Incidents | AIChE

Incidents

Equipment Identification - Incidents
  1. Toxic gas cloud affecting nearby community due to a mixed connection at MGPI processing facility, Kansas.                                         
  2. VCM vapor cloud ignited and exploded when the operator opened the bottom valve of D310 (in line at 70psig) instead of opening bottom valve of D306 for cleaning operation at Formosa Plastics.    
  3. Multiple Incidents of chlorine toxic cloud formations due to improper tagging and materials mixing – CCPS Process Safety Beacon February 2017.    
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SWP Element 

Scaffolding - Incidents
  • Scaffolding collapse at Chinese construction site kills dozens, By Associated Press November 24, 2016, BEIJING — Scaffolding at a construction site in eastern China collapsed into a deadly heap on Thursday, sending iron pipes, steel bars and wooden planks tumbling down on about 70 workers in the country’s worst work-safety accident in over two years. At least 67 people were killed by the collapse of the work platform at a power plant cooling tower that was under construction, state media reported. Two others were injured and one worker was missing.
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SWP Element 

Excavation - Incidents

Manslaughter verdict after trench collapse death | Construction Enquirer www.constructionenquirer.com/.../building-boss-guilty-of-manslaughter-af...

Sentence following multiple deaths on excavation site – Norfolk ...press.hse.gov.uk › News › Media centre, Sentence following multiple deaths on excavation site – Norfolk. Date: 25 May 2017. Two companies have been fined a total of £700,000

•OSHA: Excavation Company Could Have Prevented Workers' Deaths ..https://www.naxsa.org/.../OSHA-Excavation-Company-Could-Have-Prevented-W... Oct 2016 - BOISE –... A third man, Jorge Soto, suffered multiple injuries

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SWP Element 

Equipment Filling and Mixing - Incidents
  1. Inadvertent mixing of sulfuric acid and sodium hypochlorite produced a cloud containing chlorine and other compounds. The cloud impacted workers onsite and members of the public in the surrounding community. The incident occurred during a routine chemical delivery of sulfuric acid from a chemicals cargo tank vehicle (CTMV) at the MGPI facility tank farm.                           

  1. Several construction employees working near a collection pit were overcome with hydrogen sulfide gas. The gas was released nearby when sodium hydrosulfide was accidentally mixed with sulfuric acid. Three workers collapsed almost immediately and three others tried to rescue them. Two of those rescuers also collapsed. In all, ten workers were exposed to the toxic gas. Two died and eight others were injured.                                                                             
  2. (April 25, 2002)  An explosion and fire occurred in a 10-story mixed-occupancy building in the Chelsea district of Manhattan, New York City. Employees had just finished consolidating hazardous waste from smaller containers into two larger drums. The wastes, nitric acid and lacquer thinner, were incompatible, and an explosion occurred. Thirty-six people were injured, including six firefighters and 14 members of the public. The building was extensively damaged.

  1. (August 12, 2015)  A series of explosions killed 173 people and injured hundreds of others at a container storage station at the Port of Tianjin. The first two explosions occurred within 30 seconds of each other at the facility. The second explosion was far larger and involved the detonation of about 800 tons of ammonium nitrate. Fires caused by the initial explosions continued to burn uncontrolled throughout the weekend, resulting in eight additional explosions three days later. In addition to vast quantities of sodium cyanide and calcium carbide, paperwork was discovered showing that 800 tons of ammonium nitrate and 500 tons of potassium nitrate were at the blast site.

  1. (May 2013, Portland, Oregon)  A supplier truck driver pumped a mixture of nitric and phosphoric acids into a tank containing sodium hypochlorite at a dairy.

  1. (October 2007, Frankfurt, Germany)  Hydrochloric acid was accidently transferred into a sodium hypochlorite tank. Approximately 200 kg of chlorine were released, and more than 60 people were injured. The operator who finally stopped the transfer was fatally injured from exposure to chlorine.

  1. (August 2001, Coatbridge, UK)  A tanker driver transferred sodium hypochlorite solution and hydrochloric acid into the same tank at a swimming pool. 30 people required medical treatment.

  1. (August, 1993, Stockholm, Sweden)  A truck driver pumped phosphoric acid into a storage tank containing sodium hypochlorite at a swimming pool.

  1. (March 1985, Westmalle, Belgium)  Hydrochloric acid was pumped into a tank containing residual sodium hypochlorite.

  1. (November 1984, Slaithwaite, UK)  A plant expected a delivery of sodium hypochlorite, but received ferric chloride solution (an acidic solution) instead. The ferric chloride was unloaded into the sodium hypochlorite tank.

  1. (September 1984, Hinckley, UK)  Hydrochloric acid was unloaded into a tank containing sodium hypochlorite.
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SWP Element 

Field Review of Permits - Incidents

SWP Element 

Hot Tapping - Incidents

SWP Element 

Temporary Instrumentation and Controls Bypass - Incidents
  • Improper start-up bypass use
    • CSB. 2017. Investigation report – Airgas. Report 2016-04-I-FL. Washington, D.C.: U.S. Chemical Safety Board.
  • Insufficient access control of safeguard bypass and lack of timely response to prior audit findings and near-miss incidents involving bypass
    • CSB. 2007. Investigation report - vinyl chloride monomer explosion at Formosa Plas-tics Corporation. Report 2004-10-I-IL. Washington, D.C.: U.S. Chemical Safety Board.
  • Inadvertent bypass of safety interlock due to insufficient maintenance training and proce-dure updates after safeguard device change
    • HSE. 2007. Buncefield Standards Task Group (BSTG) Final Report. UK: Health and Safety Executive.
  • Insufficient training of bypass approver and lack of compensating measures
    • CSB. 2006. Investigation report - Sterigenics. Report 2004-11-I-CA. Washington, D.C.: U.S. Chemical Safety Board.
  • Systematic failure of bypass management program
    • CSB. 2008. Investigation report - Pesticide Chemical Runaway Reaction and Pressure Vessel Explosion at Bayer Crop Science. Report 2008-08-I-WV. Washington, D.C.: U.S. Chemical Safety Board.
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SWP Element 

Confined Space Entry - Incidents
  • Test atmosphere

Surface Nonmetal Plant Kaolin Clay, Fatal Other Accident July 2015

 
 
  • Provide rescue plan and equipment

Surface Nonmetal Plant Kaolin Clay, Fatal Other Accident July 2015

Surface Nonmetal Mine (Limestone CB), Fatal Sliding Material Accident March 11, 2005

 
 
  • Provide confined space entry observer

Surface Nonmetal Plant Kaolin Clay, Fatal Other Accident July 2015

Surface Nonmetal Mine (Limestone CB), Fatal Sliding Material Accident March 11, 2005

Tesoro sulfuric acid injury 6/2010 - CSB

 
 
  • Recognize hazard

Surface Nonmetal Plant Kaolin Clay, Fatal Other Accident July 2015

Surface Nonmetal Mine (Limestone CB), Fatal Sliding Material Accident March 11, 2005

 
 
  • Improper isolation

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SWP Element 

Hot Work - Incidents

SWP Element 

Energy Isolation - Incidents

Have at least one incident for each unique “failure mode” of the Lock-Out/Tag-Out SWP?  For example, failure to:

  • Properly de-energize equipment
  • Identify potential source of stored energy
  • Execute properly the Lock-Out/Tag-Out procedure
  • Recognize hazard 
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SWP Element 

Line Opening - Incidents
  • Line drained or cleaned
    • Tosco Avon refinery Petroleum Naphtha Fire 2/23/1999 – CSB
    • Tesoro Martinez Sulfuric Acid Spill 02/12/2014 - CSB
  • Congested area
  • Line not blinded after equipment removed
  • Line not properly identified
  • Proper PPE not worn
    • Tesoro sulfuric acid injury 6/2010 - CSB
  • Recognize hazard
    • BP Amoco Thermal Decomposition Incident 3/13/2001 - CSB
  • Improper isolation
    • Giant Industries Refinery Explosions and Fire 4/8/2004 - CSB
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SWP Element 

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