includes chemical properties. to the CSB’s investigation and findings. are included in this hazards. including the NEP for PSM Covered Chemical Facilities.html. it has a number of regulations that apply to the safe handling of chemicals. OSHA’s NEP. The standard contains requirements for managing hazards associated with handling highly hazardous chemicals. OSHA issued citations to MGPI well as their history. For information on 179 29 CFR 1910. are outside the scope of the CSB’s investigations in that they such as training and procedures. For example.show_document?p_table=STANDARDS&p_id=9760.181 As discussed in Section 5. particularly and Harcros for violations.gov/dep/neps/nep-programs. see: https:// 180 29 CFR 1910. Chemical Facilities. as MGPI facility. While other violations MGPI included mostly generic administrative safeguards. and not providing employees with the required hazard for employees to protect themselves from chemical exposure. employees with effective communication and training on violating requirements for emergency action plans.0 REGULATORY OVERSIGHT AND GUIDANCE equipment and operations for non-covered chemicals. MGPI voluntarily applied a number of PSM 181 As mentioned. 2017. specifically regarding occupied structures including.osha. for connection to this incident. which included unloading quantities in the Mod B area: (1) propylene oxide and (2) phosphorous oxychloride. OSHA conducted and completed from March 2015. Harcros was cited for failing to ensure employees were Though sodium hypochlorite and 30% sulfuric acid are not not exposed to the hazards of chemicals due to the lack covered chemicals. and measures plan.1200(h)(3)(iii). the CSB looked into PHMSA’s HMRs. Regulations identify potential process risks and safeguards in place to mitigate from two agencies. Harcros in relation to all applicable requirements while at the With respect to these. As discussed. CSB MGPI Processing Case Study 37 . was voluntary incident. In the most recent PHA for Mod B before the incident Case Study for discussion. On May 10. the CSB reviewed the HMRs. One The CSB reviewed various regulations from different agencies key provision of PSM is the PHA. the one conducted by MGPI for the regulations that covered processes and activities involved in the two chemicals involved in the incident. however.1 OSHA siting. 2017.8. the control room inside the Mod B building. Some of the violations issued to MGPI so far as inadvertent mixing of incompatible materials is pertained to OSHA’s PSM standard and were covered under concerned. PHAs are required Following the incident. unloading activities. OSHA also conducted a compliance inspection of CSB also collaborated with and reviewed PHMSA regulations. Many of the chemical to be transferred into the sodium hypochlorite bulk violations for which OSHA cited MGPI and Harcros correspond tank due to operator error or a “bad shipment” of a chemical. insight into a voluntary Process Hazard Analysis (PHA) conducted by MGPI before the incident. the OSHA The remaining OSHA violations included not having Hazard Communication standard requires employers to provide adequate emergency exits in the Mod B control room. and other information that has rulemaking. 186 49 C. 190 Hazardous Materials: Cargo Tank Motor Vehicle Loading and Unloading Operations.R. sets and enforces standards. leaving in the event of a chemical release. and issued a Notice of Proposed Rulemaking (NPRM) to amend conducts research to prevent incidents. clarify a rule or statute’s meaning. Examples of these incident (work practices). 13313. § 171. similar incidents involving the approximately 39% did not include a failure cause. https://www. A. Reg. (accessed September 13. https://www.phmsa. 186 with existing standards for hoses carried aboard CTMVs. 11. and foreign carriers by rail car. 13313. as well as emergency procedures to follow causes include “failure to attend or monitor the operation. published guidance documents safety risks of bulk loading and unloading operations through related to offloading incidents. 11. 11. Mission. 2011). 11.2 PHMSA and approximately 75% of those incidents involved CTMVs. 13313. Cargo Tank Motor Vehicle Loading and Unloading Operations. 33% can be attributed to incorrect operation when performing prevent cross contamination of chemicals while unloading a loading or unloading function. Reg. 11. for a more in-depth discussion of HMR. 76 Fed.phmsa.191 In other facilities via motor vehicle. inadvertent mixture of incompatible materials during unloading 188 Hazardous Materials: Cargo Tank Motor Vehicle Loading and Unloading Operations.182 PHMSA establishes recommendations made by the CSB and NTSB. 76 Fed. 2011).R. 2017).1(c) (2017).1.192 After receiving comments and conducting a supplementary policy PHMSA provided the CSB documentation of recent PHMSA analysis. 