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Subject: Recurring Causes of Recent Chemical Accidents
1.5a Recurring Causes of Recent Chemical Accidents
James C. Belke
U.S. Environmental Protection Agency

Chemical Emergency Preparedness and Prevention Office
Abstract
The US Environmental Protection Agency (EPA) and the Occupational Safety

and Health Administration (OSHA) have investigated recent accidents at

petroleum refineries, chemical manufacturing facilities, tolling

operations, chemical distributors, and other types of facilities. Recurring

causes of these accidents include inadequate process hazards analysis, use

of inappropriate or poorly-designed equipment, inadequate indications of

process condition, and others. Of particular note, installation of

emissions or pollution control equipment has preceded several significant

accidents, highlighting the need for stronger systems for management of

change. Other recent accidents have been preceded by a series of similar

accidents, near-misses, or low-level failures, pointing to the need for

more attention to lessons-learned implementation and more thorough company

investigation of near-misses and low-level failures as means of avoiding

major accidents.
This paper presents brief case studies of several recent chemical accidents

investigated by EPA and OSHA, and illustrates common root causes and other

recurring themes of those accidents. These accident investigations were

conducted by the EPA/OSHA Joint Chemical Accident Investigation Team. The

aim of this team is to identify the root, or underlying, causes of major

chemical accidents and to develop recommendations to prevent future similar

accidents.
Introduction
This paper presents brief case histories of several recent chemical

accidents investigated by EPA and OSHA and illustrates common causes and

other recurring themes of those accidents. When the underlying causes of

numerous accidents are brought to light and compared against one another,

recurring causes are sometimes identified - patterns that might be

overlooked if investigations stop at the tip of the iceberg, or if each

accident is viewed in isolation. There is value in identifying recurring

root causes. The value is in determining adverse trends, in discerning the

vulnerabilities and unforeseen side-effects of new technology, in

identifying the obsolescence of aging equipment and systems, and in

assessing the shortfalls of safety management systems in general. However,

generalizing about root causes can be taken too far. One common and useful

method of determining root cause is to keep asking "why?". This method must

be used with a good dose of engineering judgement. The idea is to ask

"why?" enough times to get to the underlying systemic cause of the event,

but not so many times that the cause becomes obscured in an overarching

general concern which is too vague to address. This sort of over-analysis

results in abstractions and doesn't serve any useful purpose. It's

important to keep this in mind when determining root causes; the 'common

themes' presented in this paper are intended to be specific enough that

they can be useful.
It will be useful to define some terminology that is used in this paper.

Root causes are the underlying prime reasons, such as failure of particular

management systems, that allow faulty design, inadequate training, or

deficiencies in maintenance to exist. These, in turn, lead to unsafe acts

or conditions which can result in an accident. Contributing causes are

factors that, by themselves, do not lead to the conditions that ultimately

caused the event; however, these factors facilitate the occurrence of the

event or increase its severity. Of course, people may debate about which

factors are root causes, which are contributing causes, and which are

neither, but in this day and age, major accidents generally involve more

than one cause. Virtually none of the accidents that EPA and OSHA

investigated involved only a single cause. More commonly, half a dozen root

and contributing causes were identified.
The importance of using accident investigation to identify non-causal

factors should also be noted. Non-causal factors are those systematic

deficiencies that may be identified during the course of an accident

investigation that aren't directly related to the cause of the accident. A

thorough accident investigation will usually uncover several plausible

scenarios that might have led to the accident. In fact, only one of the

scenarios actually transpired, but the others might have occurred, if

circumstances had been different. Each of these scenarios may identify

program deficiencies which need to be addressed. Accident investigations

are a valuable tool for safety program evaluation, and all deficiencies

identified in alternate scenarios should be addressed. Sometimes, it can't

be determined exactly which scenario occurred. However, whenever possible,

it's important to understand which critical factors ultimately led to the

accident and which did not. The common causal factors or "themes"

identified in this paper are all directly related to the accidents that

occurred.
Brief Accident Histories
EPA and OSHA have investigated numerous major chemical accidents over the

last several years. Most of these accidents involved fatalities, and had

some significant impact on people in nearby residential communities. All

involved worker injuries and substantial on-site property damage. The

following list includes some of the more notable among these. Some of these

were joint EPA/OSHA investigations, while others were investigated by EPA

alone1:

* Terra Industries, Inc., Port Neal, Iowa, December 13, 1994; explosion

of an ammonium nitrate unit; four employees were killed, 18 were

hospitalized. 5700 tons of anhydrous ammonia and 25,000 gallons of nitric

acid were released. Residents were evacuated from the surrounding area, and

ammonia plumes were detected several miles away.

