The Risk Management Tool Box Blog

International Code Council Launches New Fire Code

Graham Marshall - Thursday, March 06, 2014

Following the death's of six workers at the Kleen Energy Power Generation Facility in Middletown (Connecticut, USA), the International Code Council (ICC) has revised the International Fire Code (IFC) and International Fuel Gas Code (IFGC) to prohibit the unsafe practice of "gas blows"; in which flammable gas is blown under high-pressure down newly-constructed or repaired piping in an effort to clean and remove debris from the pipes prior to start-up.

The process of "gas-blowing" is inherently unsafe.

At the Kleen Energy facility, the high pressure gas blow was used to clean pipes prior to the start up of generator turbines; but the gas found an ignition source; and the six workers were killed in the subsequent huge explosion.

Alternative non-flammable gases are safe to use in "gas blowing" scenario's, including compressed air, so there is no need to use flammable gases.

Over 40 Countries, including the USA subscribe to the ICC codes.

Deadly Contract - New CSB Video

Graham Marshall - Sunday, February 24, 2013

The U.S. Chemical Safety Board (CSB) has recently released a new safety video entitled “Deadly Contract” which highlights how an explosion and fire that killed five workers during a fireworks disposal operation in Hawaii in 2011 resulted from unsafe disposal practices; insufficient safety requirements for government contractor selection and oversight; and an absence of national guidelines, standards, and regulations for fireworks disposal.

The CSB is also calling for new regulations on the safe disposal of government-confiscated illegally labeled fireworks - a growing problem across the U.S.

The  accident occurred in April 2011, as employees of Donaldson Enterprises, Inc. (DEI) worked in a tunnel-like magazine located in Waipahu, Hawaii.

The storage facility contained government-confiscated illegally labeled fireworks, which the workers had been dismantling under a subcontract to a federal prime contract.

The CSB determined there was an accumulation of a large quantity of explosive components just inside the magazine entrance, creating the essential elements for a mass explosion.

A large explosion and fire fatally injured all five workers inside the magazine.

Another worker, who had been standing outside the magazine entrance door, escaped with injuries.

The CSB investigation found that company personnel had no specific expertise in fireworks disposal, that the company’s procedures were extremely unsafe, and that there are no national standards or accepted good practices for disposing of fireworks.

DEI was awarded the subcontract from a Federal Agency because it was a local company already storing the seized fireworks in the hillside facility, and its proposal was the lowest in cost and considered the most time-efficient.

However, despite DEI’s military ordnance background, the company had no experience with fireworks disposal.

DEI improvised a disposal plan that called for soaking the fireworks in diesel fuel and then burning them at a local shooting range

However, some fireworks were not burning, but exploding.

The company concluded that the diesel was not sufficiently penetrating the aerial shells and thus altered the procedure, disassembling the individual firework tubes and cutting slits in the aerial shells so the diesel could soak into the shells to reduce the explosion hazard during burning.

The process was further altered to speed up destruction of the next batch of confiscated fireworks in early 2011.

Workers were told to separate the black powder from the shells, accumulating them in separate boxes and dramatically increasing the explosion hazard, the CSB found.

The investigation found the company did not adequately analyze the potential hazards created by making these changes to the disposal plan.

Good process safety practice would have called for a thorough hazard analysis as well as a comprehensive review of the potential safety impacts of the proposed change.

CSB Wins Awards for Safety Videos

Graham Marshall - Saturday, January 05, 2013

Congratulations go to the Chemical Safety Board (CSB) which was has received three Awards from the Television, Internet and Video Association (TIVA) for safety videos produced in 2012. TIVA is a Washington-based organization of media production professionals.

CSB safety videos are documentary style narratives on specific accidents based on CSB investigation findings.

They typically include computer-generated simulations that depict deadly sequences of events, and include commentary by investigators and CSB board members.