76 Fed. Reg. specifically 193 Guidance is not legally binding and may not mandate or require a particular action. procedures based on the results of the risk assessment. 76 Fed. its intent is to provide helpful information. 13315 (Mar.F. Reg. the rule would have required facilities like MGPI to transportation of hazardous materials in commerce. 2011). PHMSA reconsidered its approach to addressing the investigations of similar incidents. 13315 (Mar. 182 PHMSA. in 2011 PHMSA national policy. incident data involving bulk loading and unloading of hazardous Section II. The violation stated that the Harcros driver and 2007 and found that.dot. Vision and Goals. and vessel. 13313. including implement maintenance and inspection programs consistent loading. 183 The Office of Hazardous the HMRs.185 Harcros is subject to the also proposed additional personnel training and qualification HMRs because it delivers hazardous materials to MGPI and requirements for persons who perform those operations. 13313 (Mar.gov/about/mission 191 Hazardous Materials: Cargo Tank Motor Vehicle Loading and Unloading Operations. unloading.F. see Section 5. Instead. 13315 (Mar. motor vehicle. Vision and Goals. 2011).0. 13313 (Mar.0.of training under OSHA’s hazard communication training materials transported via highway and rail occurring between 2003 requirement. Mission. 2011). 76 Fed. Analysis reflects failure causes reported 8.F. 11.”188 PHMSA was created in 2004 as a DOT agency tasked with protecting people and the environment by advancing the safe Because of the frequency of bulk unloading incidents and safety transportation of hazardous materials. together with current incidents. Harcros entered an valves in the wrong position.dot. mixture of incompatible materials is discussed in Section 6. Reg. have occurred somewhat frequently. 13315 (Mar. As discussed in Section 6.189 The amendments would have required each Materials Safety within PHMSA enforces the HMRs. A similar incident involving offloading and the inadvertent regulations.”187 PHMSA also found that “90% of the serious incidents occurred during highway loading or unloading operations 8. educates. 183 PHMSA. provide direction on bulk loading and unloading. of the incidents that reported a failure had not been trained on the appropriate actions to take to cause. 2017). 187 Hazardous Materials: Cargo Tank Motor Vehicle Loading and Unloading Operations. § 171. PHMSA decided to conduct outreach allowed the CSB to conduct a thorough examination of offloading and issue a guidance document193 that.1 PHMSA GUIDANCE on incident reports. 13313. and storage incidental to transportation. 13313. 13313. Section III. 13313 (Mar. or improperly connecting hoses and Informal Settlement Agreement with OSHA May 8. or communicate PHMSA’s policy for implementing requirements. 184 49 C. 38 CSB MGPI Processing Case Study . 76 Fed.3. other equipment. intrastate. 76 Fed.gov/about/mission 192 Hazardous Materials: Cargo Tank Motor Vehicle Loading and Unloading Operations.2. Reg.R. Reg. 2011).1(c) (2017). 2017. 11.184 which person who engages in CTMV loading or unloading to perform generally apply to hazardous materials being transported a risk assessment and develop and implement safe operating via interstate. (accessed September 13. PHMSA reviewed serious 189 Hazardous Materials: Cargo Tank Motor Vehicle Loading and Unloading Operations. Not all incident reports reported a failure cause and PHMSA did not assume the cause of the failure if a failure cause was not indicated on the report. Hazardous Materials: 185 49 C. Parts 171-180 (2017). PHMSA also regulates the addition.190 PHMSA aircraft. 2011). the attendance requirement. 194 PHMSA. selecting unique fittings.pdf (accessed December 7.In 2014. 2017).2 for an analysis of MGPI’s labelling deficiencies.gov/services/publication_ 200 See Section 5. required verification that material is being transferred into whether employed by a carrier or facility.1 for an analysis of MGPI’s design of chemical transfer equipment. Certain evaluated and feedback provided on the performance of their design issues. and implementing clear operating procedures based on those assessments and Prior to the incident. Had MGPI and Harcros actively monitored engineering controls to avoid the mixture of incompatible operators while unloading.phmsa. however.197 The CSB found that neither MGPI nor Harcros had connections. https://hazmatonline. or enhance existing.1. the incident may have been avoided.199 In addition. clearly identifying whether facility personnel or the CTMV operator is responsible for each loading/unloading activity.pdf (accessed December 7.201 conducting risk assessments and audits.gov/services/publication_ documents/CTMV%20Guidelines. https://hazmatonline.gov/services/ publication_documents/CTMV%20Guidelines. 