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Georgia-Pacific Corp. Hydrogen Sulfide Poisoning

Overview

On January 16, 2002, highly toxic hydrogen sulfide (H2S) gas leaked from a sewer manway at the Georgia-Pacific Naheola mill in Pennington, Alabama. The incident killed two contractors and injured eight others. The final report concluded that sodium hydrosulfide (NaSH) drained to the acid sewer and reacted with sulfuric acid to form H2S, which then leaked through a manway seal.

Incident Snapshot

Field Value
Facility / Company Georgia-Pacific Corporation
Location Pennington, AL
Incident Date 01/16/2002
Investigation Status The final report on this investigation was approved on November 20, 2002.
Accident Type Release of highly toxic hydrogen sulfide gas from a sewer manway.
Final Report Release Date 01/2003

What Happened

  • On January 16, 2002, highly toxic hydrogen sulfide (H2S) gas leaked from a sewer manway at the Georgia-Pacific Naheola mill in Pennington, Alabama.
  • Burkes Construction employees were working on a construction project at the Naheola mill in the vicinity of the tank truck unloading station.
  • Sodium hydrosulfide (NaSH) was being unloaded on January 15–16.
  • The drain valve from the oil pit to the acid sewer was locked closed.
  • An operator opened a valve to drain the oil pit; after 5 minutes, the valve was closed and relocked.
  • Three Davison Transport tank trucks arrived carrying NaSH.
  • With the assistance of two Georgia-Pacific operators, one of the truck drivers connected his vehicle to the unloading hose.
  • Witnesses estimated that when the connection was made, up to 5 gallons of NaSH spilled to the collection drain.
  • The tank truck, however, was not actually unloaded.
  • On the day of the incident, sulfuric acid was being added to the acid sewer to control pH downstream in the effluent area.
  • NaSH from the oil pit and the collection drain drained to the sewer and reacted with the sulfuric acid to form H2S.
  • Within 5 minutes, an invisible cloud of H2S gas leaked through a gap in the seal of a manway in the area of the Burkes Construction workers.
  • Two contractors near the manway were killed by H2S poisoning; seven other Burkes employees and one Davison Transport driver were injured due to H2S exposure.
  • The victims were removed from the incident scene and taken to the mill first-aid station prior to setup of the incident command system.
  • They were not decontaminated at the scene.
  • The mill emergency response team (ERT) was notified.
  • Others who came to the area performed cardiopulmonary resuscitation (CPR) on the two fatally injured men, who were transferred by mill ambulance to the first-aid station.
  • Four Choctaw County ambulances arrived at the mill first-aid station.
  • Two ambulances transported the fatally injured men, and a third ambulance transported the injured truck driver.
  • Two victims were taken to Rush Hospital and one to Riley Hospital, both located in Meridian, Mississippi.
  • Burkes and Georgia-Pacific employees transported the other injured Burkes employees to nearby Thomasville Infirmary.
  • The six paramedics who transported the victims to hospitals in Meridian all described a strong odor in the ambulance bays.
  • They opened windows and turned fans on to reduce the odor.
  • After delivering the victims to the hospitals, the paramedics reported symptoms consistent with H2S exposure.
  • They were medically evaluated and released.

Facility and Process Context

  • The Georgia-Pacific Naheola mill is located in Pennington, Alabama, approximately 125 miles north of Mobile and 150 miles southwest of Birmingham.
  • The mill began operation in 1958 as the Marathon Southern Division of the American Can Company.
  • It was acquired in 1982 by James River Corporation.
  • In 1997, James River merged with Fort Howard Corporation to form Fort James Corporation.
  • Georgia-Pacific acquired Fort James Corporation in November 2000.
  • The mill now operates as Fort James Operating Company, a fully owned subsidiary of Georgia-Pacific Corporation.
  • The Naheola mill produces over 650,000 tons of paper, paperboard, and pulp annually.
  • Approximately 1,475 employees work at the mill.
  • The mill uses the kraft process to produce pulp.
  • The mill contains a process sewer network that collects waste; the process sewers join at a mixing basin in the effluent treatment area.
  • The pH of the untreated mill effluent is maintained between 7 and 9.
  • If the pH is low, caustic is added in the wastewater treatment area; if the pH is high, sulfuric acid is added.
  • The acid is manually added in a sewer line, commonly referred to as the acid sewer.
  • Drainage from the truck unloading station flows to the acid sewer and mixes with other mill waste streams in the mixing basin.
  • The tank truck unloading station is located on a large concrete pad sloped to a collection drain.
  • A shallow curbed concrete containment area directly next to the pad and collection drain is commonly referred to as the oil pit.
  • The oil pit collects rainwater, condensate, and incidentally spilled chemicals from the tank truck unloading station.
  • The drain valve on the pit is kept closed and locked due to environmental concerns about oil getting into the mill effluent.
  • Per procedure, operators periodically inspect the oil pit; if no oil is present, they unlock valve 1 and drain the pit to the acid sewer.
  • Burkes Construction was contracted to replace supports on an overhead piperack located near the fiberglass manway.
  • The piperack crossed over the tank truck unloading station and the oil pit.

