Skip to content

LyondellBasell La Porte Fatal Chemical Release

Overview

On July 27, 2021, a release of acetic acid and methyl iodide occurred during a maintenance event at the LyondellBasell La Porte Complex in La Porte, Texas. The incident fatally injured two contract employees and resulted in 30 other personnel being transported to medical facilities for evaluation and/or treatment.

Incident Snapshot

Field Value
Facility / Company LyondellBasell
Location La Porte, TX
Incident Date 2021-07-27
Investigation Status The CSB's final report was released on May 25, 2023.
Accident Type Fatal Release of Acetic Acid and Methyl Iodide Mixture
Final Report Release Date 2023-05-25

What Happened

  • On July 24, 2021, an operations technician discovered a small leak on methanol piping upstream of the acetic acid reactor.
  • A subsequent inspection identified that the leak originated in a weld within the methanol piping.
  • LyondellBasell personnel decided to use the shutdown opportunity to remove and repair the leaking portion of the methanol piping.
  • To isolate the piping, LyondellBasell personnel chose to use a pneumatically actuated eight-inch plug valve as an isolation device.
  • LyondellBasell personnel decided that they would remove the actuator connected to the plug valve (including its coupler) so that a pipe tee could be installed over the valve stem.
  • LyondellBasell directed its third-party contractor, Turn2, to perform the actuator removal task.
  • At around 5:00 p.m. on July 27, 2021, the Turn2 superintendent and night foreman met with LyondellBasell operations personnel to review the actuator removal task.
  • LyondellBasell did not have a procedure detailing how to remove the actuator, and neither LyondellBasell nor Turn2 trained the Turn2 personnel on how to remove the actuator.
  • At around 6:45 p.m., LyondellBasell issued the work permit for the task.
  • The Turn2 foreman and two Turn2 pipefitters began work to remove the plug valve actuator.
  • The Turn2 workers removed the insulation material from the exterior of the plug valve, then began to remove the bracket mounting bolts located on the exterior of the actuator mounting bracket.
  • The Turn2 workers removed all of the pressure-retaining nuts shown in Figure 6B, not recognizing that they had compromised the pressure integrity of the valve.
  • The Turn2 crew then finished removing all of the bracket mounting bolts shown in Figure 6A.
  • After removing all of the bracket mounting bolts and inadvertently removing the pressure-retaining valve cover nuts from the plug valve, the Turn2 work crew removed the actuator and the affixed actuator mounting bracket from the plug valve and placed it on the deck grating.
  • Once the actuator was removed, the Turn2 work crew noticed that the coupler was still seated in its designated slot on the top of the valve stem.
  • The Turn2 workers attempted to slide the coupler off of the valve stem, but because it was too tight to remove by hand, the Turn2 work crew decided to use a pry bar to try and remove it.
  • While using the pry bar on the coupler, the combination of forces from the pry bar and the process fluid pressure inside the plug valve caused the unfastened valve cover and plug to eject from the plug valve body, and acetic acid rapidly released from the open plug valve.
  • The entire contents of the acetic acid reactor, roughly 164,000 pounds of acetic acid mixture at 238 °F, emptied from the reactor by way of the open, unplugged valve.
  • All three Turn2 workers were sprayed by the releasing acetic acid mixture.
  • The Turn2 foreman and one pipefitter were fatally injured from chemical burns and inhalation of the released acetic acid and methyl iodide, and the second pipefitter was seriously injured from acid exposure.
  • LyondellBasell transported 29 personnel, who were working in an adjacent unit at the time of the incident, to medical facilities for further evaluation and treatment.

Facility and Process Context

  • LyondellBasell La Porte Complex in La Porte, Texas
  • acetic acid unit
  • methanol piping upstream of the acetic acid reactor
  • shutdown opportunity for repair work
  • pneumatically actuated eight-inch plug valve used as an isolation device
  • Master Field Services Agreement with Turn2
  • OSHA Process Safety Management (PSM) covered acetic acid unit

Consequences

  • Fatalities: Two people were fatally injured: Dusty Day and Shawn Kuhleman; the Turn2 foreman and one pipefitter were fatally injured from chemical burns and inhalation of the released acetic acid and methyl iodide.
  • Injuries: The third Turn2 worker and a LyondellBasell responder were seriously injured; 29 other personnel were transported to medical facilities for further evaluation and treatment.
  • Environmental release: Approximately 164,000 pounds of acetic acid mixture erupted from the open equipment; the reactor contained over 100,000 pounds of glacial acetic acid and over 27,000 pounds of methyl iodide.
  • Facility damage: LyondellBasell’s property damage resulting from the incident, including loss of use, was estimated to be $40 million.
  • Operational impact: The acetic acid unit shut down acetic acid production; the entire contents of the acetic acid reactor emptied from the reactor by way of the open, unplugged valve.