195 PHMSA recommends that all hazmat employees. https://hazmatonline. MGPI might page companion pocket guide (PHMSA Companion Guide) have identified the incorrect pipe marking at Mod B and lack to serve as a reference for chemical delivery drivers. Had these suggested engineering controls aware that operators and drivers were not adhering to been implemented. the companies may have become materials (Figure 17). Best Practices Guide.gov/services/publication_ documents/CTMV%20Guidelines. or at least sufficient information.pdf (accessed December 7. both Harcros’ and MGPI’s procedures audits. 201 Cargo Tank Motor Vehicle (CTMV) Loading/Unloading Operations: Recommended 198 Post-incident. Figure 17. 2017). pp 5 https://hazmatonline.200 PHMSA states that employers should use these risk assessments to The PHMSA Guide provides various best practices for training.dot. CSB MGPI Processing Case Study 39 . including to allow carriers to comply with unloading procedures. 198 oversight of carrier personnel during unloading operations. See documents/CTMV%20Guidelines. PHMSA issued roles and responsibilities for valve operation might not have the “Cargo Tank Motor Vehicle (CTMV) Loading/Unloading been switched between facility personnel and CTMV drivers.0 for an analysis of MGPI’s updated procedures. 2017). Procedures used to ensure safe loading/unloading should also be assessed to identify areas for improvement. such as adding distance between incompatible duties. 196 Employees should also be observed and oral communication between the driver and operator. and applying clearer a program or process for evaluating and providing feedback pipe markings. The PHMSA Guide also suggests implementing Harcros drivers.dot.phmsa. 2017). 202 See Section 5. Operations: Recommended Best Practices Guide” (PHMSA and critical steps missing from the procedures could have Guide). Had MGPI management completed a risk assessment prior to the incident. and providing carriers PHMSA also recommends that parties who load or unload with written instructions. CTMVs perform a risk assessment of the operation. MGPI changed its unloading procedure and. 197 Cargo Tank Motor Vehicle (CTMV) Loading/Unloading Operations: Recommended 199 See Section 5. Best Practices Guide. 194 Cargo Tank Motor Vehicle (CTMV) Loading/Unloading Operations: Recommended Best Practices Guide.3 for a discussion of Operating Procedures.dot. be evaluated annually the appropriate tank and that the tank has sufficient room to gauge their understanding of safe loading/unloading to receive the chemical.phmsa.1.202 The unloading procedures as written and could have provided PHMSA Guide also recommends that facility operators provide appropriate feedback and training to correct deficiencies.phmsa. with input from OSHA and EPA. been identified and corrected.dot. 195 Cargo Tank Motor Vehicle (CTMV) Loading/Unloading Operations: Recommended Best Practices Guide. operating procedures. Best Practices Guide.pdf (accessed December 7. Section 5. at the same time.3 for a discussion of procedural deficiencies and Section 9.dot. published a two. both procedures relied on procedures. could greatly reduce the likelihood of incorrect to Mod B employees performing unloading operations or connections. pp 5. including supervision during unloading. implement new.phmsa. documents/CTMV%20Guidelines. 2017).1. Excerpt from “CTMV Loading/Unloading Operations: 196 Cargo Tank Motor Vehicle (CTMV) Loading/Unloading Operations: Recommended Recommended Best Practices Guide” (Source: PHMSA).gov/services/publication_ now requires a salaried employee to observe operators during unloading.1. among other changes.pdf (accessed December 7. https://hazmatonline. of signs or pipe markers at the connection points. to ask before loading/ (Source: MGPI). in part. New coupling on the Mod B sulfuric acid fill line mostly geared toward carrier personnel. emergency response. As such. Although PHMSA’s mandate focuses on the other couplings at the Mod B unloading area (Figure 18). including: with MGPI to select and install new couplings on the Mod B • Chemical unloading connection adjustments (a 203 Cargo Tank Motor Vehicle (CTMV) Loading/Unloading Operations: Recommended minimum of three-foot separation between each Best Practices Guide.2. until more permanent changes could be made. MGPI made some temporary changes to its transfer equipment and unloading area to reduce the potential for a similar incident. The two-page PHMSA Companion Guide provides questions.phmsa. 