The winning videos are:

 Hot Work: Hidden Hazards (Bronze Award) – 2 contractors were performing welding a top a 10,000 gallon slurry tank at a DuPont chemical facility near Buffalo, New York, when hot sparks ignited flammable vapors inside the tank, causing an explosion that killed one of the men and seriously injured another.

 Experimenting with Danger (Bronze Award) – A laboratory worker performing an experiment for an energetic materials project at Texas Tech University in Lubbock, Texas, was severely injured in an explosion. The video highlights two other academic lab accidents, one at UCLA and the other at Dartmouth College.

 Iron in the Fire (Silver Award) – Three combustible dust flash fires over a six month period occurred at the Hoeganaes Corporation powdered-iron facility in Gallatin, Tennessee, 20 miles outside of Nashville, resulting in fatal injuries to five workers.

To date, the CSB has produced 29 safety videos.

The CSB’s safety videos received numerous other awards, including three TIVA Peer Awards in 2011.

In 2010, the CSB received two CINE Golden Eagle Awards, one for a video on the rural oil tank storage facilities and teenage deaths entitled, “No Place to Hang Out,” and the other for “Dangers of Hot Work,” which reported on fatal accidents caused by the ignition of flammable vapor during welding, cutting and grinding activities at chemical and other facilities, for which the recently-awarded “Hot Work: Hidden Hazards” was a sequel.

Other CSB video awards include:

 May 2010 - 2010 European Process Safety Centre (EPSC) Award for the CSB Safety Video series;

 August 2009 - MERLOT (Multimedia Educational Resource for Learning and Online Teaching) award for “Half an Hour to Tragedy”;

 November 2009 - TIVA Peer award (bronze) for “Half an Hour to Tragedy”.

The agency’s video program was specifically cited when the CSB was named the 2008 recipient of the American ChemicalSociety’s (ACS) Howard Fawcett Award, honoring “outstanding contributions in the field of chemical health and safety.

The CSB is an independent federal agency charged with investigating serious chemical accidents.

The agency's board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.


Nitrogen Hazard

Graham Marshall - Thursday, June 21, 2012

Although Nitrogen is inert and non-toxic, and actually makes-up 78 per cent of the air we breathe, it can become a hazard - with the potential to cause harm - whenever it becomes concentrated in the atmosphere and replaces the oxygen which we need to sustain life.

Out in the open air at sea-level, oxygen makes-up 20.9 per cent of the air we breathe. 

Legislation in the USA and elsewhere establishes a legal lower threshold limit for oxygen in workplaces of 19.5 per cent by volume. 

If the oxygen level falls much below 19.5 per cent, all sorts of health problems may rapidly develop.

One way in which oxygen can drop to levels which are immediately dangerous to life and health is where Nitrogen is used within a facility.  For example, Nitrogen is frequently used to purge pipes and tanks of potentially flammable atmospheres prior to hot work.

These enclosed environments can then be dangerous if appropriate safe-guards are not in place.

A useful process safety beacon on the hazards of Nitrogen can be found by clicking here.

CSB Announces Findings into DuPont Fatal Accident

Graham Marshall - Monday, May 07, 2012

The U.S. Chemical Safety Board (CSB) has determined that an explosion at a DuPont facility in the USA that killed one contract welder and injured his Foreman in 2010, was caused by the ignition of flammable vinyl fluoride inside a large process tank, a hazard which had been overlooked.

The accident occurred at the DuPont chemical plant in Tonawanda. 

The facility produces polymers and surface materials for countertops.

The process for making the polymers involves transferring polyvinyl fluoride (PVF) slurry from a reactor through a flash tank and then into three storage tanks.  The tanks were also inter-connected by an overflow line. 

Days before the incident the process had been shut down for tank maintenance.
The tank fill lines were correctly locked out for safety.

Tanks 2 and 3 were repaired and the process restarted, but work on tank 1 was delayed due to a lack of parts.

Although tank 1 remained locked out from the main process, the overflow line remained open which connected tank 1 to tanks 2 and 3.

The CSB found DuPont erroneously had determined that any vinyl fluoride vapor that might enter the tanks would remain below flammable limits.

