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NST/Engineers, Inc. (NST) approaches Process Safety Management (PSM) as the logical extension of the elements of 29CFR1910.119 to include all workplaces. A major element of PSM is Process Hazard Analysis (PHA). Any industrial process has some level of hazard associated with its operation. Such hazards might include worker exposure to the following conditions:

High and Low Temperatures
Uncontrolled Release of Energy
Entanglement or Crushing in Rotating or Pressing Equipment
Engulfment in Finely Divided or Liquid Materials
Unexpected Chemical Reactions
Hazardous Materials
Untested or Improperly-Tested Confined Spaces

  A thoroughly conducted and regularly updated PROCESS HAZARD ANALYSIS will discover the workplace hazards that personnel will potentially encounter while operating any process.

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Investigators from the U.S. Chemical Safety Board (CSB) have concluded that an explosion and fire at Catalyst Systems Inc. in Gnadenhutten, Ohio, in January 2003 most likely occurred when 200 pounds of benzoyl peroxide in a vacuum dryer rapidly decomposed. The runaway chemical reaction produced large volumes of gas under high pressure.

Investigators have been unable to determine the specific initiating event.

The force of the explosion propelled the heavy vacuum dryer like a rocket across the room and through a wall, causing extensive damage to the building, but missing workers eating lunch just 35 feet away in the same room.

The operators described thick black smoke with rolling flames and a loud boom. They quickly exited the building. One worker received a puncture wound in his shoulder, most likely from flying debris.

CSB Board Chairman Carolyn Merritt said: "The workers were fortunate they were not standing by the vacuum dryer at the time of the explosion. This is another example of the dangers of not recognizing the inherent hazards of materials being handled, not using properly designed equipment, and not performing hazard identification studies."

The purpose of the process was to concentrate benzoyl peroxide, or BPO, to 98 percent by drying it. In this form BPO is the consistency of beach sand, and can decompose explosively when overheated. BPO is used to make a number of products, including plastics, silicone rubber, and automobile body putty.

The process, involving a highly reactive material, was not sufficiently evaluated by management, the study said, adding that Catalyst Systems had no program to formally take the hazards, generally well known in the industry, into account in the design of the dryer.

The study found the dryer had been purchased second-hand, with no wiring diagram or engineering drawings. No written operating procedures were developed for drying the chemical. Only verbal instructions were provided operators.

The case study says, "Catalyst Systems did not have a process safety management program in place, nor were employees trained in use of these systems."

While not determining the specific initiating event of the explosion, the study listed several probable sources. These included failure of a temperature probe, a hot spot in the dryer, failure of the vacuum pump, and leaving the chemical in the dryer too long.

The U.S. Chemical Safety Board (CSB) has released detailed information on the 167 serious chemical incidents analyzed in the agency’s landmark 2002 study on REACTIVE HAZARDS. The incidents covered are fires, explosions, toxic gas releases or other events where uncontrolled chemical reactions resulted in deaths, injuries, or damage, or had the potential to do so. All the incidents occurred in the U.S. between 1980 and 2001; together they were responsible for 108 deaths and numerous injuries.

CSB has approved 18 safety recommendations intended to reduce the number and severity of reactive incidents.

Among the 18 recommendations, the Board called on the U.S. Occupational Safety and Health Administration (OSHA) and the U.S. Environmental Protection Agency (EPA) to extend their process safety regulations -- known as the Process Safety Management standard and the Risk Management Program, rule -- to better control hazards associated with chemical reactivity. The January 2003 deadly fire at an oilfield waste disposal facility south of Houston could have been avoided if the companies involved had safer procedures for handling flammable wastes, investigators from the U.S. Chemical Safety and Hazard Investigation Board (CSB) have reported.

The January 13 accident in Rosharon, Texas, occurred as two tank trucks unloaded waste liquids into an open collection pit at the BLSR Operating Ltd. disposal facility. Unknown to either the drivers or BLSR personnel, the waste material was highly volatile, and a flammable vapor cloud formed in the unloading area. Vapor was drawn into the air intakes of the trucks’ running diesel engines -- causing them to race and backfire. The flammable cloud ignited.

Two BLSR employees standing near the trucks were killed in the fire, and three others suffered serious burns. The two drivers, who were employed by T and L Environmental Services Inc., were also burned after rushing back to their trucks when they heard the engines accelerate. One of the drivers died several weeks later from his injuries.

CSB said two root causes that led to the tragedy. First, the producer of the waste, Noble Energy, did not recognize its potential flammability nor did it provide appropriate safety information to either T and L or BLSR. This liquid waste, referred to as basic sediment and water, or BS and W, settles to the bottom of storage tanks that contain either crude oil or the liquid hydrocarbons that condense from natural gas (gas condensate).

BS and W is commonly sent to deep-well injection sites for disposal. But the material can contain significant quantities of flammable hydrocarbons. When tested, most samples of BS and W obtained by Board investigators were found to be highly flammable, including material from the Noble Energy storage tanks involved in the incident.

Material Safety Data Sheets (MSDS) -- documents required by OSHA, that describe materials and hazards in detail -- should have been prepared by the waste producer and provided to the truck drivers and the disposal facility operators.

The second root cause of the accident was that BLSR management did not have safe unloading and handling practices for potentially flammable BS and W wastes. Not recognizing the hazards of the material, the company did not control potential ignition sources or use unloading techniques designed to minimize vapor formation.

CSB Investigators Cite Lack of Effective Management Systems in December 2002 Hydrogen Sulfide Incident at Cincinnati Waste Disposal Plant.

A release of potentially deadly hydrogen sulfide (H2S) at the Environmental Enterprises Inc. (EEI) waste treatment facility in Cincinnati, Ohio, resulted from treating chemical wastes in an inappropriate vessel, according to investigators from U.S. Chemical Safety and Hazard Investigation Board (CSB).