2017). by enforcing the HMRs and acid fill line. replacing Figure 19.dot. PHMSA concludes. and operating procedures. placing new (or more securely affixing existing) pipe markers closer to fill line connection points and elbows. unloading. transportation aspect of hazardous materials.203 The PHMSA Guide provides practical applications of best practices to clarify where facility personnel should play a primary role.0 MGPI AND HARCROS POST-INCIDENT CHANGES Immediately following the incident. MGPI also made a number of other engineering chemical unloading procedures. 9. After making the immediate modifications described placing new color-coded tags on the fill lines. 40 CSB MGPI Processing Case Study . that safe loading/unloading of hazardous materials is a shared responsibility between the carrier and facility. the CSB has developed “Recommended Practices for Facilities Receiving Chemicals by CTMVs” (Appendix B) that will be published as a companion document to this Case Study. like the CSB. but also a shorter reference guide that facility personnel can refer to before loading/unloading chemicals.8.2 SHARED RESPONSIBILITY sulfuric acid fill line and Harcros sulfuric acid delivery hoses. PHMSA’s mission to protect people and the environment by These couplings share the same unusual size and shape. https://hazmatonline. Separation of unloading connections with secure cages the caps on the fill lines with caps that use a different locking around connection points at Mod B (Source: MGPI). and updating the above. risk assessment. such as in training and evaluation. These included placing dedicated locks with separate keys on the different fill line caps.gov/services/ unloading connection with a secure cage around each publication_documents/CTMV%20Guidelines. Facilities receiving chemicals will benefit from not only existing PHMSA guidance. The CSB concludes that facilities also play a vital role in ensuring chemicals are unloaded safely and that lessons learned and recommendations in this Case Study will augment PHMSA and other agency guidance and regulations to prevent similar incidents. The couplings are also colored differently from all issuing guidance. such that advancing the safe transportation of energy and other hazardous only the correct delivery hose can be connected to the sulfuric materials is accomplished. Harcros worked and process safety changes at Mod B. mechanism.pdf (accessed December 7. pp 13. Additionally. Figure 18. connection point with card reader access and related B employees. (e. processes and organizations. introduced by that change. and were involved in reviewing devices. MGPI also modified the storage and all chemical unloading activities that require human accessibility of the Mod B emergency respirators. and in accordance with the investigation key lessons. In addition. represented employees were consulted on desired changes to • Additional monitoring and emergency shutdown their work area post-incident. When assessing risks associated with chemical a chemical. the Mod B control room is now equipped with a cabinet may increase the potential for an incorrect connection. additional alarm-state situations. Represented employees including the water sprinkler deluge system. Modifications to unloading equipment and complete a tanker pre-unloading checklist with customers. Instead of interaction. MGPI and Harcros worked together to develop and agree upon deliveries.. processes as exemplified in this section. have participated in facility walkthroughs with procedures in hand. install and configure MGPI continued to receive active participation from Mod safeguards. including represented employees. in the administrative controls on access) (Figure 19). piping and receiving tanks) and. where feasible. which has practices and procedures as well. In addition. can greatly reduce the opportunities Apart from the changes to practices and procedures MGPI for inadvertent mixing during chemical unloading operations. fill lines. MGPI received input from represented handling equipment. identify and address human factors issues that bottles. and following. implemented by MGPI address a number of human factors Procedures also require operators to inspect fill lines to ensure and design issues presented in this Case Study.0 KEY LESSONS drivers. such as interlocks and mitigation 204 A hood is a respiratory inlet covering that completely covers the head and