The CSB determined that flammable vinyl fluoride flowed through the overflow line into tank 1 and accumulated to explosive concentrations.

Although DuPont personnel monitored the atmosphere above the tank prior to authorizing hot work to restart once parts became available, no monitoring was done inside the tank to see if any flammable vapor existed there.

The CSB investigation found the hot work ignited the vapor as a result of the increased temperature of the metal tank, sparks falling into the tank, or vapor wafting from the tank into the hot work area.

The explosion blew most of the top off the tank.

The welder died instantly from blunt force trauma, and the foreman received first-degree burns and minor injuries.

CSB Team Lead Johnnie Banks said, “Our investigation found that DuPont’s process hazard analysis incorrectly assumed that vinyl fluoride in the process could not reach flammable levels in the slurry tanks.  And, critically, DuPont personnel did not properly isolate and lock out tank 1 from tanks 2 and 3 prior to authorizing the hot work.  The flammable vapor was able to pass through the overflow line into the tank the welder was working on, unknown to him or to the operators who signed off the hot work permit.”

Noting the CSB issued a safety bulletin on the dangers of hot work in March 2010, CSB Chairperson Rafael Moure-Eraso said, “I find it tragic that we continue to see lives lost from hot work accidents, which occur all too frequently despite long-known procedures that can prevent them.  Facility managers have an obligation to assure the absence of a flammable atmosphere in areas where hot work is to take place. Explosion hazards can be eliminated by testing inside tanks as well as in the areas around them.”

This is the 2nd fatal accident involving DuPont locations in the USA recorded in 2010.


CSB Call for Action on Tank Batteries

Graham Marshall - Tuesday, December 13, 2011

US federal investigators are urging energy companies to better secure oil storage sites against intruders following three recent fatalities.

In the first incident in New London, Texas, an exploding tank flew 48 feet from its original location after one of the two victims lit a cigarette while climbing the stairway of the catwalk at the site.

The site, which was in operation for at least 80 years, had three interconnected 1,000-barrel capacity tanks at the time of the accident.

The tank that actually exploded had not stored any hydrocarbons for at least one and a half years before the incident.

A graffiti -covered warning sign at the site warned against smoking, matches or open lights.

A separate oil tank explosion in Carnes, Mississippi, on Halloween 2009 killed two teenagers, Devon Byrd and Wade White, who were at a Delphi Oil production site about 150 feet away from one of their homes.

The force of the explosion sent the upper part of a tank flying 225 feet and propelled the bottom piece about 60 feet in the opposite direction.

The resulting fire lasted four hours and sent flames 200 feet high.

Both teenagers were killed instantly, but there was no evidence of what caused the flammable hydrocarbons to ignite.
The Mississippi explosion has inspired memorials and state lawmakers to push for tougher regulations on oil and gas storage facilities.

The Chemical Safety Board (CSB) cites 23 fatal accidents — most involving partying teenagers or curious kids — at oil and gas storage sites from 1983 to 2010.

All of the incidents involved victims under 25 years of age.

Many oil and gas storage tanks are in remote areas — unfenced, unsupervised and without any warning signs.

It can be a devastating and lethal combination when young people hanging out at the sites light up cigarettes.

“The growing number of oil and gas facilities nationally, their accessibility to members of the public and the lack of awareness among the public about the hazards posed by the tanks suggest a potential for similar incidents,” the CSB concluded.

The agency today is urging oil and gas companies to take swift steps to prevent more accidents, including adopting inherently safer tank design features that are already used in the downstream, refining sector.

For instance, the CSB says, vents fitted with pressure-vacuum devices, flame arrestors, vapor recovery systems and floating roofs would go a long way to making the tanks — and the area around them — safer.

The CSB also points to some relatively inexpensive and easy changes that could pay off, including hatch locks to prevent access to flammable hydrocarbons inside storage tanks, fencing around the tanks and warning signs.