Consequences

  • Fatalities: 2 dead
  • Injuries: 8 injured
  • Environmental release: hydrogen sulfide (H2S) gas leaked from a sewer manway; NaSH drained to the acid sewer and reacted with sulfuric acid to form H2S
  • Facility damage: Not specified in the source material
  • Operational impact: The incident triggered emergency response actions, evacuation of the area, search/rescue, zone setup, and air monitoring.

Key Findings

Immediate Causes

  • NaSH from the oil pit and the collection drain drained to the sewer and reacted with the sulfuric acid to form H2S.
  • An invisible cloud of H2S gas leaked through a gap in the seal of a manway.

Contributing Factors

  • H2S was not identified as a hazard in the immediate area of the mill where the incident occurred.
  • There were no monitors, alarms, or warning signs in the area.
  • Modifications to the acid sewer over a period of several years included connections to the chlorine dioxide sewer, to the sewer from the truck unloading area, and to the containment area known as the oil pit.
  • When these changes were made, the chemicals that could be added to the sewer and their interactions with other chemicals were not identified, nor were formal hazard evaluations or management of change (MOC) analyses conducted.
  • Georgia-Pacific did not require detailed H2S safety training for those working in this area of the mill.
  • The contractors working on the day of the incident had only a basic awareness of H2S and its hazards.
  • Beginning on the morning of January 16, sulfuric acid was continuously added to the acid sewer.
  • Because the chlorine dioxide unit that emptied into the sewer line was not running at the time of the incident, the volume of liquid in the acid sewer was lower than normal; and, consequently, the concentration of acid was high.
  • During the truck unloading process, several potential sources of NaSH could leak and drain through the oil pit or collection drain to the acid sewer.
  • In the 24 hours prior to the incident, 15 tank trucks of NaSH were unloaded, and one was connected to begin unloading.
  • This activity resulted in NaSH collecting in the oil pit and draining to the sewer.
  • The manufacturer’s material safety data sheet (MSDS) for NaSH states that this substance will generate H2S gas if it contacts acid.
  • For large spills, it recommends that runoff be prevented from entering sewers or drains.
  • The Naheola mill did not apply the principles of process safety management to truck unloading or to the acid sewer.
  • Hazard information about NaSH, available on the MSDS, was not incorporated into mill procedures or training.
  • No hazard review or MOC analysis was performed when the oil pit and the collection drain from the truck unloading area were connected to the acid sewer.
  • The manway involved in the incident was originally an unsealed open grate.
  • The sewer was modified to convert it to a closed sewer, and the manway was eventually outfitted with a fiberglass cover and sealed.
  • Interviewed employees had observed leaking chlorine dioxide from the fiberglass manway on previous occasions and recalled repairs that were sometimes documented by work orders.
  • These events were not reported as near-miss incidents, nor were the causes of the leaks formally investigated.
  • The Georgia-Pacific corporate investigation policy was not yet in place at the Naheola mill.
  • The victims were removed from the incident scene and taken to the mill first-aid station prior to setup of the incident command system.
  • They were not decontaminated at the scene.
  • Mill guidelines did not provide for decontamination at the first-aid station.
  • The clothing of one of the three victims transported to hospitals was removed, which was not the case with the other two men.
  • The six Choctaw County paramedics who evacuated the men from the mill first-aid station reported symptoms consistent with H2S exposure.
  • The ATSDR Medical Management Guidelines do not recognize that victims of H2S gas exposure may release H2S, which can pose a medical risk to responders.
  • The fiberglass manway was not adequately designed or sealed to ensure that the sewer remained closed.
  • The injured contractors did not have adequate training to understand the hazards of hydrogen sulfide (H2S).
  • H2S training should include specific instruction on the importance of wearing proper protective equipment prior to attempting rescue.
  • There was no management system to incorporate hazard warnings about mixing sodium hydrosulfide (NaSH) with acid into process safety information.
  • Design information for projects involving NaSH did not specify the hazard of mixing NaSH with acid.
  • Operating procedures for NaSH tank truck unloading and oil pit operations did not warn of the hazard of mixing NaSH with acids or the hazard of allowing NaSH to enter sewers.
  • Mill personnel were not trained on the specific hazards of NaSH, such as handling spilled material or keeping it separate from acid.