neck and 205 Management of change is a process for evaluating and controlling modifications to may also cover portions of the shoulders and torso. For example. Instead of face pieces. they also made changes to promote greater coordination between operators and 10. all dust caps are secured and locked prior to. and Harcros made independently. transfer valves. Evaluate chemical transfer equipment and processes accessible to protect operators in the event of a similar incident. all Management of Change205 documentation for all Mod-B • Design changes to the operator control room and air modifications. hoods are equipment. MGPI now prohibits been accepted and integrated into company practice. MGPI also requires its operators to ensure unloading process and equipment. CSB MGPI Processing Case Study 41 . and employees on the revision of unloading procedures and the • Emergency response and preparedness modifications. For example. to identify and address hazards that may be also used with escape bottles. Harcros created a new sulfuric acid unloading procedures and design changes to reduce the likelihood of procedure specific to MGPI and now requires its drivers to similar incident. hierarchy of controls when evaluating controls and safeguards for preventing inadvertent mixing. containing both supplied air bottles and hoods204 that are easily 2. development of new procedures. For Following the incident. apply the drivers can identify the CTMV emergency stop button. development and implementation of modifications to • Engineering system interlocks that correspond to equipment and processes following the incident. operators and drivers must complete For fixed facilities that receive chemicals: written verification forms to ensure that procedural steps are followed and to certify a correct connection prior to unloading 1. and have provided recommendations on the frequency with Both MGPI and Harcros revised their chemical unloading which operators should be retrained on procedures.g. unloading to start within 20 minutes of shift change and requires that a safety observer be present when connecting The CSB concludes that many of the post-incident changes and disconnecting a cargo tank hose to a chemical fill line. either by facility personnel or CTMV storing emergency respirator face pieces separately from escape drivers. for bases) or different sized diameters (e. occupied structures near chemical unloading stations acids delivered to an unloading area separate from to ensure occupants are protected in the event of bases) to avoid reactive incidents resulting from a spill or chemical reaction. Evaluate building design and ventilation systems for physically separated by a discernable distance (e.g. For all occupied buildings near chemical unloading round) for each fill line. such as ASME A13. and the careful especially where several chemicals are unloaded in close selection of intake locations to prevent chemicals from proximity. level. and respond to hazardous process conditions Procedures should establish a process that requires (e. This is particularly accordingly. distributors should provide effective initial and and other mitigation systems. Work with chemical distributors to select hose couplings makeup air-cleaning and filtration systems.. Work with chemical distributors to conduct a of a spill or unintended reaction and release during risk assessment and. Conduct reviews of control 2007 Scheme for the Identification of Piping Systems. 42 CSB MGPI Processing Case Study . areas and bulk storage tanks. addition. deluge. even between shifts. fill lines.g. and alarms that automatically shut down HVAC coded fittings for each chemical or class of chemicals.. The control system should monitor to ensure responsibilities are clearly defined. should include positive-pressure ventilation systems. as well as ventilation. activated remotely to stop the flow of chemicals into or when equipment or chemicals are modified. square for acids. Design or modify chemical transfer equipment procedures to ensure conformance.1.. the material contained in the equipment in accordance to ensure that workers can immediately access the with accepted industry standards. This can include a combination of accepted entering the supply. rooms and emergency evacuation routes to determine Affix pipe markers as close to fill line connection points the most accessible location of employee respirators as possible so that personnel involved in unloading near escape bottles and update emergency response activities can easily identify equipment and chemicals and respiratory protection procedures and training prior to making a connection. 