U.S. Chemical Safety and Hazard Investigation Board (CSB) - Experts & Thought Leaders

The U.S. Chemical Safety and Hazard Investigation Board (CSB) released its final report into the fatal explosion and fire at the KMCO production facility in Crosby, Texas, USA. On April 2, 2019, KMCO was producing sulfurized isobutylene as a lubrication additive. The explosion and fire occurred after isobutylene leaked from a fracture in a segment of piping and formed a flammable vapor cloud, which ignited. Fatal injury One KMCO employee was fatally injured, and two others were seriously injured. At least 28 other workers were also injured. Portions of the KMCO facility were substantially damaged from the explosion and subsequent fires. News outlets reported that the explosion shook nearby homes and was heard throughout the surrounding community. Local authorities also issued a shelter-in-place order for residents within a 1-mile radius of the facility that lasted for more than four hours. tragic death and injuries KMCO also failed to heed industry guidance about installing remote isolation equipment" CSB Chairperson - Steve Owens, said “The tragic death and injuries caused by this terrible event should never have happened. KMCO did not properly train its employees and did not give them adequate protective safety equipment." He adds, "KMCO also failed to heed industry guidance about installing remote isolation equipment so that its employees could have safely stopped this serious hazardous leak.” isobutylene release The CSB’s final report determined that the isobutylene release occurred when a piece of equipment called a y-strainer ruptured due to a brittle overload fracture. Specifically, the cast iron y-strainer was installed within an area of the piping system that, unlike other portions of KMCO’s isobutylene piping, was not equipped with a pressure-relief device or otherwise protected from potential high-pressure conditions. Therefore, when those conditions developed, most likely due to liquid thermal expansion, the y-strainer was subject to high internal pressure and ruptured releasing isobutylene and forming a vapor cloud. This flammable cloud most likely ignited from contact with electrical equipment within a poorly sealed, nearby building. key safety issues The CSB’s report identified three key safety issues that contributed to the severity of the incident. They are: Emergency Response: KMCO’s procedures and training did not properly limit the role of its operators during the emergency response. KMCO’s plant culture relied on unit operators taking quick actions to stop a release before the site’s emergency response team assembled. While those urgent communications and quick actions did help move many operators away from the danger, the workers performing the quick actions were at risk. KMCO could have reduced the severity of the April 2, 2019, event by establishing clear policies and training its workforce to not put themselves in danger at all to urgently stop a chemical release. Remote Isolation: When the y-strainer ruptured, KMCO’s workers lacked the safety equipment to stop the isobutylene release from a safe location, such as from within the blast-resistant control room. Hazard Evaluation: Hazard evaluation is one of the most important elements of a process safety management program. KMCO’s hazard evaluations consistently overlooked or misunderstood that its y-strainer was made from cast iron, a brittle material that existing industry standards and good practice guidance documents either prohibit or warn against using in hazardous applications, such as KMCO’s isobutylene system.  seven key safety lessons Both can be achieved by applying robust safety systems and establishing effective emergency response programs" Investigator-in-Charge - Dan Tillema, said “In addition to highlighting the safety issues present at KMCO, our report emphasizes seven key safety lessons that can help prevent a similar incident." Dan Tillema adds, "One such lesson is that the goal of keeping workers safe and the goal of quickly isolating releases to minimize the consequences of an incident should not be mutually exclusive. Both can be achieved by applying robust safety systems and establishing effective emergency response programs.” No recommendations Following the April 2, 2019, incident, KMCO filed for bankruptcy, and the company is no longer in business. Altivia Oxide Chemicals, LLC (Altivia) purchased the Crosby, Texas, facility in 2020 and informed the CSB that the process involved in the incident would be dismantled. As a result, the CSB is not issuing recommendations with this report. understanding the factors Nevertheless, the CSB is urging Altivia to read the report closely and understand the factors that led to the incident at the KMCO facility and the lessons stemming from it. Moreover, if Altivia reinitiates the process or any equipment involved in this incident, the company should ensure that the facts, conditions, and circumstances that caused the incident and contributed to its severity are not repeated. The CSB’s board members are appointed by the President subject to Senate confirmation. The Board does not issue citations or fines but makes safety recommendations to companies, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA.

