Page 12 - Equipment Identification - CCPS Safe Work Practice

Incidents

Community Shelter in Place Occurs From Mixing of Incompatible Chemicals

MGPI Toxic Gas Release
(October 20, 2016)
A release of toxic chlorine gas
occurred at the MGPI Processing plant
in Atchison, Kansas when a delivery
truck owned by a third party was
incorrectly connected to a storage
tank containing incompatible material.
The toxic chlorine gas cloud generated
by the chemical reaction that occurred
when the incompatible chemicals
mixed in the storage tank resulted in
a shelter-in-place order for thousands
of residents. The CSB cited the pipe
marking system at the delivery point
as a contributing factor to the incident. https://www.csb.gov/mgpi-processing-inc-toxic-chemical-release-/

Opening Incorrect Valve Results In Explosion That Causes Five Fatalities

Formosa Plastics Corporation Explosion (April 23, 2004)

Description and Investigation: An explosion and fire killed five and seriously injured three workers at the Formosa
Plastics Corporation, IL (Formosa-IL) PVC manufacturing facility in Illiopolis, Illinois. The explosion occurred after a large
quantity of highly flammable vinyl chloride monomer (VCM) was inadvertently released from a reactor and ignited. An
operator was cleaning Reactor D306 using a water pressure washer. The operator cleaning reactor D306 descended
a level to drain the wash water from D306 but went to Reactor D310 by mistake and tried to open the bottom valve of
D310 – neither reactor was labelled at the lower
level. The D310 valve would not open, however,
because the reactor was operating with the
pressure interlock activated. Because he likely
thought he was at the correct reactor (D306),
the operator may have believed that the bottom
valve on D310 was not functioning. He used
the emergency air hose to bypass the bottom
valve pressure interlock and open the reactor
bottom valve while reactor D310 was operating,
releasing the contents.
Discussion: Investigators noted the reactors
were grouped into similar sets of four,
increasing the possibility of human error. Yet
there were no gauges, indicators, or warning
lights to inform operators on the lower level of a
reactor's operating status. https://www.csb.gov/formosa-plastics-vinyl-chloride-explosion/

12 SAFE WORK PRACTICE, EQUIPMENT IDENTIFICATION