4. In facility piping or receiving tanks during an emergency. 2-inch or 3-inch 8. Where automated process control and a correct connection before discharging chemicals. systems in the event of a release. evaluate the accessibility 5. configure transfer Management of both facilities and chemical valves and equipment. Ensure pipe marking and identification of transfer of emergency respirators and escape bottles in the equipment (e. verbally and visually.. safety systems are not feasible. Design considerations inadvertent mixing. transfer piping. unloading areas for drivers and personnel in the event 6. and/or during equipment walk-downs) unloading.. temperature. and event of a toxic release. based on the results of the unloading operations.g. measures.g. hexagon regularly to ensure they are functioning properly. develop and/or agree upon procedures maintain safe operations during chemical unloading for chemical unloading and emergency operations activities. valves. management should actively monitor 3. pressure. Provide emergency escape respirators near chemical chemicals in one area. Both facility personnel and drivers should transfer of chemicals and other processes in the event verify (i. equipment at all times. in the process control system that will assessment.. so that they can be refresher training on the procedures periodically.g. important when there are multiple fill lines for different 9. to ensure fill lines for incompatible materials are 7. sensors and fill line connections with uniquely shaped and color. These systems should be checked fittings with unique shapes (e. or airborne facility personnel to be physically present during concentrations) and automatically shut down the deliveries. Avoid locking emergency tanks) identification are clear and accurately represent respirator components in lockers.e. through written of an unintended reaction or release during chemical checklists. more than 39. contaminant monitoring devices.g. Following from unintended reactions and inadvertent mixing.9 million Commission an independent engineering evaluation of the tons of product were delivered to customers every 8. respirators on CTMVs to safely evacuate in the event of an incident. In addition. the consequences to protect occupants from a chemical release. chemical distributors should 2003-13-I-LA-R22: provide the appropriate PPE for doing so on CTMVs. and distributors to adopt the Key Lessons and Recommended automation. and chemicals produced the opportunity for inadvertent mixing incidents. fill lines. chemical distributors. or spill during bulk unloading. whose membership represents more than 85% of 2017-01-I-KS-R1: U. indoor and outdoor sources of chemicals. emergency escape in the event of a release of hazardous materials. CSB MGPI Processing Case Study 43 . Where mitigating incidents is feasible. the CSB will work with the Chlorine Institute.For chemical distribution companies: 12. As a result of its investigation.4 Mod B building and ventilation system and.g.0 RECOMMENDATIONS TO THE AMERICAN SOCIETY OF HEATING REFRIGERATION 10.. INC. The incident at MGPI highlights that. Evaluate the need to train drivers to don appropriate originally issued to ASHRAE in 2005 as part of the PPE and respond to chemical spills or releases Honeywell International chlorine release investigation: during unloading operations. chemical release. in 2016. Because chemical deliveries are so common air intake locations. the CSB urges facilities and chemical filtration and removal. to prevent personnel from opening the incorrect chemical transfer valves during deliveries. Develop guidance on the effective design and maintenance Where mitigating incidents is not feasible. the CSB makes the following safety recommendations: 11. install mitigation measures to automatically shut down the transfer of chemicals into the facility based on process deviations or abnormal conditions (e. contaminant control methods such as at fixed facilities. install safeguards. The engineering evaluation of the ventilation Practices from this Case Study and work collaboratively to system should consider airborne contaminants during normal implement controls and practices that prevent or reduce operations as well as spills. such as alarms and interlocks.S. releases. NACD. The CSB reiterates the following recommendation 11. even though of that evaluation. Ensure drivers are fully aware of the location and use AND AIR CONDITIONING ENGINEERS (ASHRAE): of all CTMV emergency shutoff mechanisms. transfer valves. transfer piping.0 CONCLUSION According to the National Association of Chemical Distributors TO MGPI PROCESSING.: (NACD). (e. can greatly impact workers and surrounding communities the evaluation should assess the effectiveness of the building due to the large amount of chemicals transferred during ventilation system. implement design changes and controls unloading operations are relatively simple.. components designed to protect employees and equipment and are properly trained to wear. chemical of HVAC systems and other necessary control room distributors should ensure that drivers have access to. Where feasible. and unions representing chemical 2017-01-I-KS-R2: facility and chemical transport workers to communicate the Key Conduct an evaluation of the Mod B chemical transfer equipment Lessons and Recommended Practices to their membership. At a minimum. deliveries. based on the results seconds. tanks and other associated equipment) and install appropriate engineering safeguards to prevent and mitigate an unintended reaction. the issuance of this Case Study. The equipment should also Management to submit a Hazardous Materials be stored in an area that allows for immediate access.134).) Management Program covered facilities and all other during unloading operations. The equipment and training should emergency response training and programs. II reporting forms. Emergency Preparedness (HMEP) grant proposal to assist in funding additional training and pre-planning activities within the county. 2017-01-I-KS-R4: b) Conduct a full-scale hazardous materials exercise Establish a process whereby the respiratory hazards associated that involves an offsite chemical release scenario with chemical unloading at customer sites are evaluated. If the Identify and resolve coordination or communication results of the evaluations indicate that respiratory protection issues identified during the exercise..F. inadvertent mixing. within the next three years. an accidental reaction and/or release of chemicals. and fixed facilities. determine whether include participants from local emergency response drivers need emergency escape respirators in the event of organizations. store large amounts of hazardous chemicals. temperature. is needed. TO THE ATCHISON COUNTY DEPARTMENT OF EMERGENCY MANAGEMENT: TO HARCROS CHEMICALS: 2017-01-I-KS-R5: 2017-01-I-KS-R3: Coordinate planning and training activities to ensure emergency Establish a refresher training program to ensure drivers know responders within Atchison County are prepared for future the location of various CTMV emergency shut-off devices.g. based on annual Tier the effectiveness of the refresher training program. 44 CSB MGPI Processing Case Study . The exercise should The evaluations should. Establish a process to evaluate facilities within the county that. provide the equipment and training for such c) Increase participation in state and regional protection as appropriate.pressure. at a minimum. be provided in accordance with OSHA’s Respiratory Protection Work with the Kansas Department of Emergency Standard (29 C.R § 1910. hospitals. flow or level indications. schools. The refresher training program should include drills for drivers to simulate a) Review facility Risk Management Plans as they are the activation of all shut-off devices in defined incident submitted or revised and conduct pre-planning at Risk scenarios (e. etc. gas detection). chemical releases. incidents involving hazardous materials. The Atchison County when to use them. and the effectiveness of those devices to Local Emergency Planning Committee should do the following: stop the flow of chemicals during emergencies. APPENDIX A – SIMPLIFIED CAUSAL ANALYSIS Chlorine gas Ventilation entered control design & siting room via intakes Operators were overwhelmed with toxic gas Operators could not Respirators locked in Respirators access respirators lockers No automated or remotely operated control Design valves at facility The reaction was not immediately mitigated Driver was in cab Procedures Supply on truck not turned off Driver was overwhelmed with Respirators toxic gas Emergency shutoff on truck not Training activated Delivery occurred at Delivery schedules Operator was distracted shift change Operator did not observe connection Unloading procedures did not align with operator Procedures practice ~140 individuals exposed to chlorine gas and 1.000 Training evacuated/SIP Workers inadvertently mixed sulfuric acid & Procedures sodium hypochlorite Unloading procedures did not align with operator practice Training Driver attached hose incorrectly but unlocked fill line KEY Same size fill line connections Design Event Condition Two fill lines were ~18" Design apart Causal Factors No pipe markers at fill lines connections