The CSB is urging the American Petroleum Institute (API) to adopt new standards for upstream sites encouraging the use of safer tank designs meant to trim the chances of explosions.

The agency also says API should bolster its existing standards by insisting on locked fences, hatch locks on tank manways and barriers preventing unauthorized access to external ladders and stairways at the sites.


CSB Report into Fatal Accident at DuPont Chemical Facility

Graham Marshall - Wednesday, November 02, 2011

The CSB (Chemical Safety Board)  recently released its investigation report into three accidents that occurred over a 33-hour period in January  2010 at the DuPont Corporation‘s Belle, West Virginia, chemical facility.

The final incident involved a deadly release of the World-War One era chemical weapon - phosgene gas.

The incident is noteworthy because it contains lessons for any individual or organization with process hazards that could result in Major Accident Events (MAEs).  So please read on...

When releasing the report, CSB Chairperson Rafael Moure-Eraso said, "our final report shows in detail how a series of preventable safety shortcomings - including failure to maintain the mechanical integrity of a critical phosgene hose - led to the accidents. That this happened at a company with DuPont‘s reputation for safety should indicate the need for every chemical plant to redouble their efforts to analyze potential hazards and take steps to prevent tragedy".

The accidents began when an alarm sounded leading operators to discover that 2,000 pounds of methyl chloride, a toxic and extremely flammable gas, had been escaping to air for five days.

The next day, workers discovered a separate leak in a pipe carrying oleum, producing a toxic cloud of sulfur trioxide.

The phosgene gas release occurred later the same day, and the exposed worker died the next evening.

Dr. Moure-Eraso said, "DuPont has had a stated focus on accident prevention since its early days. DuPont became recognized across industry as a safety innovator and leader. We at the CSB were therefore quite surprised and alarmed to learn that the DuPont Belle plant had not just one, but three accidents that occurred over a 33-hour period in January 2010".

The CSB investigation found deficiencies in the DuPont Belle facility HSE-MS common across all three accidents. 

DuPont's deficiencies are worth noting because they may apply to virtually any Major Hazard Facility, and were said by the CSB to include:

1.  Maintenance and inspections;

2.  Alarm recognition and management;

3.  Accident investigation;

4.  Emergency response and communications; and

5.  Hazard recognition.

CSB board member and former chairman John Bresland noted the CSB finding that the phosgene hose that burst was supposed to be changed out at least once a month. But the hose that failed had been in service for seven months. Furthermore, the CSB found the type of hose involved in the accident was susceptible to corrosion from phosgene.

Team Lead Johnnie Banks said, "Documents obtained during the CSB investigation showed that as far back as 1987, DuPont officials realized the hazards of using braided stainless steel hoses lined with Teflon,
or polytetrafluoroethylene"

A DuPont internal expert had even recommended the use of hoses lined with Monel, a metal alloy used in corrosive applications. The DuPont official stated: "Admittedly, the Monel hose will cost more than its stainless counterpart. However, with proper construction and design so that stresses are minimized…useful life should be much greater than 3 months. Costs will be less in the long run and safety will also be improved."  Unfortunately for the dead worker, the Monel hose was never used.

Other DuPont documents also showed that  DuPont officials had considered increasing the safety of the area of the plant where phosgene was handled by enclosing the area and venting the enclosure through a scrubber system to destroy any toxic phosgene gas before it entered the atmosphere.

However, the documents indicate the company was concerned with containing costs and decided not to make the safety improvements.

CSB investigators concluded that an enclosure, scrubber system, and routine requirement for protective breathing equipment before personnel entered the enclosure would have prevented any personnel exposures or injuries.

The CSB recommended that OSHA revise the General Industry Standard for Compressed Gases to be at least as effective as the relevant National Fire Protection Association (NFPA) Code 55 (the Compressed Gases and Cryogenics Fluids Code).

This would require secondary enclosures for highly toxic gases such as phosgene and provide for ventilation and treatment systems, interlocked failsafe shutdown valves, gas detection and alarm systems, piping system components, and similar layers of protection.

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