* Powell Duffryn Terminals, Inc. (PDTI), Savannah, Georgia, April 10,

1995; crude sulfate turpentine fire and hydrogen sulfide release. The fire

was probably ignited by a newly installed and improperly designed activated

carbon vapor control unit. 2000 residents were evacuated for up to 30 days,

an elementary school was temporarily closed, and nearby marsh water was

contaminated.

* NAPP Technologies, Lodi, New Jersey, April 21, 1995; a blender

containing a mixture of sodium hydrosulfite, aluminum powder, potassium

carbonate and benzaldehyde exploded, triggering a major fire.

Water-reactive chemicals in the blender underwent an exothermic reaction

after water contaminated the blender. Four fatalities and numerous injuries

resulted. A nearby river was contaminated by runoff of firefighting water.

* Pennzoil Product Company Refinery, Rouseville, PA, October 16, 1995;

an explosion and fire erupted in storage tanks containing flammable

hydrocarbons and wastewater. Hot work near the storage tanks probably

ignited the explosion. Three employees were killed and three others were

injured. Two later died as a result of their injuries. Employees at the

plant and nearby offices, and residents from the town of Rouseville were

evacuated.

* Tosco Company Refinery, Martinez, CA, January 21, 1997; a major fire

started at a hydrocracker unit when a temperature excursion occurred,

causing a piping elbow to fail catastrophically. One employee was killed

and forty-four were injured. Nearby residents sheltered-in-place.

* Surpass Chemical Company, Albany, NY, April 8, 1997; a storage tank

failed causing a large spill of hydrochloric acid (HCl). The tank was over

pressurized during a filling operation. A hydrochloric acid cloud drifted

offsite, and spilled liquid entered the city storm sewer. 43 persons,

including employees, were treated at hospitals; of these, 4 were

hospitalized. One square block around the facility was evacuated. Students

and faculty at nearby elementary schools sheltered-in-place.

* Shell Chemical Company, Deer Park, TX, June 22, 1997; a large

explosion and fire occurred in an olefins production unit. Shaft blow-out

of a pneumatically-assisted check valve resulted in the release of large

quantities of flammable hydrocarbon gas into a congested area. A vapor

cloud explosion resulted, which was felt 10 miles away. Major plant damage

occurred. One employee was hospitalized, and several others received minor

injuries. Nearby residential areas suffered minor blast damage, and

residents sheltered-in-place. Highways west and south of the plant were

closed for three hours.

* A series of explosions and fires involving ethylene oxide (ETO)

packaging or sterilization operations occurred between April and November

1997; Two of the incidents occurred after installation of catalytic

oxidizers in ETO exhaust ventilation systems. As a result of an accident

involving ETO at Accra Pac in Elkhart, Indiana, one employee was killed, 59

others were treated at a hospital, and 3 were hospitalized. Approximately

2,500 people were evacuated from a 1 mile radius around the Accra Pac plant.

* Georgia Pacific, Columbus, Ohio, September 10, 1997; an explosion

occurred in the phenol/formaldehyde reaction kettle of a resin

manufacturing process. Reactants were added to the kettle in the wrong

sequence and at an excessive rate, resulting in an uncontrolled exothermic

reaction. One employee was killed and 13 others were treated for injuries.

Fifteen nearby homes were evacuated.

Common Factors
These accidents involved different events, varying circumstances, and a

unique set of causes. However, when the incidents are compared to one

another, some common themes can be discerned. These include the following:
1. Inadequate hazard review or process hazards analysis
In almost every accident EPA and OSHA have recently investigated, some

aspect of hazard review or process hazards analysis (PHA) was found to be

lacking. This can take a variety of forms. In some cases, the PHA did not

address known equipment failure scenarios. For example, at Shell Chemical

Company in Deer Park, the PHA did not consider the possibility of check

valve shaft blow-out, even though the facility and other Shell facilities

had experienced near-miss blow-outs in the past. In fact, the PHA at Shell

Deer Park was actually suspended in order to conduct repairs following one

such incident. At Georgia Pacific in Columbus, Ohio, the PHA did not

consider the runaway batch reaction resulting from a "dump-in" scenario

(i.e., failure to control the rate of chemical addition to an exothermic

process), and emergency pressure relief systems were not capable of

relieving the pressure rise associated with such an event. The only line of

defense against the event was the operator, and this was not enough.
In some accidents, a PHA was performed but it did not identify all process

hazards. For example, at Napp Technologies in Lodi, New Jersey, Material

Safety Data Sheets (MSDSs) were relied upon as the primary source of hazard

information for gold precipitating agent, a water reactive chemical.

