Disclaimer. Agenda. US Chemical Safety Board Case Review and Steps Forward

Size: px

Start display at page:

Download "Disclaimer. Agenda. US Chemical Safety Board Case Review and Steps Forward"

Shannon Houston
5 years ago
Views:

1 Process Safety and Reliability Group PSM Forum September 21-22, 2016 Lake Charles,LA & Houston, TX US Chemical Safety Board Case Review and Steps Forward Johnnie A. Banks, CFEI Disclaimer The presentation regarding CSB investigations and Steps Forward, by Johnnie Banks of the United States Chemical Safety and Hazard Investigation Board to the Process Safety and Reliability Group at their September 21 st, and September 22 nd conference in Lake Charles, LA, and Houston, TX is given for general informational purposes only. The presentation represents the individual views of the presenter. Furthermore, the statements today and this presentation may not represent a formal adopted view of the Board. Users of this presentation should also note that the contents were compiled solely for this presentation. For specific information on CSB investigations, please refer to the CSB website at 2 Agenda CSB at a glance West Fertilizer Incident Description Emergency Response Related Key Issues 3 1

2 Agenda Freedom Industries Delaware City Refining Company (DCRC) Drivers of Critical Chemical Safety Change Questions & Answers 4 Chemical Safety Board (CSB) Independent federal agency Investigates major chemical accidents Finds root causes of accidents Conducts safety studies Issues recommendations to stakeholders 5 Chemical Safety Board (CSB) Regulatory Agencies (OSHA, EPA) Non-Governmental Organizations (NFPA, API, ASME) Companies & Industrial Sectors Legislative Bodies (States, Local) Disseminates findings-reports and Videos 6 2

12 Firefighters and EMTs 3 Community Members Injuries Over 260 Community Members and

3 West Fertilizer / Adair Grain Company Fertilizer Grade Ammonium Nitrate Fire and Explosion West, Texas April 17, Consequences Less than 20 Minutes 15 Fatalities 12 Firefighters and EMTs 3 Community Members Injuries Over 260 Community Members and Emergency Responders Community Damage Apartment Complex Schools Nursing Home Private Residences 9 3

4 10 West Terrace Apartments 11 West Rest Haven Nursing Home 12 4

5 West Intermediate School WFC and Fertilizer Building 15 5

WHAT Fire and Explosion Firefighter and civilian fatalities Proximity of community to facility Regulatory Oversight Insurance Shortfall 16 Key Findings (Why) Land Use Planning Emergency Planning

6 WHAT Fire and Explosion Firefighter and civilian fatalities Proximity of community to facility Regulatory Oversight Insurance Shortfall 16 Key Findings (Why) Land Use Planning Emergency Planning Technical Land Use Planning Emergency Planning Emergency Response Technical Regulatory Insurance Emergency Response Responders had Limited Combustible oversight material WFC WVFD insufficient No zoning dropped did not regulations information conduct by FGAN contributed storage previous drills existed to respond and at insurance exercises the to time the fire WFC at the at provider WFC began intensity facility operations for of noncompliance anhydrous EPCRA City Current of West lacks training ammonia developed clear (vs. the fire Regulatory Regulations covered FGAN) No sprinkler system at information over WFC curriculum the insurance years on places which and providers little WFC did facilities Insurance expanded emphasis not focus fall toward on under on FGAN FGAN WFC the Ag FGAN not OSHA PSM hazards Use Emergency Exemption Planning or EPA RMP list of WFC Burning facility asphalt was not chemicals subject shingles 48% No Lessons emergency of to FGAN and zoning learned soot sites response likely from in Texas plan regulations contaminated previous are place located FGAN governing for FGAN personnel fires within pile not 0.5 responding the shared miles sitingwith of of schools to an WVFD incidents FGAN or healthcare facility facilities 17 West Through the Years Fertilizer Fertilizer Fertilizer Facility Facility Location Fertilizer Facility Facility

7 Recommendations 19 Recommendations (How) US EPA OSHA FEMA ICC SFFMA TEEX TCFP TDI WVFD EDC 20 Freedom Industries Investigation Update Charleston, West Virginia January 9,