Key Findings

Immediate Causes

  • The inadvertent removal of pressure-retaining components from a plug valve in pressurized service while workers were removing the valve’s actuator.
  • The combination of pry bar forces and process fluid pressure inside the plug valve caused the unfastened valve cover and plug to eject from the plug valve body.

Contributing Factors

  • a plug valve design that did not include sufficient design features to prevent the inadvertent removal of pressure-retaining valve components
  • the lack of procedures to conduct the actuator removal work
  • the lack of training for the workers conducting the work
  • the Turn2 workers did not know that removing the nuts shown in Figure 6B was not necessary to remove the actuator
  • the Turn2 workers did not know that the nuts were pressure-retaining, holding the valve cover in place
  • LyondellBasell considered the actuator removal job to be a simple task

Organizational and Systemic Factors

  • LyondellBasell did not provide the work crew with a procedure detailing how to remove the actuator from the plug valve
  • neither LyondellBasell nor Turn2 trained the work crew on the steps necessary to remove the actuator
  • LyondellBasell did not adequately assess the potential risk of exposing the contract crew to hazardous chemicals during the actuator removal in light of historical incidents in the industry
  • LyondellBasell did not sufficiently determine that the contractors performing the work were competent, adequately trained, or qualified to perform the actuator removal
  • LyondellBasell did not provide sufficient oversight of the actuator removal task
  • Turn2 communicated that it had a night crew that was qualified and available to remove the actuator
  • Neither ASME Standard B16.34 nor API Standard 599 contained requirements or recommendations to distinguish pressure-retaining components from those that are not pressure-retaining.

Failed Safeguards or Barrier Breakdowns

  • LyondellBasell’s Energy Isolation Procedure specified that the only pneumatically actuated control valves that were deemed to be approved energy isolation devices were those equipped with manual hand jacks, which could be physically closed and locked.
  • LyondellBasell did not have a procedure detailing how to remove the actuator.
  • neither LyondellBasell nor Turn2 trained the Turn2 personnel on how to remove the actuator.
  • The Turn2 employees did not know that removing the nuts shown in Figure 6B was not necessary to remove the actuator.
  • The Turn2 workers did not know that the nuts were pressure-retaining, holding the valve cover in place.
  • The work crew removed all of the pressure-retaining nuts shown in Figure 6B, not recognizing that they had compromised the pressure integrity of the valve.
  • The plug valve design did not prevent workers from inadvertently removing pressure-retaining components while removing the actuator.

