Many safety and process safety professional think incidents like this are “rare”. They would be wrong, unless of course their definition of “rare” is a bit looser than mine! I do not have official numbers of the frequency of this type of incident but I am trying to obtain them and will certainly pass them along when, and if, I ever get them. But using my Incident Alerts from the past 14 years I have counted 78 such incidents that resulted in consequences that it made the news or triggered an agency inspection/investigation. Who knows how many occur with consequences so insignificant that they never make the news or any official reporting mechanism. But this 2012 incident is a PERFECT example of how these incidents occur and how their consequences can be lethal (however this incident only required the hospitalization of the drive for several days)…
PART I – REPORT TYPE
1. Incident Id: I2012040368
2. This is to report: Hazardous Material Incident
PART II – GENERAL INCIDENT INFORMATION
3. Date of Incident: 02/07/2012
4. Time of Incident (use 24-hour time): 16:00
5. Enter National Response Center Report Number (if applicable): 1002598
6. If you submitted a report to another Federal DOT agency, enter the agency and report number:
7. Location of Incident:
City: PAUL, County: MINIDOKA, State: ID, Zip Code: (if known): 83347
Street Address/Mile Marker/Yard Name/Airport/Body of Water/River Mile: 50 SOUTH 500 WEST
8. Mode of Transportation: FMCSA-HIGHWAY
9. Transportation Phase: UNLOADING
10. Carrier/Reporter:
Name: THATCHER TRANSPORTATION Street: 1905 W FORTUNE RD City: SALT LAKE CITY State: UT Zip Code: 84104
Federal DOT Id Number: 0
Hazmat Registration Number: 081606001048OQ
11. Shipper/Offeror:
Name: THATCHER COMPANY
Street: 1905 W FORTUNE RD City: SALT LAKE CITY State: UT Zip Code: 84104
Waybill/Shipping Paper: 1280641
Hazmat Registration Number: 051909018014RT
12. Origin (if different from shipper address) City: SALT LAKE CITY State: UT Zip Code: 84104-3724
13. Destination: City: PAUL State: ID Zip Code: 83347
14. Proper Shipping Name of Hazardous Material: HYDROCHLORIC ACID, SOLUTION
15. Technical/Trade Name: HYDROCHLORIC ACID SOLUTION
16. Hazardous Class/Division: 8 CORROSIVE MATERIAL
17. Identification Number: UN1789 (E.g. UN2764, NA 2020)
18. Packing Group: (if applicable) II
19. Quantity Released: (Include Measurement Units) 5.3875 Liquid – Gallon
20. Was the material shipped as a hazardous waste? NO If yes, provide the EPA Manifest Number:
21. Is this a Toxic by Inhalation (TIH) material? NO If yes, provide the Hazard Zone:
22. Was the material shipped under an Exemption, Approval, or Competent Authority Certificate? NO If yes, provide the Exemption, Approval, or CA number:
23. Was this an undeclared hazardous materials shipment? NO
PART III – PACKAGING INFORMATION
24. Check Packaging Type (check only one – if more than one, list type of packaging, copy Part III, and complete for each type: Cargo Tank Motor Vehicle (CTMV)
25. See instructions and enter the appropriate failure codes found at the end of the instructions. Be sure to enter the codes from the list that corresponds to the particular packaging type checked above. Enter the number of codes as appropriate to describe the incident. Enter the most important failure point in line 1. If there are more than two failure points, provide in this format in part VI.
What Failed: –
How Failed: –
Causes of Failure: 515 – Human Error
26a. Provide the packaging identification markings, if available. Identification Markings: NO MARKINGS PROVIDED (Examples: 1A1/Y1.4/150/92/USA/RB/93/RL, UN31H1/Y0493/USA/M9339/10800/1200, DOT – 105A – 100W (RAIL), DOT 406 (HIGHWAY), DOT 51, DOT 3-A)
26b. For Non-bulk, IBC, or non-specification packaging, if identification markings are incomplete or unavailable, see instructions and complete the following: Single Package or Outer Packaging: Single Package or Inner Packaging (if any): Packaging Type: Packaging Type: Material of Construction: Material of Construction: Head Type (Drums only):
27. Describe the package capacity and the quantity: Single Package or Outer Packaging: Single Package or Inner Packaging (if any): Package Capacity: Package Capacity: Amount in Package: Amount in Package: Number in Shipment: Number in Shipment: Number Failed: Number Failed:
28. Provide packaging construction and test information, as appropriate:
Manufacturer:
Manufacture Date: null
Serial Number:
Last Test Date: null
Material of Construction: (if Tank Car, CTMV, Portable Tank, or Cylinder)
Design Pressure: (if Tank Car, CTMV, Portable Tank)
Shell Thickness: (if Tank Car, CTMV, Portable Tank)
Head Thickness: (if Tank Car, CTMV)
Service Pressure: (if Cylinder)
If valve or device failed:
Type:
Model:
Manufacturer:
29. If the packaging is for Radioactive Materials, complete the following:
Packaging Category:
Packaging Certification:
Certification Number:
Nuclide(s) Present:
Transport Index:
Activity:
Critical Safety Index:
PART IV – CONSEQUENCES
30. Result of Incident (check all that apply): –
Spillage: NO –
Fire: NO –
Explosion: NO –
Vapor (Gas) Dispersion: YES –
Environmental Damage: NO – No
Release: NO
31. Emergency Response: The following entities responded to the incident: (Check all that apply)
Fire/EMS Report #: YES UNKNOWN
Police Report #: NO
In-house cleanup: NO
Other Cleanup: YES
32. Damages
Was the total damage cost more than $500? YES If yes, enter the following information: (If no, go to question 33.)