Pipe Markings CSB MGPI Processing Case Study 45 . APPENDIX B – RECOMMENDED PRACTICES FOR CHEMICAL UNLOADING OPERATIONS This Page Intentionally Left Blank 46 CSB MGPI Processing Case Study . including members equipment and processes.pdf. inherently safer strategies or design controls) some required hospitalization. Over 140 individuals.gov/staticfiles/ PHMSA/DownloadableFiles/Files/ctmv_pocket_guide_short_09212015. Inadvertent Mixing Incident and when there are modifications to chemicals. Thousands of community members were ordered to shelter-in-place and some • When applying the hierarchy of controls to unloading areas were evacuated. that can be implemented or installed to avoid mixing? The CSB found that this and similar incidents could have been prevented through improved design of the chemical • When examining how workers and drivers interface unloading area to prevent incorrect connections of incompatible with equipment.. the flow of chemicals from CTMVs into facility piping and equipment during an emergency (i.dot. sought medical attention. In addition. Therefore. AVOIDING INADVERTENT MIXING DURING UNLOADING OPERATIONS: RECOMMENDED PRACTICES FOR FACILITIES RECEIVING CHEMICALS BY CARGO TANK MOTOR VEHICLES (CTMVS) Facilities are strongly encouraged to consider the following questions when evaluating the potential for inadvertent mixing incidents during chemical deliveries. are there more protective of the public and company employees. chemical The CSB investigated an incident involving the inadvertent mixture of sulfuric acid from a CTMV into a sodium hypochlorite unloading equipment. or chemical distributors:1206 tank at a facility in Atchison. which can be found here: https://www. Kansas.e. transfer emergency action plans? Are those procedures and valve)? Can those controls be activated remotely plans being periodically updated and shared with one through the control system or an emergency switch? another whenever changes are made? • Is the chemical transfer equipment appropriately labeled so that drivers can easily locate corresponding Procedures fill lines? Are labels affixed to the fill lines to avoid the • Does your unloading process include verification need for tracing piping prior to making a connection? steps to ensure both facility personnel and drivers Hierarchy of Controls work together to ensure a correct connection is made? Pipe Markings • Are responsibilities for unloading operations clearly Elimination • Did your facility work defined and understood? Substitution with the chemical distributor • Is personal protective equipment (PPE). • Can fill lines or receiving vessels for incompatible Preventing incidents during chemical unloading materials be isolated or separated by distance? operations is a shared responsibility between chemical • Is it possible to select unique fittings on fill lines to distributors and facilities receiving chemicals. CSB MGPI Processing Case Study 47 . readily accessible at all Engineering Controls site-specific procedures for times for all facility personnel and drivers in the event Administrative unloading each chemical delivered of a spill or release? Controls by the distributor? Did you review • Have you worked with chemical distributors to PPE potential incompatible mixtures and define actions for drivers during a chemical delivery emergency? Do you know if drivers are trained to 1206 The Pipeline and Hazardous Materials Safety Administration (PHMSA) developed activate emergency shutoff devices on CTMVs? guidance for CTMVs. The mixture of the two materials resulted in a chemical reaction that produced a dense. safeguards (e. facilities and distributors must work together to develop and agree upon prevent incorrect connections? procedures that clearly define roles and responsibilities and • Does your facility have an automation that can stop ensure safe execution of unloading operations. what human factors issues increase materials.phmsa. Design green-yellow cloud containing chlorine gas. such as to develop and/or agree upon respirators and escape packs. clear pipe markers at fill line connection the opportunity for inadvertent mixing? points also decrease the opportunity for error when connections are made between the CTMV and facility fill line.g. Ph. Member . J.S. Chemical Safety and Hazard Investigation Board Key Lessons for Preventing Inadvertent Mixing During Chemical Unloading Operations Chemical Reaction and Release in Atchison. Chemical Safety and Hazard Investigation Board: Vanessa Allen Sutherland. Chairperson Manuel Ehrlich Member Richard Engler Member Kristen Kulinowski.D. Kansas Members of the U.S.D.A./M.Case Study U.B.