Organizational and Systemic Factors

  • The Naheola mill did not follow good engineering practices during the conceptual design phase of the capital project that installed the sewer line from the oil pit to the acid sewer.
  • There was no detailed information on chemicals that could be present in the oil pit and drain to the acid sewer.
  • There was no management of change (MOC) analysis or formal hazard review.
  • The Naheola mill had no formal reactive hazard management system to identify and control reactive hazards.
  • The mill used a chemical approval form to collect information on all chemicals brought onsite, but none of this information was incorporated into operating procedures or training.
  • Georgia-Pacific corporate incident investigation policy required investigation of near-miss incidents, including releases of hazardous materials, but had not yet been put in place at the Naheola mill.
  • The Naheola mill did not adequately identify areas that contain or have the potential to contain dangerous levels of H2S gas.
  • The Naheola mill applied the site process safety management plan only to areas of the facility that were covered by the PSM Standard.
  • The area where the incident occurred was not part of a PSM-covered process.
  • The OSHA Hazard Communication Standard requires a formal communication program, to include labels, MSDSs, and training.
  • The Naheola mill is subject to Hazwoper requirements; among other things, the standard mandates specific emergency response training.
  • The paramedics did not have hazardous material training, nor were they trained on use of the Emergency Response Guidebook.

Failed Safeguards or Barrier Breakdowns

  • There were no monitors, alarms, or warning signs in the area.
  • No formal hazard evaluations or management of change (MOC) analyses were conducted.
  • No hazard review or MOC analysis was performed when the oil pit and the collection drain from the truck unloading area were connected to the acid sewer.
  • Hazard information about NaSH was not incorporated into mill procedures or training.
  • The manway was not adequately designed or sealed to ensure that the sewer remained closed.
  • These events were not reported as near-miss incidents, nor were the causes of the leaks formally investigated.
  • The victims were not decontaminated at the scene.
  • Mill guidelines did not provide for decontamination at the first-aid station.
  • The paramedics had only the Emergency Response Guidebook to refer to for treatment of these chemical exposures.
  • The paramedics did not have hazardous material training.
  • The ATSDR Medical Management Guidelines do not recognize that victims of H2S gas exposure may release H2S, which can pose a medical risk to responders.