The U.S. Chemical Safety and Hazard Investigation Board (CSB) released its final report into the deadly explosions and fires at the Didion Milling, Inc. (Didion) dry corn milling facility in Cambria, Wisconsin, USA. The explosion occurred in May 2017, and fatally injured five employees and seriously injured another 14. The incident also ultimately destroyed the facility, resulting in over $15 million in property damage. source of the smoke On the night of May 31, 2017, during normal mill facility operations, employees smelled smoke in parts of the mill. They investigated the source of the smoke and determined that it likely was located on the first floor of one of the buildings. While investigating milling process equipment, several employees heard an explosion and saw fire coming from piping on the rotary gap mill equipment discharge. The employees began to evacuate and attempted to notify other employees of the emergency using their radios, but conflicting radio traffic was confused with the message.  interconnected dust collection systems The employees who were not within the immediate vicinity of the observed fire were unaware of the emergency A fire spread through the process equipment via interconnected dust collection systems resulting in explosions in some of the dust collection equipment. Secondary explosions subsequently occurred throughout the facility. The employees who were not within the immediate vicinity of the observed fire were unaware of the emergency and the need to evacuate before the explosions. Combustible dust explosions and fires CSB Chairperson - Steve Owens said, “Combustible dust explosions and fires can be deadly and incredibly destructive. The tragedy at Didion was made even worse due to the lack of important safeguards in the design of the mill equipment and the lack of engineering controls at the facility that could have reduced the potential for serious fires and explosions."  He adds, "Our investigation also determined that Didion had a poor safety culture and inadequate leadership on safety issues that contributed to these tragic circumstances.” cause of the dust explosions The CSB report emphasized that Didion did not recognize the hazards posed by combustible dust The CSB determined the cause of the dust explosions and collapsed buildings was the ignition of combustible corn dust inside process equipment, which transitioned to multiple explosions.   The CSB report emphasized that Didion did not recognize the hazards posed by combustible dust throughout the milling process. This resulted in Didion not understanding or addressing those combustible dust hazards.   Lack of fire risk evaluation The CSB’s investigation found that a key factor that contributed to the seriousness of the injuries was that Didion did not evaluate the risk of fires nor the need for flame-resistant personal protective equipment.  Because of this, Didion did not provide personal protective equipment to employees in the mill, some of whom suffered burn injuries during the incident, including some fatal injuries. no effective corrective measures The CSB’s investigation further found that the company failed to investigate prior incidents at the mill and implement corrective measures to prevent recurrence. Despite several previous fires, no effective corrective measures were taken to prevent fires from happening again. Incident issues The CSB’s investigation found several issues that contributed to the severity of this incident" Investigator-In-Charge - Cruz Redman said, “The CSB’s investigation found several issues that contributed to the severity of this incident. They include a lack of hazard recognition, a failure to provide proper engineering controls, and a failure to implement safety management systems to mitigate combustible dust hazards which could ultimately impact the safety of all the workers at the facility.” insufficient safety regulations The CSB’s report determined insufficient safety regulations which cover combustible dust operations. While the Occupational Safety and Health Administration (OSHA) regulates some aspects of combustible dust hazards, OSHA does not have an overarching standard to manage the hazards presented by combustible dust.  As a result, Didion was not required to implement safety management systems, such as those required for other highly hazardous materials. CSB recommendations As a result of its findings, the CSB is issuing more than a dozen recommendations to Didion, the National Fire Protection Association (NFPA), and OSHA. The CSB is recommending that Didion develop a comprehensive combustible dust safety program, which will include management of change, safety information management, fugitive dust management, management of audits, incident investigations, dust hazard analyses, personal protective equipment, and emergency preparedness. national regulation for industries CSB is calling on NFPA to update its combustible dust standards to include more requirements The CSB also is recommending that OSHA develop a national regulation for industries that handle combustible dust, as well as increase follow-up inspections when combustible dust hazards have been identified at facilities. Similarly, the CSB is calling on the National Fire Protection Association (NFPA), to update its combustible dust standards to include more comprehensive requirements for dust hazard analyses, incident investigations, and management of change. No citations or fines The CSB’s board members are appointed by the President subject to Senate confirmation. The Board does not issue citations or fines but makes safety recommendations to companies, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA.

