The U.S. Chemical Safety Board (CSB) has formally announced that “Emergency Planning and Response” and “Preventive Maintenance” are the Board’s newest “Most Wanted Safety Improvements”. The CSB has concluded that inadequate or poor emergency planning or response is a recurring finding in the CSB’s investigations. And that inadequate mechanical integrity programs, delayed or deferred preventive maintenance, and the aging infrastructure of equipment at chemical facilities have been a recurring root cause of incidents investigated by the CSB.
Emergency Planning and Response
To date, 12 CSB investigations and 46 resulting recommendations are aimed to address deficiencies found in a community’s, facility’s or emergency responder’s response to an incident at a chemical facility. The CSB’s recommendations department determined that the majority of CSB’s recommendations on this issue can be categorized in the following areas:
- 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;
- Conducting emergency response exercises;
- Information sharing between facilities, emergency responders and the community
The CSB’s history of examining emergency response issues spans well over a decade. In 2009 the CSB released a safety video detailing a number of related issues and recommendations
Despite the CSB’s many recommendations, emergency responders continue to be fatally injured due to poor emergency planning or response. Most recently 12 emergency responders were fatally injured as a result of the 2013 ammonium nitrate explosion and fire at the West Fertilizer Company located in West, Texas. The CSB’s final report contained a number of recommendations intended to improve the training of volunteer fire departments across the country.
The CSB’s full report, safety video, and recommendations can be found at http://www.csb.gov/west-fertilizer-explosion-and-fire-/
Preventive Maintenance
The CSB has investigated 11 incidents and currently has 21 open recommendations aimed at addressing gaps at a number of levels, including facility, corporate, regulatory programs and industry standards. The intent of the board’s recommendations is to promptly identify equipment upgrades, ensure that replacements are not delayed and equipment is not made to operate longer than it should.
Several of the 11 investigations identified occurred at refineries.
The CSB’s investigation into the catastrophic failure of a forty-year-old heat exchanger at a Refinery found that the fatal explosion and fire was caused by damage to the heat exchanger, a mechanism known as “high-temperature hydrogen attack,” or HTHA, which severely cracked and weakened carbon steel tubing lead to a rupture. The refinery used an inspection strategy that relied on design operating conditions rather than verifying actual operating parameters, and the CSB determined that inspections for this type of damage are unreliable, as the microscopic cracks can be localized and difficult to identify.
Another refinery investigation in which a lack of preventive maintenance was a root cause is a 2012 accident where a catastrophic pipe failure led to a massive fire. Testing determined that the pipe failed due to thinning caused by sulfidation corrosion, a common damage mechanism in refineries. The CSB’s investigation of the incident found that the refinery repeatedly failed over a ten-year period to upgrade piping in its crude oil processing unit, which was extremely corroded and ultimately ruptured on August 6, 2012. The CSB found a failure by the refinery to identify and evaluate damage mechanism hazards, which if acted upon, would likely have identified the possibility of a catastrophic sulfidation corrosion-related piping failure.
For more information, contact Communications Manager Hillary Cohen, cell 202-446-8094 or Sandy Gilmour, Public Affairs, cell 202-251-5496.