However, while MSDSs usually provide substantial information on chemical

hazards, they often provide very little information on process hazards. The

MSDSs did not reveal accident history, identify or account for potential

sources of water, or address the proper technology and design of equipment

necessary to safely blend water reactive substances. Even for situations

not involving complex chemical processing operations, MSDSs are not always

sufficient to identify all reactivity, thermal stability, or explosive hazards.
In other accidents, no hazard review or PHA was performed on the process

involved in the accident. This was the case at Terra Industries in Port

Neal, Iowa, at PDTI in Savannah, Georgia, and at Pennzoil in Rouseville,

Pennsylvania. If hazards are never reviewed or analyzed, then avoiding

accidents is more a matter of luck than design.
2. Installation of pollution control equipment
Several of the accidents described above occurred following the

installation of devices to eliminate or reduce vapor emissions. This is a

reflection of inadequate hazards analysis and inadequate management of

change procedures. These incidents are discussed separately, instead of

being included in the general discussion above, because of the frequency of

their occurrence. Each case involved a process change made with good

intentions (i.e., protecting the environment), but the full implications to

personnel safety were not considered.

* Prior to the accident at PDTI, the company installed an activated

carbon vapor control system. The system was designed to prevent crude

sulfate turpentine (CST) vapor from escaping into the environment as a

result of volumetric expansion due to increasing ambient temperatures or

during tank filling. PDTI installed this system in response to repeated

complaints from neighboring residents of a strong odor arising from the

facility. However, the company had not designed the system to prevent

outside air from entering the activated carbon bed (a known cause of fires

in these systems) and failed to install flame arrestors in the vapor

control system, which allowed a fire to spread from the activated carbon

unit to the CST storage tanks.

* In two of the accidents involving ethylene oxide explosions,

catalytic oxidation units had recently been installed to oxidize toxic

emissions from ETO sterilization chambers. However, the companies did not

adequately consider the hazards of confining flammable vapors in vent

collection systems. Trevor Kletz has stated "The ignition of a few tens of

kilograms of flammable gas inside a building can destroy it. If the gas is

release out-of-doors several tonnes ... are needed to destroy a building."

(Kletz, 1993). The catalytic oxidizer provided an ignition source for the

confined flammable vapors.

* At Surpass, the company had recently installed a scrubber at the end

of the vent pipe connected to a large hydrochloric acid storage tank. The

purpose of the scrubber was to neutralize acid vapor emissions from the

storage tank. However, the scrubber also caused back pressure to build up

in the tank when it was being filled, and the tank ruptured.

New equipment, even when well-designed, can create additional hazards if it

is not properly integrated into existing systems. These accidents highlight

the need for rigorous implementation of management of change procedures so

that all hazards of new equipment are analyzed and accounted for.
3. Use of inappropriate or poorly designed equipment
In several accidents, equipment used for a task was inappropriate or not in

accordance with current standards:

* At Napp Technologies, the blender used to mix chemicals was not

designed to mix water reactive chemicals, because water seals were used in

the blender, and any seal leakage could lead to a runaway reaction. The

investigation revealed that water probably did get in the blender and cause

a runaway exothermic reaction.

* At Shell Chemical Company, a check valve used to control process gas

flow was not properly designed for heavy-duty hydrocarbon gas service. The

design of the valve and the service it was used for placed extremely high

stresses on a relatively thin drive shaft dowel pin. The pin fractured and

the drive shaft was expelled from the valve, resulting in a large flammable

gas leak and vapor cloud explosion.

* At Pennzoil, the storage tanks involved in the fire did not have

frangible roofs, which are standard for flammable liquid storage. When

vapors in the storage tank ignited, the tank failed at the bottom,

releasing the entire contents of the tank.

* At Georgia Pacific, the pressure relief system was incapable of

relieving the two-phase flow resulting from a runaway batch reaction. The

resulting pressure transient caused a vessel explosion, killing one worker.