A maintenance worker collapsed after he walked near the waste vessel and inhaled toxic hydrogen sulfide, which carries a signature rotten egg odor. Inhaling the gas can cause accumulation of fluid in the lungs and respiratory arrest. The victim, who was initially unable to breathe, was treated at a local hospital and released.

Environmental Enterprises had not adequately trained its employees on the hazards of hydrogen sulfide, according to CSB investigator Johnnie Banks. Therefore the employees did not recognize the rotten egg odor as a sign of imminent danger.

EEI treats water-based hazardous waste containing various contaminants, including heavy metals, for disposal. CSB investigators said the hydrogen sulfide release occurred after an operator added solid sodium sulfide to a batch of waste in an effort to remove mercury. Later the same operator added an acidic chemical (polyaluminum chloride) to adjust the pH of the waste.

Unknown to the operator, excess sodium sulfide reacted with the acidic chemical to form hydrogen sulfide gas, which was released from the open-top clarifier vessel where the treatment was attempted. Later the maintenance worker entered the treatment area, which was then unattended, to retrieve a tool when he was overcome by the gas. The clarifier was not designed to handle the possibility of toxic gas formation and had no equipment to collect and treat such gases.

"This is the second serious incident we have investigated recently where the reaction of a sulfide salt with acid produced a dangerous gas release," according to CSB Chairman Carolyn W. Merritt. In November 2002 the Board completed its investigation of an incident at an Alabama paper mill where two workers were killed and eight others injured when a similar reaction in a process sewer caused a release of hydrogen sulfide gas. “Clearly there is a strong need for greater awareness of the hazards of reactive sulfides,” Merritt said.

A hydrogen sulfide warning device, installed under provisions of a city order, was not working at the time of the December 11 incident.

CSB Report Blames Motiva Enterprise LLC's Failure at its Delaware City, Delaware Refinery Sulfuric Acid Tank Farm to Follow PSM for the July 2001 Fatal Fire and HAZMAT Leak!

Contractor employee Jeffrey Davis, 50, was killed in the explosion. His body was never recovered. Eight other workers were injured when a spark from carbon-arc welding equipment ignited flammable vapors in a 415,000-gallon sulfuric acid storage tank at the refinery.

The surrounding sulfuric acid tank farm was heavily damaged in the blast, and an estimated 1.1 million gallons of the powerful corrosive were ultimately released to the environment, including nearly 100,000 gallons that flowed into the nearby Delaware River. A significant fish kill occurred there.

The CSB investigation found significant deficiencies in Motiva's mechanical integrity program. If effective, this program should have prevented the extensive corrosion damage that was evident in several tanks at the farm. Some of the tanks contained thousands of pounds of flammable hydrocarbons in addition to the corrosive sulfuric acid.

According to CSB lead investigator David Heller, "Motiva did not act to prevent hot work - high-temperature cutting that could generate molten metal and sparks - from being performed directly above a corroded hazardous storage tank that had holes in its roof and shell and was known to contain flammable vapors."

The Board found that the incident likely would have been prevented if good safety management processes had been adequately implemented at the refinery. Investigators found Motiva did not consider the tank farm to be covered by the requirements of the OSHA Process Safety Management Standard, which sets safety standards for various chemical operations.

The refinery's sulfuric acid tanks had a history of leaks. But Motiva took no effective action, even when its own tank inspectors recommended full internal inspections "as soon as possible" in three successive annual reports prior to the explosion. Three weeks before the explosion, an operator submitted a formal Unsafe Condition Report noting holes in two tanks and pointing out that the hose used to blanket the tank with nonflammable carbon dioxide was improperly installed.

The Board found Motiva investigated the Unsafe Condition Report but took no action to correct the deficiencies.
Interviews with Motiva workers and managers revealed that Motiva did not consider the tank leaks to pose a safety or environmental risk and did not properly engineer an earlier change when the tanks were converted from fresh sulfuric acid storage to used or "spent" acid, which contains flammable hydrocarbons.

Motiva Enterprises is a joint venture of Saudi Refining Co. and Shell Oil.

__________________________________________________________________________________________ Maintaining process safety and protecting workers from process hazards is serious business!
The owner of a fertilizer manufacturing company has received a long prison sentence and large fine for a RCRA violation. Allan Elias, owner of Evergreen Resources of Soda Springs, Idaho was given a 17 year sentence and fined $6 million for "willful disregard for employee safety that left one man with serious brain damage from cyanide contact.

Elias was convicted of sending workers to clean out mining waste in a tank that contained cyanide compounds. This was after the workers had complained of health problems from being in the tank. Elias had also been frequently warned by OSHA about the dangers of cyanide in the waste tank.

__________________________________________________________________________________________ The Mary Kay O'Connor Process Safety Center at Texas A&M University

This process safety resource, located at College Station, Texas is named in the memory of a chemical engineer who died in the line of duty. She was killed, along with 22 others in the October 1989 explosion at a Phillips 66 chemical plant near Houston. Also, there were 130 injuries in the incident. Ethylene and isobutane leaked from a pipeline and ignited. Mrs. O'Connor was operations superintendent with responsibility for the plant's day-to-day operations.

The O'Connor family received a settlement from Phillips and her husband directed that the proceeds from a $4 million portion of the settlement be used to support a process safety research and teaching program at Texas A&M. Texas A&M's R&D funding is second only to that of MIT in the U.S.

Michael O'Connor, Mary Kay's husband, also a chemical engineer, serves on the center's Steering, Technical, and Executive Committees. ___________________________________________________________________________________________

For a fee-based consultation call with a Licensed Professional Engineer between 3:00pm and 5:00pm Eastern Daylight Time, call (302) 239-2700.

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