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CSB releases a new safety video on its investigation into the fatal release of hydrogen chloride
The U.S. Chemical Safety and Hazard Investigation Board (CSB) released a new safety video on its investigation into the fatal release of hydrogen chloride at the Wacker Polysilicon North America facility in Charleston, Tennessee, on November 13, 2020. One contract worker was killed - and two others were seriously injured - when attempting to escape the release. The CSB's new safety video, “No Way Down: Chemical Release at Wacker Polysilicon,” includes an animation of the events leading to the incident. The CSB’s investigation found that at the time of the incident there were multiple contract workers present on the fifth floor of an equipment access platform at the facility. The contract workers were from two different firms, conducting different work, and were wearing different levels of Personal Protective Equipment. One of the workers applied excessive torque to flange bolts on a heat exchanger outlet pipe containing hydrogen chloride, causing the pipe to crack and release the hazardous chemical in the vicinity of the workers. There was only one way to exit the platform – via a staircase. As the white cloud of hydrogen chloride expanded, the workers on the platform were not able to see their surroundings or access the staircase. Three of the workers who were not wearing full-body chemical resistant suits began climbing down the side of the structure to escape the hazardous cloud. All three workers fell approximately 70 feet during their attempt to escape. One of the workers died from the fall, and the other two sustained serious injuries. Add new comment
Inspection Guidance for Animal Slaughtering and Processing Establishments
October 15, 2024
This memorandum establishes guidance for inspections conducted in all animal slaughtering and processing establishments, North American Industry Classification System (NAICS) 3116, Animal Slaughtering and Processing.1 This memorandum updates and supersedes OSHA's previous inspection guidance specific to a subset of this NAICS, poultry slaughtering and processing establishments (NAICS 311615), OSHA Memorandum, October 28, 2015. This expansion into the broader Animal Slaughtering and Processing industry (NAICS 3116) is based on OSHA's determination that this industry has a high Bureau of Labor Statistics (BLS) days away, restricted, or transfer (DART) rate (i.e., above the 1.7 private industry national average). The goal of this initiative is to significantly reduce injuries and illnesses resulting from occupational hazards, through a combination of enforcement, compliance assistance, and outreach. Under this new memorandum, all programmed and unprogrammed inspections in NAICS 3116 shall cover the focus hazards associated with the list below, in accordance with the FOM:
These focus hazards shall be assessed in addition to other hazards that may be the subject of the inspection or based on information gathered by the compliance safety and health officer (CSHO) during the inspection. Additionally, the Department of Labor's Wage and Hour Division (WHD) protects workers from unlawful wage and hour practices and child labor violations. Therefore, OSHA offices should initiate referrals and exchange appropriate information relating to complaints, inspections, or investigations and related matters, to support the enforcement activities of the agencies. If OSHA discovers information relating a possible violation of the laws and regulations enforced by WHD, OSHA offices are to provide timely information to WHD by making a referral, per the Memorandum of Understanding between WHD and OSHA, dated May 4, 2023. All workers, regardless of their socioeconomic backgrounds or immigration status, have the right to a workplace that is free of known safety and health hazards and to report hazards to OSHA without fear of retaliation. OSHA shall also make referrals to whistleblower staff when indicated. Scope: This guidance applies to all Federal OSHA inspections, programmed and unprogrammed, conducted in: 1998 H2S incident (same contractor; wrong place-wrong time)
Looking at the contractor involved with the refinery H2S incident last week, I came across another refinery accident involving H2S where this contractor had their employees exposed. I have no special info on this latest incident, and I will let the media release the name of the contractor, but this 1998 incident was being in the wrong place at the wrong time. Another contractor company had its team exposed to this H2S event. Employees #1 through #10 worked at a crude oil refinery where nearby process units (crude oil and gas oil treater) were undergoing a planned turnaround. The units had staggered shutdown and startup schedules and shared some product transfer piping leading to storage. When the product flow was rerouted by operations prematurely, sour naphtha liquid was released into the crude unit from an OPEN connection installed on a NEW 6 in. piping section that served as an exchanger bypass line. The low-pressure release lasted for several minutes and allowed clouds of toxic hydrogen sulfide (H2S) gas to accumulate in and around the nearby control room and through nearby process units. Line Break gone bad? (High pH solution and Verifying ZES w/o guage)
We routinely discuss the challenges and risks of performing Line/Equipment Opening (LEO) tasks, with one of the top 5 challenges being the "means used to verify" the pipe/equipment is at a Zero-Energy-State (ZES). The factors that occurred in this incident probably happens by the hour in the process industry; it is why we ALWAYS have on a layer of PPE that will protect us when this type of failure occurs. On June 8, 2020, at 10:00 a.m., Employee #1, 29, was working for a pipe fitting contractor. Employee #1 removed steel bolts from a flange fitting to open the process piping. The job site was a roofing materials production facility, and the work was adding process piping and equipment to enlarge an existing chemical process. The scope of this work included tying in new relief valve piping to the existing line process piping. This line piping is NORMALLY empty. The additive is a corrosive chemical with a pH of 10.8. When deliveries are made, the piping conveys the additive from the delivery truck to a fixed storage tank located outdoors. Only during deliveries does the line contain the flowing additive. However, approximately 8 gallons of residual liquid remains trapped in a 2-inch vertical pipe riser. This liquid is trapped by a one-way check valve downstream of the riser. Employee #1 was opening the pipe flange to drain this residual liquid before adding the relief valve. Employee #1 began to open the four-bolt pipe flange between the pipe riser and check valve. Is Caustic (NAOH) in your Line/Equipment Opening SWP? ($121K in OSHA citations)
During my time in the process industry, we usually had a "caustic scrubber" attached to our PSM/RMP covered process(s). This meant this scrubber was "part of" the covered process. I get a lot of pushback regarding covering "safety critical utilities" that are in place to either PREVENT, PROTECT, or MITIGATE an event from the covered process, but for me, these caustic systems are clearly part of the covered process. In recent years, as a consultant, I have pushed to apply the PSM/RMP Line/Equipment Opening (LEO) Safe Work Practice(s) to other hazardous processes that are NOT officially a PSM/RMP-covered process. Systems such as steam, heat transfer fluids, acids, and bases (such as NAOH) should be included in this SWP. Case in point: LEARN from others' mistakes. Employees were removing a flange blank on a caustic liquid pipe that was supposed to be evacuated. The employees were sprayed with caustic liquid and suffered chemical burns to their faces and eyes. Two (2) employees, both 50, required hospitalization for treatment, and three (3) others were injured but did not require hospitalization. Hazards of filling PIT LPG cylinders (Hydrostatic RV w/ INCORRECT Set Point)
In recent years, we have seen many facilities begin to fill their own PIT LPG cylinders on-site rather than contract this service out. Typically, we find this "change" was poorly managed: no PPE Hazard Assessment, no (or very poor) training on the task, LPG improperly located, improper electrical classification around the LPG tank and the filling station, etc. This comes down to management not recognizing the risk associated with what is viewed as a very simple task, which they equate to a low-hazard/risk task. Here is an incident that is not all that rare when a facility fills its own LPG cylinders associated with PIT operations... A forklift operator at an industrial site was filling a liquid propane cylinder on the forklift and also heard a hissing sound. The operator then started the forklift, and a flash fire explosion occurred at the forklift and propane dispensing system. Failure scenario(s) Failure to PROPERLY pressure test, leak test, and purge gas lines after testing leads to NG explosion @ fruit orchard
An explosion occurred inside a mobile trailer containing five (5) gas-fueled clothing dryers at a fruit orchard and processing facility. The blast caused damage to the building, and the facilities manager, who was inside when it took place, received burns and contusions. In 2019, the gas-fueled clothing dryers were installed and converted from natural gas to propane by unqualified individuals who left appliance gas valves connections loose. At that time, the appliances were not connected to a fuel source, and the trailer was stored for future use. In 2024, a licensed contractor sent an uncertified plumber who finished connecting the appliances but did NOT check for leaks downstream of the shut-off valves, nor did they purge the gas piping of air. When the facilities manager started the appliances, he did not immediately smell the odor of gas since the pipes had not been purged of air. The activation of the dryers created a source of ignition that likely ignited the air and fuel mixture to create the explosion. Lack of Training and Poor labeling of Emergency Shutdown Button, and an altered excess flow valve leads to serious event
When we use the phrase "cascading failures," this event is nearly a perfect example. 1) A gas station employee attempted to fill a propane tank without the required training. This led to the uncontrolled release of approximately 1500 liters (396 gallons or 1,600 pounds) of liquid propane and evacuated nearby homes. 2) When the staff went to use the emergency shut-off, poor labeling resulted in the wrong switch being used. 3) In addition, the excess flow valve, a safety mechanism meant to limit the flow automatically, had previously been altered and made ineffective. Improper "cleaning" of process leads to 16 workers treated and released (bromo acetone and hydrogen bromide)
The process in progress at the time of the event was the manufacture of methatrexate, an anti-cancer drug. Shortly after employee #1 began to draw bromine liquid into the supposedly clean and empty charging pot, he heard a hissing sound. He then saw a purple haze spewing out from under the lid of the pot. Analysis of the residue left behind inside the charging pot showed that bromine had reacted vigorously and exothermically with acetone to form bromo acetone and hydrogen bromide. Bromo acetone is a purple substance which is extremely irritating to the eyes and highly irritating to all mucous membranes and the skin. Sixteen employees were taken to the hospital, treated for eye irritation and released. The cause of the event was the failure to remove acetone, which had been used for cleaning, from the charging pot.
Scrubber under N2 blanket kills entrant
On February 19, 2015, employees were to perform a preventive maintenance inspection inside of a scrubber, which is maintained free of oxygen using a nitrogen blanket. When the designated attendant could not find the entrant employee, other employees searched for him. The entrant employee was found inside the scrubber (a metal tube) where he had been preparing to clean it out. He was found to be unresponsive. The employee was pronounced deceased at the scene by the Lake County coroner. |
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