Recommendations

  1. 2021-05-I-TX-R1 | Recipient: LyondellBasell | Status: Closed – Acceptable Action | Update LyondellBasell policy documents to require that procedures are developed for properly removing actuating equipment from plug valves. Require that the procedures clearly identify which non-pressure-retaining components are safe to remove and pressure-retaining components that shall not be removed, as well as ensure LyondellBasell personnel are trained on these procedures. Ensure that hazardous energy is controlled when performing these procedures, as required by 29 C.F.R. 1910.147. Require in the policy document that risk assessments for process safety are conducted before the actuating equipment removal work is authorized. Ensure that sufficient procedures and safeguards are in place to prevent worker exposure to process fluid.
  2. 2021-05-I-TX-R2 | Recipient: LyondellBasell | Status: Closed – Acceptable Alternative Action | Update LyondellBasell policy documents to require that LyondellBasell competent employee(s), as defined by 29 C.F.R. 1926.32(f), verify that contractors are competent, adequately trained, and qualified to perform the required work. To make this determination and to ensure work on process equipment is conducted in a safe manner, LyondellBasell competent employees may be required to oversee the work conducted by contractors on the process equipment. In the updated policy documents, include requirements to ensure that contract employees are informed of relevant process hazards and relevant details about the process equipment and are provided with equipment-specific procedures necessary to safely conduct their work.
  3. 2021-05-I-TX-R3 | Recipient: Turn2 Specialty Companies | Status: Closed – Acceptable Action | Update Turn2 policy documents to require that Turn2 employees are provided with written, detailed procedures for safely conducting work on process equipment and are trained on the procedures before the work is authorized to be performed.
  4. 2021-05-I-TX-R4 | Recipient: American Society of Mechanical Engineers | Status: Open – Awaiting Response or Evaluation/Approval of Response | Revise American Society of Mechanical Engineers (ASME) Standard B16.34 Valves—Flanged, Threaded, and Welding End as follows: a. For existing plug valves, require facilities to clearly mark all pressure-retaining components (for example, with paint, accompanying warning signs, etc.). Work with American Petroleum Institute (API) and the Valve Manufacturers Association of America (VMA) to ensure a consistent methodology is specified across both API and ASME standards. b. Require that new plug valves be designed, consistent with Prevention through Design principles, to prevent the inadvertent removal of pressure-retaining components when removing the actuator or gearbox. Evaluate past plug valve incidents, and the associated plug valve designs involved in those incidents, when formulating a new plug valve design. Work with API and VMA to ensure a consistent methodology is specified across both API and ASME standards.
  5. 2021-05-I-TX-R5 | Recipient: American Petroleum Institute | Status: Closed – Acceptable Alternative Action | Revise API Standard 599 Metal Plug Valves—Flanged, Threaded, and Welding Ends as follows: a. State that there have been multiple incidents in which workers have inadvertently removed pressure-retaining components from plug valves while workers were attempting to remove the valve’s actuator or gearbox. b. Recommend that facilities using plug valves establish written procedures detailing the correct way to remove the plug valve actuator or gearbox for each specific plug valve design at the facility. c. For existing plug valves, require facilities to clearly mark all pressure-retaining components (for example, with paint, accompanying warning signs, etc.). Work with ASME and VMA to ensure a consistent methodology is specified across both API and ASME standards. d. Require that new plug valves be designed, consistent with Prevention through Design principles, to prevent the inadvertent removal of pressure-retaining components when removing the actuator or gearbox. Evaluate past plug valve incidents, and the associated plug valve designs involved in those incidents, when formulating a new plug valve design. Work with ASME and VMA to ensure a consistent methodology is specified across both API and ASME standards.
  6. 2021-05-I-TX-R6 | Recipient: Valve Manufacturers Association of America Technical Committee | Status: Open – Awaiting Response or Evaluation/Approval of Response | Work with ASME and API and develop a white paper to the Valve Manufacturers Association of America addressing the issue of plug valve design with a focus on the following: a. Recommend as an industry good practice that facilities using plug valves establish written procedures detailing the correct way to remove the plug valve actuator or gearbox for each specific plug valve design. b. For existing plug valves, recommend as an industry good practice for facilities to clearly mark all pressure-retaining components (for example, with paint, accompanying warning signs, etc.). Work with ASME and API to ensure a consistent methodology is specified to the industry. c. Recommend new plug valves be designed, consistent with Prevention through Design principles, to prevent the inadvertent removal of pressure-retaining components when removing the actuator or gearbox. Evaluate past plug valve incidents, and the associated plug valve designs involved in those incidents, when formulating a new plug valve design recommendation. Work with ASME and API to ensure a consistent design is recommended to the industry.

Key Engineering Lessons

  • Plug valve designs should prevent inadvertent removal of pressure-retaining components during actuator or gearbox removal.
  • Existing plug valves should clearly mark pressure-retaining components so they can be distinguished from non-pressure-retaining parts.
  • Facilities should have written, equipment-specific procedures for removing actuating equipment from plug valves.
  • Procedures should clearly identify which components are safe to remove and which are pressure-retaining.
  • Hazardous energy and process fluid exposure must be controlled during actuator removal work.

Source Notes

  • Priority 1 final report used as the primary authority for incident facts, sequence, causes, consequences, and recommendations.
  • Priority 3 recommendation status summaries were used to confirm recommendation statuses and later closure actions.
  • The incident involved a release of acetic acid and methyl iodide from the acetic acid reactor; the crawler metadata's reference to a 100,000-pound acetic acid release is superseded by the final report's approximately 164,000-pound acetic acid mixture release.
  • The final report identifies the fatalities as Dusty Day and Shawn Kuhleman.
  • The final report states the acetic acid unit is covered by OSHA PSM and not covered by EPA RMP.

Similar Incidents

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

Same Equipment

Same Root Cause

Same Hazard

← View in Knowledge Graph