6% propylene glycol phenyl ethers (PPH) -10,000 gallons released into Elk River Little health information on both Facility

8 Freedom Industries 4/2010 odor 1/9/14 complaint; Facility unable prompted to provide DEP to MSDS investigate leak Freedom Industries Incident January 9, ,000-gallon steel tank (Tank 396) Leak of Crude Methylcyclohexane methanol (MCHM) -5.6% propylene glycol phenyl ethers (PPH) -10,000 gallons released into Elk River Little health information on both Facility located 1.5 miles upstream from WV American Water intake Tank 396 Atmospheric storage tank Deteriorated secondary containment Over 50 years old 8

9 Public Health Impact MCHM contaminated drinking water supply for ~300K residents in Charleston, WV Drinking water warning for ~2 months. MCHM MSDS No data available for inhalation and repeated dose exposure 9

people in nine counties were advised not to drink the water 1/15/2014 CDC issues water advisory issued to pregnant women Drink bottled water 2/28/2014 Governor

10 Public Health Impact WV Department of Health Jan. 23: -369 patients treated for possible exposure -13 patients admitted Holes found in bottom of tank 29 Drinking Water Warning 1/9/14 No use order where 300,000 people in nine counties were advised not to drink the water 1/15/2014 CDC issues water advisory issued to pregnant women Drink bottled water 2/28/2014 Governor Tomblin (WV) lifts State of Emergency order. 1/13/14 VA American Water advises flushing water systems in certain zones 1/21/2014 PHP detected in water supply 3/3/2014 CDC announces no evidence of adverse health effect to any segment of population from MCHM below 10ppb 10

11 Secondary Containment Cinder block construction provided little protection from release Unlined containment wall Tank 396 rested on porous material -gravel and soil Regulatory Gaps MCHM stored in tank 396 considered non-hazardous by EPA and not regulated by state or federal government Not regulated under SPCC Although Tank 396 passed API 653 inspection -not in full compliance or EPA Standards Regulatory Gaps cont. No clear mandatory standards for how to cite, design, maintain and inspect non petroleum tanks Toxic Substance Control Actaddressing the lack of information available to the public -MCHM MSDS stated no data available for toxicological properties or chronic toxicity 11

Path Forward Internal inspection of Tank 396 to examine wall thickness Examine tank design and material of construction Examine inspection practices and regulatory

S The U.S. Chemical Safety and Hazard Investigation Board Drivers of Critical Chemical Safety Change PSM Regulations Modernize U.S. Process Safety Management

12 Path Forward Internal inspection of Tank 396 to examine wall thickness Examine tank design and material of construction Examine inspection practices and regulatory oversight Examine industry best practices Examine response to leaks Examine adequacy of information on MCHM on MSDS The U.S. Chemical Safety and Hazard Investigation Board Drivers of Critical Chemical Safety Change PSM Regulations Modernize U.S. Process Safety Management Regulations Little reform since their inception in the 1990s implementation of key federal and state CSB safety recommendations will result in significant improvement of Process Safety Management (PSM) regulations in the United States 36 12

13 Drivers of Critical Chemical Safety Change The nature of the risk and estimated extent of exposure to workers and offsite populations; Previous loss and potential for future loss of life or property, illnesses, and environmental damage; Very high risks disproportionately affecting discrete but highly identifiable groups of individuals (e.g., a narrow sector of industry or certain specialized workers facing a very high probability of risk); Strong concern of important sectors of a community, civic leaders or the like; and The possibility that advocacy will help bring about change. 37 OSHA Combustible Dust Std. Comprehensive Dust Standard In 2013 the CSB designated four recommendations to OSHA calling for the issuance of a comprehensive general industry standard for combustible Driven by four dust cases Combustible Dust Study (2008) Imperial Sugar, Port Wentworth, GA Hoeganaes, Gallatin, TN AL Solutions, New Cumberland, WV 38 Emergency Response and Planning Emergency Response Deficiencies 12 CSB investigations 46 recommendations Addressed deficiencies West Fertilizer (West, TX) MFG Chemical, Inc. (Dalton, GA) Herrig Brothers Propane Tank Explosion (Albert City, IA) DPC Enterprises, (Festus, MO) 39 13