Many other causal factors contributed to each of these accidents, but use

of inappropriate or poorly designed equipment clearly stands out as a

primary cause in these and other recent accidents.
4. Inadequate indications of process condition
In several accidents, process instrumentation did not provide operators

with indications needed to clearly identify unsafe process conditions:

* At Terra Industries, a probe used to monitor pH in an ammonium

nitrate unit neutralization tank was out of commission for two weeks prior

to the accident, but operations continued. Operators were unable to

determine when unsafe acidic conditions developed in the tank, contributing

to the accident.

* At the Tosco refinery in Martinez, California, control room

indications of hydrocracker temperature were unreliable, and operators were

forced to obtain temperature readings from a distant field instrument

panel. This prevented operators from taking timely action to mitigate a

dangerous temperature excursion. A pipe rupture occurred, killing one

worker (ironically, the same worker who was monitoring the field

temperature reading).

* At Shell, control room operators did not have instrumentation to

provide indications of a major hydrocarbon leak, and therefore took no

mitigating actions for four minutes after the leak started. Earlier action

might have avoided or reduced the severity of the ensuing explosion.

* At Surpass Chemical Company, there was no instrument installed to

indicate pressure in an HCL storage tank that was being filled using air

pressure as the pumping force. Pressure increased above the tank's pressure

limit and the tank failed catastrophically.

* In two accidents at ethylene oxide sterilization facilities, no

instrument to indicate ethylene oxide concentration in the sterilization

chamber was installed, and operators were not able to determine if ETO

concentration was greater than the lower explosive limit prior to

initiating catalytic oxidation, resulting in explosions in each case.

Each of these accidents occurred or was made more severe because the

instrumentation necessary to safely control the process was not available.

Operators were essentially forced to "fly blind".
5. Warnings went unheeded
History shows repeatedly that major disasters are often preceded by a

series of smaller accidents, near-misses, or accident precursors. This was

true in some of the most notorious accidents in recent decades. In the

Challenger space-shuttle accident, engineers at NASA and its contractor,

Morton Thiokol, were well aware of previous malfunctions in solid rocket

booster O-ring joints, and that 4 of 21 previous shuttle launches had

experienced booster O-ring leakage. Engineers even met with launch managers

on the morning of the accident to consider the safety implications of the

O-ring problem. It was known that low ambient temperatures exacerbated the

problem, and the day of the accident was the coldest launch day yet. In

spite of knowledge of past problems and the explicit warnings from

engineers, project managers decided to proceed with the launch over

engineering objections. At Bhopal, India, smaller accidents had occurred at

the plant prior to the disastrous methyl isocyanate (MIC) release in 1984,

and small MIC leaks had been noted on numerous previous occasions

highlighting the need for automatic MIC leak detection. In fact, workers

stated that experiencing eye irritation (a symptom associated with low

levels of airborne MIC) was not an unusual phenomenon, but these warnings

went unheeded.
The same type of warnings existed in several of the recent accidents

investigated by EPA and OSHA. Prior to the accident at Georgia Pacific, the

facility had recently experienced a near miss involving similar

circumstances to those resulting in the later accident. An operator added

chemicals to a batch resin process at too high a rate. Other alert

operators noted the procedural deviation, and were able to prevent an

accident. The company investigated the incident and disciplined the first

operator. No other actions were taken. In the case of Shell, the company

had experienced mechanical integrity problems involving the same type of

check valve on at least four earlier occasions at Deer Park and other Shell

plants. One of these events involved a serious flammable gas leak at a

facility in Saudi Arabia. Fortunately, the gas never ignited. The plant

which experienced the earlier incident conducted an investigation, but the

recommendations which might have prevented the later accident at Deer Park

were never implemented there. At Tosco, operators had experienced

hydrocracker temperature excursions on several previous occasions, but were

able to bring process temperatures back into normal operating ranges

without shutting down the unit (the standard procedure) or suffering

adverse consequences. Other process upsets had been investigated, but

lessons learned were generally not incorporated into operating practice.
Causes That Didn't Make the List
If understanding recurring causal factors and root causes is important in

learning about accident patterns, it's perhaps nearly as important to

recognize what root causes have not "made the list". These include training

and operator error. For example, in the Shell Deer Park accident

investigation, EPA and OSHA identified a total of 7 root and contributing

causes and 13 recommendations. None of them explicitly addressed training

or operator error. This may seem surprising, since these are often

considered "the usual suspects" in accident investigations. However, while

operator performance clearly plays a crucial role in safe plant operation,

it is only one aspect of a proper safety management system. For most major

chemical accidents, EPA and OSHA believe that it is rarely the action or

inaction of a single operator that is the sole or even primary cause of an

accident. The Safety Precedence Sequence2 illustrates that numerous

barriers must fail before operator action can cause an accident:
Safety Precedence Sequence:

1. Design for Minimum Hazard

2. Install Safety Devices

3. Use Safety Warnings

4. Control with Procedures / Administrative Controls

5. Personnel Action by Training, Awareness, Knowledge

6. Accepted Risk
Note that personnel action is almost on the bottom of the list. In keeping

with this philosophy, during root cause accident investigations EPA and

OSHA normally focus attention on the actions of operators as they reflect

the performance of the organization and its management systems. Viewed from

this perspective, operator errors, excluding willful negligence or

malfeasance, are often symptoms and not really root causes. If an incident

investigation program frequently assigns operator error and inadequate

training as root causes, or if the recommendations frequently include

disciplining operators or conducting more training, this may be a sign that

the program isn't identifying or addressing the true root causes. Likewise,

if a safety management system relies on properly trained operators to take

correct action as the only line of defense against a major disaster, then a

facility that employs such a system is asking for trouble in the long run,

because humans make mistakes.
Conclusion
From the perspective of the individual facility manager, catastrophic

events are so rare that they may appear to be essentially impossible, and

the circumstances and causes of an accident at a distant facility in a

different industry sector may seem irrelevant. However, from our nationwide

perspective at EPA and OSHA, while chemical accidents are not routine, they

are a monthly or even weekly occurrence, and there is much to learn from

the story behind each accident. Catastrophic chemical accidents still occur

too often. Furthermore, when we look beyond the obvious to the underlying

systemic causes of an accident, we see that the same root and contributing

causes keep popping up again and again. This indicates that government and

industry together are not doing a good enough job at sharing accident

information and implementing lessons learned.
Disclaimer: The views expressed in this document are the opinions of the

author and may not represent official agency positions.
References:
Kharbanda, O.P. and Stallworthy, E.A. Safety in the Chemical Industry:

Lessons from Major Disasters, G.P. Publishing, Inc., Columbia, Md, 1988
Engineers, Center for Chemical Process Safety, Guidelines for Investigating

Chemical Process Incidents, American Institute of Chemical Engineers, New

York, 1992
Conger, D. and Elsea, K., Root Cause/Incident Investigation Workshop,

Course Notes, Conger & Elsea, Inc., Woodstock, GA, 1997.
Kletz, T.A., The Unforeseen Side-Effects of Improving the Environment,

Process Safety Progress, Volume 12, No. 3, June 1993.
Rogers, William P., Armstrong, Neil A., Acheson, David C., Covert, Eugene

E., Feynman, Richard P., Hotz, Robert B., Kutyna, Donald J., Ride, Sally

K., Rummel, Robert W., Sutter, Joseph F., Walker, Jr., Arthur B.C.,

Wheelon, Albert D., Yeager, Charles, Keel, Alton G., Report of the

Presidential Commission on the Space Shuttle Challenger Accident, National

Aeronautics and Space Administration, Washington, DC, 1986
U.S. Environmental Protection Agency, EPA Chemical Accident Investigation

Report: Pennzoil Product Company Refinery Rouseville, Pennsylvania, March 1998
U.S. Environmental Protection Agency, EPA Chemical Accident Investigation

Report: Powell Duffryn Terminals, Inc., Savannah, Georgia, May 1998
U.S. Environmental Protection Agency and United States Occupational Safety

and Health Administration, EPA/OSHA Joint Chemical Accident Investigation

Report: Napp Technologies, Inc., Lodi, New Jersey, October 1997
U.S. Environmental Protection Agency and United States Occupational Safety

and Health Administration, EPA/OSHA Joint Chemical Accident Investigation

Report: Shell Chemical Company, Deer Park, Texas, June, 1998
U.S. Environmental Protection Agency and United States Occupational Safety

and Health Administration, EPA/OSHA Joint Chemical Accident Investigation

Report: Surpass Chemical Company, Albany, NY, January 1998 draft
__________________

1 OSHA investigated all of theses accidents for violation of occupational

health and safety laws. However, OSHA did not participate with EPA in a

more in-depth "root cause" investigation for some of the incidents.
2 Copyright 1997 Conger & Elsea, Inc., Used by permission


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