Material Loss: $ 1000
Carrier Damage: $ 0
Property Damage: $ 0
Response Cost: $ 0
Remediation/Cleanup Cost: $ 300 (See damage definitions in the instructions)
33a. Did the hazardous material cause or contribute to a human fatality? NO If yes, enter the number of fatalities resulting from the hazardous material:
Employees: 0
Responders: 0
General Public: 0
33b. Were there human fatalities that did not result from the hazardous material? NO If yes, how many? 0
34. Did the hazardous material cause or contribute to personal Injury? YES If yes, enter the number of injuries resulting from the hazardous material: Hospitalized (Admitted Only):
Employees: 1
Responders: 0
General Public: 0
Non-Hospitalized: (e.g.: On site first aid or Emergency Room observation and release)
Employees: 0
Responders: 0
General Public: 0
35. Did the hazardous material cause or contribute to an evacuation? NO If yes, provide the following information:
Total number of general public evacuated: 0
Total number of employees evacuated: 0
Total evacuated: 0
Duration of the evacuation: 0
36. Was a major transportation artery or facility closed? NO If yes, how many? 0
37. Was the material involved in a crash or derailment? NO If yes, provide the following information:
Estimated speed (mph): 0
Weather conditions:
Vehicle overturned? NO
Vehicle left roadway/track? NO
PART V – AIR INCIDENT INFORMATION (n/a)
PART VI – DESCRIPTION OF EVENTS & PACKAGE FAILURE – Describe the sequence of events that led to the incident and the actions taken at the time it was discovered. Describe the package failure, including the size and location of holes, cracks, etc. Photographs and diagrams should be submitted if needed for clarification. Estimate the duration of the release, if possible. Describe what was done to mitigate the effects of the release. Continue on additional sheets if necessary. Describe:
THATCHER TRANSPORTATION’S DRIVER ASKED THE OPERATOR WHERE THE HYDROCHLORIC ACID WAS TO BE DELIVERED BUT THE OPERATOR KNEW THE PRODUCT AS MURIATIC ACID AND APPARENTLY THOUGHT THE DRIVER WAS DELIVERING HYPOCHLORITE SOLUTION. WHEN THE DRIVER POINTED TO A TANK ACROSS THE CANAL ( WHAT TURNED OUT TO BE THE HYPOCHLORITE TANK) AND ASKED IF THAT WAS THE RIGHT TANK, SHE SAID YES. SHE ALSO SIGNED THATCHER TRANSPORTATION’S PRODUCT-TANK IDENTIFICATION CHECKLIST THAT SHE HAD VERIFIED THAT THE PRODUCT SHOWN ON THE BILL OF LADING MATCHES THE PRODUCT IDENTIFICATION SHOWN ON THE STORAGE TANK (SEE ATTACHMENT). WHEN THE DRIVER STARTED FILLING THE STORAGE TANK THE HYDROCHLORIC ACID AND SODIUM HYPOCHLORITE REACTED CAUSING A RELEASE OF CHLORINE GAS. THE DRIVER QUICKLY CLOSED THE VALVE AND BUT THE GAS CONTINUED TO COME OUT THE VENT CAUSING THE DRIVER TO BE OVERCOME WITH CHLORINE VAPORS. HE WAS TRANSPORTED TO A LOCAL HOSPITAL AND THEN TRANSFERRED TO THE UNIVERSITY OF UTAH HOSPITAL IN SALT LAKE CITY, UTAH WHERE HE WAS RELEASED A COUPLE OF DAYS LATER. PART VII – RECOMMENDATIONS/ACTIONS TAKEN TO PREVENT RECURRENCE –
Where you are able to do so, suggest or describe changes (such as additional training, use of better packaging, or improved operating procedures) to help prevent recurrence. Provide recommendations for improvement to hazardous materials transportation beyond the control of your individual company. Continue on additional sheets if necessary. Describe:
THE CUSTOMER PLACED A LOCK ON THE FILL PIPE OF THE HYPOCHLORITE TANK MAKING IT IMPOSSIBLE TO CONNECT TO IT WITHOUT AN OPERATOR PHYSICALLY UNLOCKING IT. THE CUSTOMER ALSO PLACED TANK IDENTIFICATION SIGNS IN LARGE AND BOLD LETTERING (THE TANK WAS IDENTIFIED WITH THE PROPER SHIPPING NAME, BUT IN SMALL LETTERING). THEY ALSO PLACED A UN IDENTIFICATION SIGN ON THE TANK IN BOLD LETTERING.