14 Preventive Maintenance Poor Preventive Maintenance Programs Inadequate mechanical integrity programs Delayed or deferred preventive maintenance Aging infrastructure Examples in: Tesoro Chevron Valero 40 Critical to Chemical Safety Change: Emergency Planning & Response CSB investigations have found inadequate or poor emergency planning or response to be a root cause. 14 investigations: Early investigations Herrig Brothers Farm Propane Tank Explosion (1998) Recent investigations West Fertilizer Company (2013) 41 Key Findings/Recommendations Training for emergency responders, including hazardous materials training; Local emergency planning, and community response plans and teams; Use of community notification systems; Use of an incident command system and the National Incident Management System; 14

15 Key Findings/Recommendations Conducting emergency response exercises; Information sharing between facilities, emergency responders and the community; and Communication during emergencies (including 911 operator communication, interoperability of radios, etc). Key Contributing Factors West Incident command system Incident management system HAZMAT Training Pre incident planning Limited and conflicting technical guidance on FGAN Inconsistent firefighting measures 44 Lack of Incident Command System Incident command system was not established No evidence of routine NIMS process No evidence of discussion on who should be Incident Commander No prior IC experience with industrial fires 45 15

16 Lack of Established Incident Management System (IMS) IMS not effectively set up, implemented, or coordinated Public emergency alert systems not activated before explosion Residents left unaware of risk Watched fire from inside their homes and vehicles or from the street Placed within range of high pressure blast wave and debris 46 HAZMAT Training & Knowledge Lack of knowledge and understanding of FGAN detonation hazards Few responding firefighters had HAZMAT training Hazards and severity of FGAN incidents not addressed in HAZMAT training 47 Lack of Pre Incident Planning Pre incident planning for FGAN not conducted No anticipation of possible FGAN explosion Efforts concentrated on anhydrous ammonia tanks Anhydrous ammonia drills conducted None focused on FGAN related fire 48 16

17 Lack of Pre Incident Planning Pre incident planning provides the foundation for decision making during an emergency NFPA 1620 Standard for Pre Incident Planning (2010 Edition) Pre incident plan development depends on volunteer fire departments Currently, no federal agency regulates municipal fire departments in the U.S. 49 West Fertilizer Recommendations Funding mechanisms to provide training on FGAN fires. Develop training and certification on how to respond to FGAN fires/hazardous materials fires, including on use of preincident planning. Outreach programs to disseminate information on training programs. MFG Chemical Inc. Toxic Gas Release 2004, Dalton, GA Chemical reactor overheated at MFG Chemical manufacturing plant, releasing toxic allyl alcohol vapor. Resulting cloud sent 154 people to a local hospital and forced the evacuation of nearby residents. 17

18 MFG Inadequate emergency response planning was a contributing cause of the injuries and exposures among the public and responders. None of the responding police officers had the proper training or protective equipment to safely enter the toxic vapor cloud. MFG City of Dalton had no automated emergency notification system or evacuation plan. Police officers were instructed to drive into the chemical cloud to alert neighborhood residents to evacuate. The toxic vapor forced the unprotected police officers to retreat. Firefighters wearing special breathing apparatus were eventually called in to complete the evacuation. MFG Whitfield County did not have an established LEPC. Dalton fire & police depts, hospital and ambulance staff were not aware of the potential of a major chemical release. WC did have an Emergency Response Operations Plan. Procedures to alert the public in event of an emergency were not developed. 18

19 U.S. Chemical Safety Board 1750 Pennsylvania Ave, NW Suite 910 Washington, DC

Management of Organizational Change: A CSB Perspective

Management of Organizational Change: A CSB Perspective Rick Engler CSB Board Member Process Safety Conference May 17, 2017 - Dordrecht Driving Chemical Safety Change through Independent Investigations