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Honeywell Chemical Incidents

Overview

CSB investigation of three chemical release incidents at the Honeywell International, Inc. Baton Rouge plant in summer 2003. The incidents were a July 20 chlorine release, a July 29 antimony pentachloride cylinder release, and an August 13 hydrofluoric acid exposure. The final report identified issues with hazard analysis, nonroutine situations, and operating procedures.

Incident Snapshot

Field Value
Facility / Company Honeywell International, Inc.
Location Baton Rouge, LA
Incident Date 07/20/2003
Investigation Status The final report on the three incidents was approved by the Board on August 8, 2005, and released at a news conference in Baton Rouge on August 10.
Accident Type Release Investigation Status: On July 20, 2003, there was a release of chlorine gas from the Honeywell refrigerant manufacturing plant in Baton Rouge, Louisiana. On July 29, 2003, a worker was fatally injured by exposure to antimony pentachloride when a gas cylinder released its contents to the atmosphere. On August 13, 2003, two plant workers were exposed to hydrofluoric acid, and one was hospitalized.
Final Report Release Date 08/10/2005

What Happened

  • On July 20, 2003, a release of chlorine gas from the Honeywell International, Inc. chemical plant in Baton Rouge, Louisiana, resulted in injuries to seven plant workers and issuance of a shelter-in-place advisory for residents within a 0.5-mile radius.
  • At 3:10 am on July 20, 2003, Omni unit operators inside the control room noticed a chlorine odor.
  • One operator went outside to investigate and observed a leak near the G-143a coolant system pumps.
  • By 3:25 am, plant personnel had evacuated to the main plant gate.
  • By 3:29 am, Honeywell raised the incident to level III.
  • At 4:00 am, the local fire department issued a shelter-in-place advisory for residents within a 0.5-mile radius of the plant.
  • The chlorine leak was finally stopped at approximately 6:46 am, when the railcar valve was manually closed by Honeywell’s emergency response team.
  • On July 29, 2003, a 1-ton cylinder at the same plant released its contents to the atmosphere, fatally injuring a plant worker by exposing the worker to contaminated antimony pentachloride.
  • On the morning of July 29, 2003, a ton-cylinder operator began to prepare “out of test” 1-ton refrigerant cylinders for offsite testing.
  • At approximately 1:30 pm on July 29, 2003, employees saw a large cloud in the ton-cylinder area, and one employee sounded the plant alarm.
  • The operator died from his exposure at 9:45 am the next morning.
  • On August 12, operators began using a venturi stick to remove liquid hydrogen fluoride from a vaporizer in the G-22 process.
  • On August 13, at approximately 9 am, an operator monitoring the venturi process checked on its progress and opened and closed some valves to create a surge in the system and clear any blockage.
  • Flow to the sewer rapidly increased, causing the venturi stick to lift out of the sewer, which created a cloud that likely contained hydrogen fluoride.

Facility and Process Context

  • The Honeywell Baton Rouge plant began operation in 1945 as General Chemical.
  • The site produces fluorocarbon-based refrigerants (brand named Genetron) and calcium chloride.
  • The site also operates a reclamation and recycling facility for Genetron refrigerants and their shipping containers.
  • Hydrogen fluoride and chlorine are two of the primary raw materials used at the facility.
  • The facility handled enough chlorine and hydrogen fluoride to be covered by the OSHA Process Safety Management (PSM) Standard and the EPA Risk Management Program (RMP) Standard.
  • Several refrigerant manufacturing processes combined form what Honeywell calls the Omni unit, which operates out of the Omni control room.
  • Honeywell converted the Omni control room into a positive pressure control room in 1998 after plant personnel complained of odors getting into the control room and an engineering study identified potential infiltration of the highly hazardous substance hydrogen fluoride.
  • The Honeywell Baton Rouge site produces Genetron refrigerants packaged for sale in reusable 1-ton cylinders.
  • Customers return the empty cylinders to Honeywell, and truckloads of cylinders arrive almost daily.
  • On any given day, there may be 500 to 600 1-ton cylinders at the facility.
  • At the Honeywell Baton Rouge facility, hydrogen fluoride is used to manufacture G-22 refrigerant.
  • The area involved in the antimony pentachloride incident handles only refrigerant cylinders.
  • The August 13 hydrofluoric acid incident occurred in a liquid HF system that included a surge drum, two pumps, piping and a vaporizer.

Consequences

  • Fatalities: 1 killed
  • Injuries: 7 injured on July 20; 1 injured and 1 exposed on August 13
  • Environmental release: chlorine released to the atmosphere; contaminated antimony pentachloride released to the atmosphere; hydrogen fluoride release to atmosphere
  • Facility damage: chlorine entered the control room and damaged process control equipment; the process control system was corroded and rendered inoperable
  • Operational impact: the entire plant was evacuated; the G-143a process was manually shut down; the release lasted approximately 3.5 hours; the plant was shut down and work was limited to maintenance and inspection

Key Findings

Immediate Causes

  • The G-143a chlorine cooler tubes failed, releasing chlorine into the G-143a coolant system.
  • The materials of construction for the G-143a coolant system pump were not compatible with chlorine; therefore, system components failed, releasing chlorine to the atmosphere.
  • Cylinder 83-3410 was full of contaminated antimony pentachloride and was opened during preparation for offsite testing.
  • Flow to the sewer rapidly increased, causing the venturi stick to lift out of the sewer, which created a cloud that likely contained hydrogen fluoride.
  • chlorine entered the control room through the HVAC system
  • the chlorine then corroded the process control system, rendering it inoperable
  • an operator in the ton cylinder-receiving area was sprayed with contaminated antimony pentachloride after he removed a plug from a cylinder he believed contained only residual amounts of refrigerant
  • Neither worker was wearing appropriate personal protective equipment (PPE) during a non-routine operation to drain liquid hydrogen fluoride from a vaporizer.
  • workers were removing liquid HF from a vaporizer, a non-routine activity for which there was no standard operating procedure
  • Operators adapted a generic procedure and added references for HF handling, none of which contained specific instructions for identifying and controlling hazards

Contributing Factors

  • Incident timelines show a 31-minute delay between the Honeywell report of a level III incident and the Baton Rouge Fire Department activation of the shelter-in-place alert.
  • Although the chlorine cooler was constructed of materials suitable for its intended use, inspection and testing were the only layers of protection against failure.
  • The chlorine cooler had been inspected in 2001 using the magnetic flux NDT method. Test results then showed no flaws.
  • Magnetic flux testing done after the incident, when three holes were present, showed two complete holes through walls, but only wall thinning at the location of the third hole.
  • EPRI has demonstrated that magnetic flux testing may not be the best NDT method for ferrous coolers with tube walls as thick as those in the chlorine cooler (.109 inches).
  • The G-143a PHA did not identify the potential for chlorine leaking into the coolant system.
  • The PHA on a similar process in the same facility (G-113 R1) identified the possibility of chlorine leaking into the coolant system but did not evaluate the consequences.
  • The MOC review conducted when the chlorine feed system was modified to allow use of railcars did not identify a need to integrate the chlorine railcar and G-143a shutdown procedures.
  • The G-143a shutdown sequence and procedures did not include isolation of the chlorine railcar.
  • Chlorine released from the cooler entered the positive pressure control room through holes or gaps in the HVAC ductwork.
  • The design of the positive pressure control room system was not adequate for protecting operators long enough to allow them to identify the source of the chlorine leak and shut down the G-143a process.
  • The Omni unit control room was designed to be positive pressure, but the positive pressure system was not routinely inspected or maintained.
  • Previous incidents of chlorine entering the Omni control room had occurred.
  • No hazard analysis was completed to identify potential hazards in the ton-cylinder area.
  • Honeywell had no program to identify and address potential hazards in the ton-cylinder area.
  • Honeywell and C&MI have no systematic processes for positively verifying the contents of cylinders rejected by C&MI.
  • The Honeywell systems for segregating and storing 1-ton cylinders did not include procedures for identifying and handling abnormal cylinders.
  • Day-to-day operator practices and operator training did not conform to the standard operating procedures for handling R-22 cylinders.
  • Honeywell had no procedures for identifying and planning for nonroutine job situations.
  • Beyond the initial job setup, it was not plant practice to wear standard HF PPE.
  • guidance and standards for design and maintenance of positive pressure control rooms were lacking in the U.S. chemical industry
  • the Baton Rouge facility’s PPE matrix did not specify the PPE required for specific activities, such as draining HF equipment
  • this contrasted with guidance published by the Hydrogen Fluoride Industry Practices Institute (HFIPI)
  • HF handling practices varied across different Honeywell facilities
  • the subject cylinder had been rejected by its catalyst supplier, Chemical & Metal Industries (C&MI) before it was returned to the Baton Rouge facility
  • Honeywell did not have procedures in place to identify abnormal shipments, such as those rejected by contractors, to ensure that their contents are identified and handled safely and appropriately
  • the highly hazardous nature of HF
  • operations following an emergency shutdown
  • there was no standard operating procedure for the non-routine activity
  • procedures did not contain specific instructions for identifying and controlling hazards
  • Honeywell reported that its procedures require the conduct of a job safety briefing for new jobs or jobs for which an existing standard operating procedure cannot be followed or does not exist and a highly hazardous chemical, such as HF, is involved
  • Honeywell reported that all unit restarts after shutdowns are subject to Pre-Startup Safety Reviews (PSSRs)

Organizational and Systemic Factors

  • Hazard analyses did not ensure a review of all equipment, procedures, and likely scenarios.
  • The safeguards listed were generic and, in many cases, relied too heavily on administrative procedures.
  • Nonroutine situations were not always recognized and reviewed to ensure that work could proceed safely.
  • Work practices at the plant did not always strictly follow written operating procedures.
  • There was no maintenance program for the control room, including HVAC ductwork.
  • There were no toxic gas alarms on the HVAC intake system.
  • The positive pressure control room system was not designated as critical equipment or maintained as such.
  • The positive pressure control room system was not documented in Honeywell procedures or identified as critical equipment.
  • Procedures did not include warnings that odors in the control room are not expected and need to be investigated.
  • No formal investigation was conducted of how the chlorine entered the positive pressure control room.
  • The plant had only a generic venturi stick procedure and not one specifically for draining liquid hydrogen fluoride.
  • Honeywell did not identify draining hydrogen fluoride from the vaporizer with a venturi stick as nonroutine.
  • Honeywell did not consider the consequences of an emergency shutdown in the G-22 process.
  • Honeywell has no current corporate guidelines for handling hydrogen fluoride.
  • PPE levels were routinely downgraded by plant personnel after setting up a job.
  • The operator working on the day of the incident had not worked with antimony pentachloride cylinders and likely did not know the difference between these cylinders and refrigerant cylinders.
  • Shipping papers for arriving cylinders were not reviewed for weights.
  • Written procedures did not explain likely abnormal or nonroutine situations, detail specifically how to handle these situations, or list consequences of common deviations.
  • Normal practice in the receiving and ton-cylinder operations area did not directly follow written procedures.
  • The CSB therefore made a recommendation to the American Society of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE) to develop such guidance.
  • Honeywell reported that it issued corporate-level HF-handling standards
  • Honeywell reported that it issued a revised PPE matrix, based in part upon HFIPI guidelines
  • Honeywell reported actions consistent with the intent of the CSB’s recommendation
  • Honeywell reported that all unit restarts after shutdowns are subject to Pre-Startup Safety Reviews (PSSRs)
  • Honeywell informed the CSB that since the Baton Rouge facility is the only one of its Specialty Materials fluorine-based facilities that receives cylinders from contractors, it did not feel that a corporate-level procedure was needed
  • the company revised the Baton Rouge facility’s procedures for receiving ton cylinders following the CSB’s investigation
  • HFIPI had construction, transportation, storage, and personal protective equipment guidelines for HF, but it does not have general handling practice guidelines for activities like draining equipment and maintenance preparation
  • HFIPI formed a working group with representatives from all eight member companies and two associate member companies to share current practices for HF handling activities
  • The working group considered the feasibility of creating best practices guidance and concluded that the variety of situations related to different processes operated under different management systems made guidelines for best practices impractical
  • Local #5 appears to have taken no action to implement the CSB’s recommendation
  • This recommendation is now more than seven years old and the Board concludes that additional follow-up is unlikely to secure its implementation

Failed Safeguards or Barrier Breakdowns

  • mechanical integrity program
  • hazard analyses
  • management of change
  • positive pressure control room system
  • HVAC ductwork maintenance
  • toxic gas alarms on the HVAC intake system
  • incident investigation procedure for odors inside positive pressure control rooms
  • shutdown systems and procedures integrated to stop all potential sources of chlorine
  • procedures for identifying and planning nonroutine activities
  • PPE matrix for specific activities such as draining HF equipment
  • procedures for positively identifying material rejected by contractors such as C&MI
  • procedures for receiving cylinders to require that weights be recorded on incoming materials and suspicious materials be isolated
  • chlorine monitors tied to automatic shutdown system(s)
  • sufficient layers of protection to stop a catastrophic release
  • recommendations to be implemented when existing protection is incomplete
  • appropriate personal protective equipment (PPE)
  • no standard operating procedure
  • generic procedure
  • references for HF handling, none of which contained specific instructions for identifying and controlling hazards

Recommendations

  1. 2003-13-I-LA-R1 — Recipient: Honeywell International, Inc. — Status: Not specified — Revise inspection and testing procedures to include effective methods for detecting and preventing leaks in coolers that use chlorine. These procedures should include the use of appropriate NDT methods.
  2. 2003-13-I-LA-R2 — Recipient: Honeywell International, Inc. — Status: Not specified — Analyze layers of protection installed to prevent possible consequences of failure of heat exchangers that use chlorine, and implement corrective actions as appropriate. Examples of additional measures include installing monitors on the coolant stream to detect the presence of chlorine, and determining the feasibility of operating the coolant stream at a pressure high enough to prevent the entry of chlorine in the event of a leak.
  3. 2003-13-I-LA-R3 — Recipient: Honeywell International, Inc. — Status: Closed- Acceptable Action — Require an evaluation of the effects of leaks in heat exchangers.
  4. 2003-13-I-LA-R4 — Recipient: Honeywell International, Inc. — Status: Closed- Acceptable Action — Consider the layers of protection necessary to prevent a catastrophic incident and require recommendations to be implemented when existing protection is incomplete.
  5. 2003-13-I-LA-R5 — Recipient: Honeywell International, Inc. — Status: Not specified — Revise the incident investigation procedure to ensure that odors inside positive pressure control rooms are investigated, the causes identified, and the appropriate corrective actions implemented. Address causes of the releases as well as entry of the material into the building.
  6. 2003-13-I-LA-R6 — Recipient: Honeywell International, Inc. — Status: Not specified — Survey units that handle chlorine and evaluate the effectiveness of shutdown systems for detecting and preventing the release of chlorine. At a minimum, ensure that shutdown systems and procedures are integrated to stop all potential sources of chlorine.
  7. 2003-13-I-LA-R7 — Recipient: Honeywell International, Inc. — Status: Not specified — Conduct training to emphasize that MOC evaluations must consider whether emergency shutdown procedures need to be changed when there are changes in material inventory.
  8. 2003-13-I-LA-R8 — Recipient: Honeywell International, Inc. — Status: Not specified — Conduct a hazard analysis (such as a job safety analysis) in the ton-cylinder area, incorporate appropriate findings into unit operating procedures, and train personnel accordingly.
  9. 2003-13-I-LA-R9 — Recipient: Honeywell International, Inc. — Status: Not specified — Revise plant procedures on receiving cylinders to require that weights be recorded on incoming materials and suspicious materials be isolated so that hazardous materials are handled appropriately.
  10. 2003-13-I-LA-R10 — Recipient: Honeywell International, Inc. — Status: Closed- Acceptable Action — Revise the personal protective equipment matrix to include requirements for specific activities, such as draining [hydrogen fluoride] equipment. Refer to the [Hydrogen Fluoride Industry Practices Institute] guidelines as appropriate.
  11. 2003-13-I-LA-R11 — Recipient: Honeywell International, Inc. — Status: Not specified — Develop and implement a program for the identification and management of hazards in nonroutine situations. Ensure that this program covers situations where employees are unable to follow standard operating procedures, such as properly purging equipment.
  12. 2003-13-I-LA-R12 — Recipient: Honeywell International, Inc. — Status: Not specified — Develop and implement a program for the identification and management of hazards in nonroutine situations. Ensure that this program covers circumstances where there is no specific formal procedure for handling a highly hazardous chemical.
  13. 2003-13-I-LA-R13 — Recipient: Honeywell International, Inc. Baton Rouge Facility — Status: Closed- Acceptable Action — Develop and implement a program for the identification and management of hazards in nonroutine situations. Ensure that this program covers the following: Operations following an emergency shutdown.
  14. 2003-13-I-LA-R14 — Recipient: Honeywell International, Inc. — Status: Not specified — Develop and implement corporate standards to ensure positive pressure control rooms, including the HVAC systems, are designed and maintained to prevent the short-term entry of hazardous materials. Implement corporate standard changes at the Baton Rouge facility, and other Honeywell facilities as appropriate.
  15. 2003-13-I-LA-R15 — Recipient: Honeywell International, Inc. — Status: Closed- Acceptable Action — Develop and implement procedures for positively identifying material rejected by contractors such as C&MI so that hazardous materials are handled appropriately.
  16. 2003-13-I-LA-R16 — Recipient: Honeywell International, Inc. — Status: Closed- Acceptable Action — Develop and implement corporate standards for safely handling hydrogen fluoride.
  17. 2003-13-I-LA-R17 — Recipient: Honeywell International, Inc. — Status: Not specified — In light of the findings of this investigation report, conduct a comprehensive audit of fluorine-based manufacturing facilities in your Specialty Materials group facilities. Ensure that the audit addresses thoroughness of hazard analysis and adequacy of safeguards.
  18. 2003-13-I-LA-R18 — Recipient: Honeywell International, Inc. — Status: Not specified — In light of the findings of this investigation report, conduct a comprehensive audit of fluorine-based manufacturing facilities in your Specialty Materials group facilities. Ensure that the audit addresses recognition and management of nonroutine situations.
  19. 2003-13-I-LA-R19 — Recipient: Honeywell International, Inc. — Status: Not specified — In light of the findings of this investigation report, conduct a comprehensive audit of fluorine-based manufacturing facilities in your Specialty Materials group facilities. Ensure that the audit addresses adherence to standard operating procedures.
  20. 2003-13-I-LA-R20 — Recipient: Honeywell International, Inc. — Status: Not specified — Implement the recommendations from the audit and communicate the findings to the work force.
  21. 2003-13-I-LA-R21 — Recipient: Honeywell International, Inc. — Status: Not specified — Communicate the findings and recommendations of this report to your employees at fluorine-based manufacturing facilities in your Specialty Materials group.
  22. 2003-13-I-LA-R22 — Recipient: American Society of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE) — Status: Closed – Acceptable Action — Develop guidance on the effective design and maintenance of HVAC systems and other necessary control room components designed to protect employees and equipment in the event of a release of hazardous materials.
  23. 2003-13-I-LA-R23 — Recipient: Baton Rouge Fire Department — Status: Not specified — Evaluate and update as necessary community notification procedures to include timely notification of residents in the event of a chemical release. Conduct periodic refresher training with staff on the requirements in the procedures.
  24. 2003-13-I-LA-R24 — Recipient: East Baton Rouge Parish Office of Homeland Security and Emergency Preparedness (OHSEP) — Status: Not specified — Conduct an awareness campaign to educate residents on the proper response during a chemical release. Include instructions on the way residents (including those outside the affected area) can obtain information during an emergency.
  25. 2003-13-I-LA-R25 — Recipient: Hydrogen Fluoride Industry Practices Institute (HFIPI) — Status: Closed – Acceptable Action — Conduct a survey of members to determine best industry practices for HF handling activities, such as draining equipment, use of open systems, and nonroutine work. Develop best practices guidance as appropriate and communicate it to your members.
  26. 2003-13-I-LA-R26 — Recipient: Hydrogen Fluoride Industry Practices Institute (HFIPI) — Status: Not specified — Communicate the findings and recommendations from the August 13 incident to your membership.
  27. 2003-13-I-LA-R27 — Recipient: Chemical and Metal Industries (C&MI) — Status: Not specified — Develop formal procedures for disposition of nonconforming materials received from customers. Ensure that procedures include positive identification prior to shipment.
  28. 2003-13-I-LA-R28 — Recipient: American Society for Nondestructive Testing (ASNT) — Status: Not specified — Communicate the findings and recommendations from the July 20 incident to your membership. Emphasize the need to evaluate test methods for appropriateness in the given equipment.
  29. 2003-13-I-LA-R29 — Recipient: International Brotherhood of Teamsters Local #5 — Status: Closed- Unacceptable Action — Work with Honeywell to communicate the findings and recommendations of this report to your members employed at the Honeywell Baton Rouge Facility.

Key Engineering Lessons

  • Inspection and testing methods for chlorine-containing coolers must be effective for the specific equipment and wall thickness. The report notes that magnetic flux testing may not be the best NDT method for the chlorine cooler.
  • Layers of protection for chlorine heat exchangers must be evaluated for catastrophic leak scenarios, including monitors and shutdown integration that stop all potential chlorine sources.
  • Positive pressure control rooms and HVAC systems must be designed and maintained to prevent short-term entry of hazardous materials and should not rely on undocumented or unmaintained systems.
  • Process hazard analyses must evaluate leak consequences in heat exchangers and consider whether existing protection is adequate.
  • Nonroutine HF draining operations require specific procedures and PPE requirements. Generic procedures were not sufficient.
  • Receiving systems for cylinders must positively identify abnormal or contractor-rejected materials before opening or handling them.
  • Emergency shutdown conditions can create new hazards that require specific planning, procedures, and reviews before restart.

Source Notes

  • Priority 1 final report was used as the primary authority for incident facts, causes, and recommendations.
  • Priority 3 recommendation status change summaries were used to confirm later recommendation statuses and some implementation details.
  • Priority 4 transcript was used only where it provided incident detail not conflicting with higher-priority sources.
  • Where sources differed, higher-priority final report language was preferred.

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