CSB U S Chemical Safety and Hazard Investigatio : Releases 2016 Impact Report

U.S. Chemical Safety and Hazard Investigation Board

Information is subject to change after September 30, 2017 1

Impact Report

FY 2016

U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD

The U.S. Chemical Safety and Hazard Investigation Board (CSB) is an independent federal agency whose mission is to drive chemical safety change through independent investigations to protect people and the environment. The CSB advocates for the implementation of the resulting safety recommendations to better protect workers, the public and the environment. The vision of the CSB is to create a nation safe from chemical disasters. This report highlights the CSB's impact of activities undertaken in fiscal year (FY) 2016 to achieve this vision.

INVESTIGATIONS

The CSB conducts incident investigations and safety studies concerning releases of hazardous chemical substances. Throughout FY 2016, investigative field work and analysis have continued on several important open accident investigations. The CSB deployed to four chemical incidents in FY 2016. The CSB anticipates that it will continue to advance these investigations in FY 2017.

FY 2016 COMPLETED REPORTS

Caribbean Petroleum Refining Tank Explosion and Fire (Bayamón, PR): On October 23, 2009, a massive explosion occurred at the Caribbean Petroleum Corporation, or CAPECO, terminal facility near San Juan, Puerto Rico. The CSB's final report issued recommendations for addressing regulatory gaps in safety oversight of petroleum storage facilities by the Occupational Safety and Health Administration (OSHA) and Environmental Protection Agency (EPA). The final report was released at an October 21, 2015, public business meeting in Washington, DC.

West Fertilizer Explosion and Fire (West, TX): On April 17, 2013, the West Fertilizer fire and explosion in West, Texas, resulted in 15 fatalities, more than 260 injuries, and an estimated $230 million in community damage. The deadly fire and explosion occurred when approximately thirty tons of fertilizer grade ammonium nitrate (FGAN) exploded after being heated by a fire at the storage and distribution facility. The CSB made recommendations to address a lack of awareness of hazardous chemicals and emergency preparedness. The final report was released at a public meeting on January 28, 2016.

Macondo Blowout and Explosion (Gulf of Mexico): On April 20, 2010, a complex interplay of physical, operational, and organizational barriers failed, sending oil and gas from deep below the ocean floor onto the drilling rig, triggering explosions and an ensuing fire that left 11 of the 126 workers dead and critically injured at least 17 others. Volumes III and IV of the report included proposed safety recommendations to the U.S. Department of Interior's Bureau of Safety and Environmental Enforcement (BSEE), the American Petroleum Institute, the Ocean Energy Safety Institute, and the Sustainability Accounting Standards Board. The final report was released on April 20, 2016.

Tesoro Martinez (Martinez, CA): On February 12, 2014, an incident occurred at the Tesoro Refinery in Martinez, California, which burned two workers and released an estimated 84,000 pounds of sulfuric acid. Less than a month later, on March 10, 2014, sulfuric acid sprayed and burned two contract workers during the removal of piping. Both incidents occurred in the alkylation unit - where high-octane blending components are produced for gasoline. The CSB's case study examines the Tesoro Martinez Refinery through the evaluation of previous incidents, worker statements, gaps in safety standards, deviations from established procedures and practices, and past efforts to assess and strengthen site safety culture. The final report was released at a news conference on August 2, 2016.

Freedom Industries Chemical Release (Charleston, WV): On the morning of January 9, 2014, an estimated 10,000 gallons of crude methylcyclohexanemethanol (MCHM) mixed with propylene glycol phenyl ethers (PPH Stripped) were released into the Elk River when a 46,000-gallon storage tank located at the Freedom Industries site in Charleston, WV, failed, disrupting the drinking water supply for approximately 300,000 residents in nine counties. The CSB's report highlights lessons learned and is calling on aboveground storage tank facilities, government officials, drinking water utilities and public health agencies across the country to follow recommended best practices in order to prevent similar incidents. The final report was released at a public meeting on September 28, 2016.

Safety Alert: Preventing High Temperature Hydrogen Attack (HTHA): In the absence of industry guidance that incorporates key findings from the Tesoro Anacortes 2010 heat exchanger failure, the CSB issued a safety alert to provide additional direction for the industry to prevent the damage mechanism HTHA. The bulletin was released on August 11, 2016.

Williams Olefins Plant Fire and Explosion (Geismar, LA): On June 13, 2013, an explosion and fire occurred at the Williams Olefins plant during non-routine operational activities that introduced heat to the reboiler, which was offline and isolated from its pressure relief device. The heat increased the temperature of a liquid propane mixture confined within the reboiler, resulting in a dramatic pressure rise within the vessel. The reboiler shell catastrophically ruptured, causing a boiling liquid expanding vapor explosion (BLEVE) and fire, which killed two workers; 167 others reported injuries, the majority of which were contractors. The CSB's report highlighted the importance of using risk reduction strategies, such as the "hierarchy of controls"; establishing a strong organizational process safety culture; and developing a robust process safety management program. The final report was approved on September 26 and released at a news conference on October 19, 2016.

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FY 2016 OPEN INVESTIGATIONS

Investigation Location Incident Date

DuPont LaPorte Facility Toxic Chemical Release La Porte, TX Nov 15, 2014

Exxon Mobil Refinery Explosion	Torrance, CA	Feb 18, 2015
Delaware City Refining Company	Delaware City, DE	Nov 29, 2015
Enterprise Product Partners	Pascagoula, MS	Jun 27, 2016
Sunoco	Nederland, TX	Aug 12, 2016
Airgas	Cantonment, FL	Aug 28, 2016

RECOMMENDATIONS

CSB investigations produce high-impact recommendations to regulatory agencies, state and local governments, corporations, industry organizations and others, aiming to drive chemical safety and environmental protection. The CSB advocates for timely implementation of these recommendations. During FY 2016, implementation of CSB recommendations resulted in key safety improvements. For example, as a result of the CSB's West Fertilizer investigation, the CSB made recommendations to Federal Emergency Management Agency (FEMA) within the Department of Homeland Security (DHS) to create a funding mechanism that would provide training and curriculum development for first responders on response to ammonium nitrate incidents. On September 16, 2016, FEMA awarded two grants of one million dollars each to the Georgia Tech Research Institute (GTRI) and the International Association of Fire Fighters (IAFF) to develop and deliver HAZMAT training, focusing on FGAN hazards in accordance with the CSB's recommendations.