The U.S. Chemical Safety and Hazard Investigation Board (CSB) released its final investigation report on the 2019 tank farm fire at the Intercontinental Terminals Company, LLC (ITC) bulk liquid storage terminal in Deer Park, Texas. The massive fire caused substantial property damage, significantly impacted the environment, and led to the issuance of several shelter-in-place orders that seriously disrupted the local community. Disruptive fire event CSB Chairperson Steve Owens said, “This was a very large and disruptive event. The fire burned for three days, caused over 150 million dollars in property damage at the facility, put the surrounding community potentially at risk, and significantly impacted the environment. This disastrous event could have been prevented if proper safeguards had been in place at the facility.” The ITC Deer Park terminal housed over 240 aboveground storage tanks, which were used to store petrochemical liquids and gases, fuel oil, bunker oil, and distillates for various oil and chemical companies that leased the tanks from ITC. Faulty Tank 80-8 circulation pump operation Tank 80-8 circulation pump continued to operate as the butane-enriched naphtha product released from the failed pump The incident occurred just after 10:00 a.m. on March 17, 2019, when an accidental release of butane-enriched naphtha product accumulated and ignited near a large aboveground atmospheric storage tank, known as Tank 80-8. The CSB found that a circulation pump connected to Tank 80-8 failed, allowing the butane-enriched naphtha product contained in the tank to escape. The Tank 80-8 circulation pump continued to operate as the butane-enriched naphtha product released from the failed pump for roughly 30 minutes before its flammable vapors ignited, causing a fire to erupt and engulf the Tank 80-8 piping manifold. Once the fire erupted, ITC was unable to isolate or stop the release. the fire burned, intensified, and spread As a result, the fire burned, intensified, and spread to the other 14 tanks located in the same containment area. The fire burned for three days until it finally was extinguished. The fire caused substantial property damage at the ITC Deer Park terminal, including the destruction of fifteen (15) 80,000-barrel aboveground atmospheric storage tanks and their contents.  Containment wall collapse Because of benzene-related air quality concerns, a shelter-in-place was issued for the entire City of Deer Park at one point Because of benzene-related air quality concerns, a shelter-in-place was issued for the entire City of Deer Park at one point, and local schools and businesses either closed or operated under modified conditions. A portion of a major highway in the area also was closed.  Additionally, the secondary containment wall surrounding the tank farm partially collapsed, allowing the mixture of released hydrocarbon products, firefighting foam, and contaminated water in the containment area to release into the surrounding waterways, resulting in the closure of a seven-mile stretch of the Houston Ship Channel adjacent to the ITC Deer Park terminal, as well as several waterfront parks in Harris County and the City of LaPorte, due to the contamination. Safety issues highlighted The CSB’s final investigation report highlights the following five key safety issues: Pump Mechanical Integrity: ITC did not have a formal mechanical integrity procedure to maintain the integrity of Tank-80-8 and its associated equipment, including the Tank 80-8 circulation pump. Flammable Gas Detection System: Tank 80-8 was not equipped with a flammable gas detention system to warn personnel of a hazardous atmosphere resulting from loss of containment from the tank or its associated equipment. Remotely Operated Emergency Isolation Valves: Tank 80-8 and other tanks in the tank farm were not equipped with remotely operated emergency isolation valves designed to mitigate process releases remotely from a safe location. Tank Farm Design: Elements of the tank farm design, including tank spacing, subdivisions, engineering controls for pumps located inside the containment area, and drainage systems allowed the fire to spread to other tanks within the tank farm. PSM and RMP Applicability: ITC did not apply a formal process safety management (PSM) program to Tank 80-8 because neither the OSHA PSM standard nor the EPA Risk Management Program (RMP) rule applied to the tank and its associated equipment due to exemptions contained in the regulations.  cause of the incident Contributing to the severity of the incident was the absence of a flammable gas detection system to alert the operators The CSB determined that the cause of the incident was the release of flammable butane-enriched naphtha vapor from the failed Tank 80-8 circulation pump, which accumulated in the area and ignited, resulting in a fire.  Contributing to the severity of the incident was the absence of a flammable gas detection system to alert the operators to the flammable mixture before it ignited approximately 30 minutes after the release began, and the absence of remotely operated emergency isolation valves to safely secure the flammable liquids in Tank 80-8 and the surrounding tanks in the tank farm. safety shortcomings The CSB also determined that because of gaps in relevant regulations issued by the U.S. Occupational Safety and Health Administration (OSHA) and the U.S. Environmental Protection Agency (EPA), ITC was not required to have a formal program for Tank 80-8 and its associated equipment that could have provided a process to identify and control the specific hazards that resulted in this incident. Investigator-in-Charge Crystal Thomas said, “The CSB’s investigation found that the cause of the incident was linked to a number of safety shortcomings including the lack of an effective mechanical integrity program, tank farm design, deficient remote isolation valve capabilities, as well as a lack of a formal process safety management program for Tank 80-8.” recommendations CSB is issuing recommendations to the company, OSHA, EPA, and a standard-setting organization to take action As a result of its findings, the CSB is issuing recommendations to the company, OSHA, EPA, and a standard-setting organization to take action to address gaps linked to the identified safety issues. The CSB is an independent federal agency charged with investigating incidents and hazards that result or may result, in the catastrophic release of extremely hazardous substances. core mission activities The agency’s core mission activities include conducting incident investigations; determining the cause of the release; formulating preventive or mitigative recommendations based on investigation findings and advocating for their implementation; issuing reports containing the findings, conclusions, and recommendations arising from incident investigations; and conducting studies on chemical hazards. The agency's board members are appointed by the President subject to Senate confirmation. The Board does not issue citations or fines but makes safety recommendations to companies, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA.