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Improving Reactive Hazard Management

Overview

CSB final report on reactive hazard management based on 167 serious U.S. incidents involving uncontrolled chemical reactivity from January 1980 to June 2001. The report found that 48 incidents caused 108 fatalities, nearly 50 affected the public, and more than half involved chemicals not covered by existing OSHA or EPA process safety regulations. The report issued recommendations to OSHA, EPA, NIST, and industry organizations to improve regulatory coverage, incident reporting, test data sharing, and reactive hazard management guidance.

Incident Snapshot

Field Value
Facility / Company
Location
Incident Date 08/01/2000
Investigation Status On September 17, 2003, the CSB released data on the complete set of 167 serious reactive incidents that formed the basis of the investigation. In August 2000, following its investigation of a serious reactive incident at Morton International, the Board initiated a comprehensive review of reactive hazards nationwide. The purpose of the investigation was to develop recommendations to reduce the number and severity of such incidents.
Accident Type Reactive Incident
Final Report Release Date 10/08/2002

What Happened

The report examined 167 serious incidents in the United States involving uncontrolled chemical reactivity from January 1980 to June 2001.

On April 21, 1995, an explosion and fire at Napp Technologies in Lodi, New Jersey, killed five employees and destroyed the facility.

On May 8, 1997, BPS (Bartlo Packaging, Inc.) in West Helena, Arkansas, was repackaging an organic pesticide, AZM50W. Employees noticed smoke and an explosion occurred. Three firefighters were killed and one person was injured.

On June 4, 1999, the inadvertent mixing of two incompatible chemicals caused a toxic gas release at Whitehall Leather Company in Whitehall, Michigan. The truck driver died and one employee was injured.

On February 19, 1999, an explosion occurred during distillation of aqueous hydroxylamine and potassium sulfate at Concept Sciences, Inc. in Hanover Township, Pennsylvania. The facility was completely destroyed.

On March 13, 2001, a vessel failure and fire occurred at the BP Amoco Polymers plant in Augusta, Georgia after polymer in a catch tank continued to react and generate gas, pressurizing the vessel.

CSB staff conducted site visits and survey work on reactive hazard management practices at selected facilities.

The Board issued recommendations to OSHA, EPA, NIST, ACC, SOCMA, NACD, CCPS, and several labor and professional organizations.

Facility and Process Context

  • Napp Technologies in Lodi, New Jersey was conducting a toll blending operation to produce a commercial gold precipitation agent.
  • BPS (Bartlo Packaging, Inc.) was a bulk storage and distribution facility in West Helena, Arkansas.
  • Whitehall Leather Company in Whitehall, Michigan received deliveries on the night shift and had a facility pickle acid tank and a ferrous sulfate tank.
  • Concept Sciences, Inc. in Hanover Township, Pennsylvania was in the process of producing its first full-scale batch of 50 wt-percent hydroxylamine.
  • BP Amoco Polymers plant in Augusta, Georgia produces plastics.
  • The report scope focuses on chemical manufacturing and other industrial activities involving bulk chemicals, such as storage/distribution, waste processing, and petroleum refining.

Consequences

  • Fatalities: 108 fatalities in the 167 incidents; specific incidents include five employees killed at Napp Technologies, three firefighters killed at BPS, one truck driver killed at Whitehall Leather, five persons killed at Concept Sciences, and three people killed at BP Amoco Polymers.
  • Injuries: Average of six injury-related incidents per year, resulting in an average of five fatalities annually; specific incidents include nine injuries at Morton International, five injured at Condea Vista, 14 injured at Concept Sciences, and one injured at Whitehall Leather.
  • Environmental release: Firefighting generated chemically contaminated water that ran off into a river at Napp Technologies; approximately 10,000 gallons of contaminated water ran off into a nearby river at Morton International; reactive incidents can result in toxic gas emissions and hazardous liquid spills.
  • Facility damage: Napp Technologies destroyed a majority of the facility and property damage exceeded $20 million; BPS property damage was extensive; Concept Sciences facility was completely destroyed; BP Amoco Polymers vessel failure and fire occurred; at least a dozen incidents resulted in property damage alone exceeding $10 million, with three cases in which loss exceeded $100 million.
  • Operational impact: Napp Technologies resulted in evacuation of 300 residents from their homes and a school; BPS caused hundreds of residents, including patients at a local hospital, to be evacuated or sheltered-in-place and major roads were closed; Morton International had residents in a 10- by 10-block area shelter-in-place for up to 3 hours; reactive incidents caused lost production and business interruption.

Key Findings

Immediate Causes

  • the inadvertent introduction of water into water-reactive materials
  • the decomposition of bulk sacks of the pesticide, which had been placed too close to a hot compressor discharge pipe, and the release of flammable vapors
  • the inadvertent mixing of two incompatible chemicals
  • the explosive decomposition of hydroxylamine at high concentration
  • inadequate hazard identification during process development
  • inadequate evaluation and communication of reactive hazards

Contributing Factors

  • mechanical failure
  • inadequate understanding of reactive chemistry
  • inadequate hazard evaluation
  • inadequate procedures for storage, handling, or processing of chemicals
  • inadequate management of change (MOC) system to Identify/evaluate reactivity hazards
  • inadequate process design for reactive hazards
  • inadequate design to prevent human error
  • inadequate company-wide communication of hazards
  • inadequate emergency relief system design
  • inadequate safe operating limits
  • inadequate near miss/incident investigation
  • inadequate inspection/maintenance/monitoring of safety critical devices in reactive chemical service
  • previously unknown reactive hazards
  • inadequate operating procedures and training
  • inadequate evaluation of reactive hazards during process development
  • the hazard was known, but its potential magnitude was not–nor was the potential severity of the consequence
  • the hazard evaluation did not properly identify initiating events

Organizational and Systemic Factors

  • The OSHA PSM Standard has significant gaps in coverage of reactive hazards because it is based on a limited list of individual chemicals with inherently reactive properties.
  • The EPA Accidental Release Prevention Requirements (40 CFR 68) have significant gaps in coverage of reactive hazards.
  • Using lists of chemicals is an inadequate approach for regulatory coverage of reactive hazards.
  • Neither the OSHA PSM Standard nor the EPA RMP regulation explicitly requires specific hazards, such as reactive hazards, to be examined when performing a process hazard analysis.
  • The OSHA PSM Standard and the EPA RMP regulation do not require the use of multiple sources when compiling process safety information.
  • Publicly available resources are not always used by industry to assist in identifying reactive hazards.
  • There is no publicly available database to share reactive chemical test information.
  • Current good practice guidelines on how to effectively manage reactive hazards throughout the life cycle of a chemical manufacturing process are neither complete nor sufficiently explicit.
  • No one comprehensive data source contains the data needed to adequately understand root causes and lessons learned from reactive incidents or other process safety incidents.
  • Incident data collected by OSHA and EPA provide no functional capability to track reactive incidents so as to analyze incident trends and develop preventive actions at a national level.
  • No industry consensus standard has been identified for the management of reactive hazards in support of a GDC citation.
  • ACC and SOCMA do not list specific requirements for reactive hazard management.
  • RDP does not contain explicit requirements for reactive hazard management.

Failed Safeguards or Barrier Breakdowns

  • water was introduced into the blender
  • the facility was not covered by OSHA PSM
  • neither ferrous sulfate nor sodium hydrosulfide is rated by NFPA, and neither compound is an OSHA PSM-listed chemical
  • the explosive decomposition hazard of hydroxylamine was not adequately translated into CSI’s process design, operating procedures, mitigation measures, or precautionary instructions for operators
  • normal and emergency vents were blocked
  • the material in the core of the vessel remained hot and molten, continued to react and decompose, generating gas that could not escape
  • inadequate hazard identification
  • inadequate hazard evaluation
  • inadequate procedures for storage/handling of reactive chemicals
  • inadequate training for storage/handling of reactive chemicals
  • inadequate management of change (MOC) system to Identify/evaluate reactivity hazards
  • inadequate emergency relief system design

Recommendations

  1. 2001-01-H-R1 | Recipient: Occupational Safety and Health Administration (OSHA) | Status: | Summary: Amend the Process Safety Management Standard (PSM), 29 CFR 1910.119, to achieve more comprehensive control of reactive hazards that could have catastrophic consequences.
  2. 2001-01-H-R2 | Recipient: Occupational Safety and Health Administration (OSHA) | Status: | Summary: Implement a program to define and record information on reactive incidents that OSHA investigates or requires to be investigated under OSHA regulations.
  3. 2001-01-H-R3 | Recipient: U.S. Environmental Protection Agency (EPA) | Status: | Summary: Revise the Accidental Release Prevention Requirements, 40 CFR 68, to explicitly cover catastrophic reactive hazards that have the potential to seriously impact the public, including those resulting from self-reactive chemicals and combinations of chemicals and process-specific conditions.
  4. 2001-01-H-R4 | Recipient: U.S. Environmental Protection Agency (EPA) | Status: | Summary: Modify the accident reporting requirements in RMP*Info to define and record reactive incidents.
  5. 2001-01-H-R5 | Recipient: National Institute of Standards and Technology (NIST) | Status: | Summary: Develop and implement a publicly available database for reactive hazard test information.
  6. 2001-01-H-R6 | Recipient: Center for Chemical Process Safety (CCPS) | Status: | Summary: Publish comprehensive guidance on model reactive hazard management systems.
  7. 2001-01-H-R7 | Recipient: Center for Chemical Process Safety (CCPS) | Status: | Summary: Communicate the findings and recommendations of this report to your membership.
  8. 2001-01-H-R8 | Recipient: American Chemistry Council (ACC) | Status: | Summary: Expand the Responsible Care Process Safety Code to emphasize the need for managing reactive hazards.
  9. 2001-01-H-R9 | Recipient: American Chemistry Council (ACC) | Status: | Summary: Ensure that relevant safety knowledge and lessons learned with your membership, the public, and government to improve safety system performance and prevent future incidents.
  10. 2001-01-H-R10 | Recipient: American Chemistry Council (ACC) | Status: | Summary: Promote submissions of data by your membership.
  11. 2001-01-H-R11 | Recipient: American Chemistry Council (ACC) | Status: | Summary:
  12. 2001-01-H-R12 | Recipient: Synthetic Organic Chemical Manufacturers Association (SOCMA) | Status: | Summary: Expand the Responsible Care Process Safety Code to emphasize the need for managing reactive hazards.
  13. 2001-01-H-R13 | Recipient: Synthetic Organic Chemical Manufacturers Association (SOCMA) | Status: | Summary: Ensure that relevant safety knowledge and lessons learned with your membership, the public, and government to improve safety system performance and prevent future incidents.
  14. 2001-01-H-R14 | Recipient: Synthetic Organic Chemical Manufacturers Association (SOCMA) | Status: | Summary: Promote submissions of data by your membership.
  15. 2001-01-H-R15 | Recipient: Synthetic Organic Chemical Manufacturers Association (SOCMA) | Status: | Summary:
  16. 2001-01-H-R16 | Recipient: National Association of Chemical Distributors (NACD) | Status: | Summary: Expand the existing Responsible Distribution Process to include reactive hazard management as an area of emphasis.
  17. 2001-01-H-R17 | Recipient: National Association of Chemical Distributors (NACD) | Status: | Summary:
  18. 2001-01-H-R18 | Recipient: International Association of Firefighters | Status: | Summary: Communicate the findings and recommendations of this report to your membership.
  19. 2001-01-H-R19 | Recipient: Paper, Allied-Industrial, Chemical & Energy Workers International Union (PACE) | Status: | Summary: Communicate the findings and recommendations of this report to your membership.
  20. 2001-01-H-R20 | Recipient: The United Steelworkers of America | Status: | Summary: Communicate the findings and recommendations of this report to your membership.
  21. 2001-01-H-R21 | Recipient: Union of Needletrades, Industrial, and Textile Employees (UNITE) | Status: | Summary: Communicate the findings and recommendations of this report to your membership.
  22. 2001-01-H-R22 | Recipient: Union of Needletrades, Industrial, and Textile Employees (UNITE) | Status: | Summary: Communicate the findings and recommendations of this report to your membership.
  23. 2001-01-H-R23 | Recipient: American Society of Safety Engineers (ASSE) | Status: | Summary: Communicate the findings and recommendations of this report to your membership.
  24. 2001-01-H-R24 | Recipient: American Industrial Hygiene Association (AIHA) | Status: | Summary: Communicate the findings and recommendations of this report to your membership.

Key Engineering Lessons

  • Reactive hazards cannot be managed adequately by relying only on lists of individual chemicals; process-specific conditions and combinations of chemicals must be evaluated.
  • Process hazard analysis must explicitly examine reactive hazards and identify initiating events.
  • Reactive hazard information from multiple sources should be used in process safety information and hazard evaluation.
  • Emergency relief and venting systems must be designed so that gas generation from runaway reactions cannot overpressurize vessels.
  • Storage, handling, and transfer procedures for reactive chemicals must address inadvertent mixing and incompatible materials.
  • Reactive hazard test information and lessons learned need a mechanism for sharing across companies and organizations.
  • Reactive hazard management guidance should cover the full life cycle of a chemical manufacturing process.

Source Notes

  • Priority 1 final report used as the authoritative source for incident-level findings and recommendations.
  • Priority 3 recommendation status summaries were used only to preserve official recommendation statuses where explicitly stated.
  • The provided source set is a composite report on reactive incidents nationwide, not a single-facility incident narrative; location and facility fields are therefore left blank at the top level.
  • Some source documents contained truncated or duplicated recommendation entries; only explicitly stated text was retained.

Similar Incidents

Incidents sharing the same equipment, root causes, or hazard types.

Same Equipment

Same Root Cause

  • Sierra Chemical Co. High Explosives Accident — Shared failure mode: Communication Failure · Design Deficiency · Inspection Failure · Management Of Change Failure · Operator Error · Procedural Failure · Training Deficiency
  • Kaltech Industries Waste Mixing Explosion — Shared failure mode: Communication Failure · Design Deficiency · Inspection Failure · Operator Error · Procedural Failure · Training Deficiency
  • Technic Inc. Ventilation System Explosion — Shared failure mode: Communication Failure · Design Deficiency · Inspection Failure · Management Of Change Failure · Operator Error · Procedural Failure · Training Deficiency
  • Marathon Martinez Renewable Fuels Fire — Shared failure mode: Communication Failure · Design Deficiency · Management Of Change Failure · Operator Error · Procedural Failure · Training Deficiency
  • Tesoro Martinez Sulfuric Acid Spill — Shared failure mode: Communication Failure · Design Deficiency · Inspection Failure · Management Of Change Failure · Operator Error · Procedural Failure

Same Hazard

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