Recommendations

  1. 2002-01-I-AL-R1 | Recipient: Georgia-Pacific Corporation | Status: Not specified | Conduct periodic safety audits of Georgia-Pacific pulp and paper mills in light of the findings of this report. At a minimum, ensure that management systems are in place at the mills to: Evaluate process sewers where chemicals may collect and interact, and identify potential hazardous reaction scenarios to determine if safeguards are in place to decrease the likelihood or consequences of such interactions. Take into account sewer system connections and the ability to prevent inadvertent mixing of materials that could react to create a hazardous condition.
  2. 2002-01-I-AL-R2 | Recipient: Georgia-Pacific Corporation | Status: Not specified | Identify areas of the mill where hydrogen sulfide (H2S) could be present or generated, and institute safeguards (including warning devices) to limit employee exposure. Require that personnel working in the area are trained to recognize the presence of H2S and respond appropriately. Update emergency response plans for such areas, to include procedures for decontaminating personnel exposed to toxic gas.
  3. 2002-01-I-AL-R3 | Recipient: Georgia-Pacific Corporation | Status: Not specified | Apply good engineering and process safety principles to process sewer systems. For instance, ensure that hazard reviews and management of change (MOC) analyses are completed when additions or changes are made where chemicals could collect and react in process sewers.
  4. 2002-01-I-AL-R4 | Recipient: Georgia-Pacific Corporation | Status: Not specified | the workforce and contractors at all Georgia-Pacific pulp and paper mills.
  5. 2002-01-I-AL-R5 | Recipient: Georgia-Pacific Naheola Mill | Status: Not specified | Evaluate mill process sewer systems where chemicals may collect and react to identify potential hazardous reaction scenarios to determine if safeguards are in place to decrease the likelihood or consequences of such interactions. Evaluate sewer connections and ensure that materials that could react to create a hazardous condition are not inadvertently mixed, and that adequate mitigation measures are in place if such mixing does occur.
  6. 2002-01-I-AL-R6 | Recipient: Georgia-Pacific Naheola Mill | Status: Not specified | Establish programs to comply with recommendations from manufacturers of sodium hydrosulfide (NaSH) regarding its handling, such as preventing it from entering sewers because of the potential for acidic conditions.
  7. 2002-01-I-AL-R7 | Recipient: Georgia-Pacific Naheola Mill | Status: Not specified | Establish programs to require the proper design and maintenance of manway seals on closed sewers where hazardous materials are present.
  8. 2002-01-I-AL-R8 | Recipient: Georgia-Pacific Naheola Mill | Status: Not specified | Identify areas of the plant where hydrogen sulfide (H2S) could be present or generated, and institute safeguards (including warning devices) to limit personnel exposure. Institute a plan and procedures for dealing with potential H2S releases in these areas, and require that anyone who may be present is adequately trained on appropriate emergency response practices, including attempting rescue. Require contractors working in these areas to train their employees on the specific hazards of H2S, including appropriate emergency response practices.
  9. 2002-01-I-AL-R9 | Recipient: Georgia-Pacific Naheola Mill | Status: Not specified | Update the Naheola mill emergency response plan to include procedures for decontaminating personnel who are brought to the first-aid station. Include specific instructions for decontaminating personnel exposed to H2S so that they do not pose a secondary exposure threat to medical personnel.
  10. 2002-01-I-AL-R10 | Recipient: Agency for Toxic Substances and Disease Registry (ATSDR) | Status: Not specified | Evaluate and amend as necessary the ATSDR Medical Management Guidelines to consider the risk to responders posed by exposure to victims of high levels of hydrogen sulfide (H2S) gas. Specify procedures for adequate decontamination. Communicate the results of this activity to relevant organizations, such as the American Association of Occupational Health Nurses.
  11. 2002-01-I-AL-R11 | Recipient: Burkes Construction, Inc. | Status: Not specified | Train your employees on the specific hazards of hydrogen sulfide (H2S), including appropriate emergency response practices, in areas where Georgia-Pacific has identified this material as a hazard.
  12. 2002-01-I-AL-R12 | Recipient: Davison Transport, Inc. | Status: Not specified | those employees who haul or handle sodium hydrosulfide (NaSH).
  13. 2002-01-I-AL-R13 | Recipient: American Forest and Paper Association (AFPA) | Status: Not specified | to your membership.
  14. 2002-01-I-AL-R14 | Recipient: International Brotherhood of Electrical Workers (IBEW) | Status: Not specified | to your membership.
  15. 2002-01-I-AL-R15 | Recipient: Paper, Allied-Industrial, Chemical & Energy Workers International Union (PACE) | Status: Not specified | to your membership.
  16. 2002-01-I-AL-R16 | Recipient: Pulp and Paper Safety Association (PPSA) | Status: Not specified | to your membership.

Key Engineering Lessons

  • Process sewers where chemicals may collect and interact require hazard evaluation of possible reaction scenarios, including sewer system connections and inadvertent mixing of incompatible materials.
  • When additions or changes are made to process sewer systems, hazard reviews and management of change (MOC) analyses are required to identify reactive hazards.
  • Sodium hydrosulfide (NaSH) handling must account for the manufacturer warning that it can generate H2S gas if it contacts acid, and runoff should be prevented from entering sewers or drains where acidic conditions may exist.
  • Closed sewer manways must be properly designed and maintained so the sewer remains sealed when hazardous materials may be present.
  • Areas where H2S could be present or generated require warning devices and procedures for emergency response and decontamination to prevent secondary exposure of responders.

Source Notes

  • Priority 1 final report was used to resolve conflicts and populate the authoritative incident dataset.
  • Supporting documents were used only where consistent with the final report or to supplement narrative detail not contradicted by the final report.
  • The final report release date is represented as 01/2003 because the report states ISSUE DATE: JANUARY 2003.
  • Some recommendation summaries preserve partial wording from the source text where the provided extract was fragmentary.

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