Today, the CSB released its final report addressing three (3) serious chemical incidents involving toxic hydrogen fluoride (HF) at a facility in Geismar, Louisiana. The incidents occurred over a period of less than three years, from October 2021 to June 2024, and reveal systemic safety failures at the facility.
These incidents were LOPC events, two (2) of which involved Flanges and Line Breaking.
October 21, 2021: GASKET FAILURE; FATALITY (Gasket Failure)
January 23, 2023: HF REBOILER EXPLOSION (Pressure Vessel Failure)
June 7, 2024: HF RELEASE; SERIOUS INJURY (Line Break)
October 21, 2021:
GASKET FAILURE; FATALITY
- Technology Change Implementation
- Mechanical Integrity
- Safe Work Practices
A fatal HF release occurred during a unit startup when a corroded flange gasket catastrophically failed, spraying toxic HF on a worker’s face, ear, and neck. The worker, who was not wearing sufficient personal protective equipment, was transported to a hospital for treatment but died later that day. In addition to the fatality, Honeywell also reported $14 million in damages.
The facility was aware of corrosion damage to 304 stainless steel spiral wound gaskets in recycle HF service beginning in the first five years of the 245 unit’s operation. It identified a different gasket technology and documented the need to change the gasket technology in 2007, but despite ongoing gasket corrosion, it elected to replace the gaskets on an attrition basis. In 2021, 14 years after documenting the need to change the gasket technology, the facility still had not fully implemented the change. Although the MOC did not set a specific completion date, the facility’s failure to fully implement this change contributed to the incident. Had it fully implemented the gasket technology change, the loss of containment of HF may not have occurred, and the incident and the fatal injury may have been prevented.
There were serious flaws in the fcaility’s systems for change management, process knowledge management, and MI. These flaws caused the site to have not fully implemented the gasket technology change 14 years after the change was initiated and may have contributed to the fatal incident.
The CSB determined that the cause of the HF release was the failure of a flanged piping connection. The gasket within the connection had deteriorated from stress corrosion cracking, and the flange assembly was likely loosened because its fastening studs were thinned from wet HF acid corrosion, resulting in the release. The facility’s systems for mechanical integrity, change management, and process knowledge management contributed to the incident. The facility’s mechanical integrity systems did not identify and replace the corroded gasket prior to its failure, and its change management and process knowledge management systems allowed it to not fully implement a 2007 gasket technology change that could have prevented the gasket corrosion. The facility’s ineffective safe work practices contributed to the severity of the incident. The facility did not follow its written unit startup procedures, which caused the fatally injured operator to be in the immediate vicinity of the incident gasket. The use of inadequate personal protective equipment resulted in the operator’s fatal exposure to the released toxic HF.
January 23, 2023:
HF REBOILER EXPLOSION
- Mechanical Integrity
- Management of Organizational and
Personnel Change - Capital Project Management
- Organizational Resilience
A reboiler exploded at the facility, releasing over 800 pounds of toxic HF and 1,600 pounds of chlorine. Although no injuries occurred in this incident, the explosion caused $4 million in damage and resulted in a site-wide shelter-in-place order being issued and nearby highways being closed.
The CSB determined that the cause of the accidental release of toxic HF and chlorine was the catastrophic failure of a reboiler. The reboiler had thinned due to HF corrosion of its carbon steel shell to the point that it could no longer contain its normal operating pressure. Contributing to the incident were the facility’s ineffective implementation of its safety management systems for 1) mechanical integrity, 2) personnel and organizational change, and 3) capital projects. The facility’s incomplete implementation of its organizational resilience policies and procedures, which could have enabled it to identify instability in its other management systems, also contributed to the incident.
June 7, 2024:
HF RELEASE; SERIOUS INJURY
- Safe Work Practices
A contract worker, who was not wearing face or respiratory protection, was seriously injured during maintenance when residual toxic HF was unexpectedly released from piping and contacted the worker in the face. The worker was transported to a local hospital, where he was admitted and spent two days recovering as a result of his serious injury. He sustained second-degree burns from the HF exposure. The CSB found that neither the worker who was seriously injured nor others on site were aware that the piping had not been cleared of HF prior to the maintenance work. However, there was HF trapped between a valve plug and a flange, and when the fasteners on the flange were loosened, the HF was released, contacting the worker in the face.
The facility did not ensure that all piping within the bounds of the lockout was free of hazardous energy. The incident valve should have been cleared of HF as part of the facility’s preparation for the maintenance work. Doing so would have prevented the HF release and the serious injury.
The facility did not ensure that important work scope information was provided to the operator. Because he did not review the annotated P&ID or piping isometric, the operator likely was not aware of the specific flanges that were to be changed and instead was likely only aware of the general piping segment on which the two Turner workers would change gaskets. Had the operator been provided with the correct documentation, he could have identified the potential hazard of the closed (and therefore potentially containing HF) valve, and he could have directed the two contract workers to address the
valve while they were wearing Level B PPE. Doing so would have prevented the release, the serious injury, or both.
The contract workers and supervisor did not consider or otherwise account for the potential hazard of the closed incident valve during their pre-job risk assessment, despite the it’s risk assessment form clearly prompting them to do so. Had they identified the potential hazard, they could have notified the unit operator of the potential hazard and addressed the risk prior to the work commencing, or during the job prior to removing their Level B PPE. Doing so would have prevented the release, the serious injury, or both.
Because the facility and its contractor closed out the line break permit, the two contract workers removed their Level B PPE once they believed the piping segment was free of hazardous energy. Had the injured
contract worker been wearing sufficiently protective PPE, his injury would have been prevented.
The number of gaps in the performance of the facility and the contrcator requirements during this incident is indicative of systemic problems with the site’s implementation of its safe work practices including preparation of equipment for maintenance, control of hazardous energy, line break safety, and contractor management.
The CSB determined that the cause of the accidental HF release was the partial removal of a blind flange from a valve that contained pressurized HF during a maintenance activity. The facility did not effectively remove all HF from the valve before turning it over to contract workers for maintenance. Contributing to the incident were the facility’s and the contractors’ ineffective implementation of safe work practices, including hazard identification and mitigation
All three (3) incidents resulted from the ineffective implementation of the facility’s existing safety management system. Had the facility followed its existing normal procedures, policies, and practices, it could have, and likely would have, prevented each of the three (3) incidents.
Source: https://www.csb.gov/assets/1/6/honeywell_geismar_investigation_report_-_final.pdf