ABSS Public Meeting Presentation Final - PDF Flipbook
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Chemical Reaction, Hydrogen Release, Explosion and Fire at
CSB Public Meeting
AB Specialty Silicones, LLC
Waukegan, Illinois
September 24, 2021
May 3, 2019
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Stephen Klejst, Executive Director of Investigations and Recommendations
Executive Director’s Introduction
Supervisory Chemical
Investigator-In-Charge
Incident Investigator
Investigation Team
Wills Hougland amara Qureshi T Mark Wingard
Lauren Grim Vonzella Vincent Steve Cutchen Chris Lyon Dan Tillema
Chemical Reaction, Hydrogen Release, Explosion and Fire at
www.csb.gov
Investigation Presentation
AB Specialty Silicones, LLC
Waukegan, Illinois
September 24, 2021
May 3, 2019 Vonzella Vincent Investigator-In-Charge
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The chemical reaction produced and released hydrogen gas
The CSB investigation team identified ten safety issues and
containing an incompatible chemical ingredient that reacted
Incident Overview
• On May 2, 2019, operators at the AB Specialty Silicones facility were performing a batch operation inside the production building that involved manually adding and mixing chemicals in a tank An operator added an incorrect chemical into the tank • • in the building that ignited, causing an explosion and fire Four employees were fatally injured • • proposes several recommendations that will be discussed
AB Specialty Silicones EM 652 Batch Operation
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Incident occurred while manufacturing
an emulsion, commercially sold as
EM 652 EM 652 was manufactured using loosely sealed tanks inside the Emulsions Area The batch operation began by adding multiple XL 10 drums and TD-6/12 Blend QC issued pH adjustments for out of specification final product before packaging
Andisil ®
• • • •
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XL 10 is a siloxane copolymer containing silicon hydride
Silicon Hydride Reactivity
(SiH) bonds Compounds with SiH bonds react readily with aqueous bases, including potassium hydroxide, among other substances When 10% KOH, an aqueous base, contacts molecules with SiH bonds, the KOH catalyzes a reaction between the SiH and water, producing flammable hydrogen gas
• • •
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Incident Description
May 3, 2019 AB Specialty Silicones operators packaged the first EM 652 batch Partial leftover chemical containers were likely left from the first batch, resulting in up to eleven nearly identical drums containing incompatible chemicals in the immediate process area at the start of the second batch
• • •
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The hydrogen gas released inside the production building
The XL 10, TD 6/12 Blend, and 10% KOH mixture inside
solution) to the tank, while adding first two chemicals for
The explosion fatally injured four AB Specialty Silicones
(instructions) and not intended to be introduced to the
Incident Description (continued)
Operator 1 added an incorrect chemical (10% KOH
the second batch including, multiple XL 10 drums
10% KOH was not included on the batch ticket
ignited, causing a massive explosion and fire
the tank reacted, producing hydrogen gas
batch at this point
employees
• • • • •
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Safety Management System that Addresses Process Safety
Safety Issues
• Mixing of Incompatible Materials Hazard Analysis Program • Storage and Handling of Incompatible Materials • Batch Equipment and Ventilation System Design • Gas Detection System • Emergency Preparedness • Double Initial Procedure Program • Process Safety Culture • • Regulatory Coverage of Reactive Hazards •
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Mixing of Incompatible Materials
generated a large quantity of hydrogen gas
staged in the Emulsions Area for possible
One experimental chemical reactivity test
witness observations: the addition of 10% KOH to a
Partial chemical containers, including
employees to remove partial containers
from the area in between back-to-back
AB Specialty Silicones did not require
XL 10 and 10% KOH, were likely left
use in the second batch
batches and produced foaming similar to mixture of XL 10 and TD 6/12 Blend
• • •
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In 2014, AB Specialty Silicones concluded that “lack of a
manufacturing operations through what it calls technical
Effective controls were not implemented to prevent the
comprehensive hazard analysis,” among other things,
AB Specialty Silicones did not sufficiently analyze the
AB Specialty Silicones assesses proposed product
Hazard Analysis Program
contributed to an EM 652 drum explosion
mixing of 10% KOH solution and XL 10
hazards of the EM 652 process:
service request: Neither technical service request performed for EM 652 in 2014 and 2018 documented any hazards or safeguards
• • •
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Hazard Analysis Program (continued)
The AB Specialty Silicones TSR
program assessed potential
primarily aiming to answer:
business and safety risks,
do it? Adequacy of existing equipment? The TSR program did not and was not intended to assess process operation hazards or establish safeguards to reduce
do it?
Can we Should we
– – – risk
• •
Storage and Handling of Incompatible Materials
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chemical ingredients were
solution were stored in an
stored in nearly identical
At least three EM 652
55-gallon blue plastic
XL 10 and 10% KOH
identical drum, differentiated by a small label and bung caps
drums
• •
Storage and Handling of Incompatible Materials
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(continued) AB Specialty Silicones did not have a procedure requiring partial leftover chemical containers to be segregated or removed from the process area after use, contributing to the co-location of incompatible Industry guidance and strategies are available for reducing the likelihood of mixing incompatible
XL 10 and 10% KOH solution
materials
• •
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Batch Equipment and Ventilation System Design
The AB Specialty Silicones production building’s main air
mover positioned in the Emulsions Area near tanks used
AB Specialty Silicones used tanks containing hatch-type
This manually operated unit was designed to introduce outside air
to manufacture EM 652, may have helped distribute the
The tanks were not equipped with vent pipes to divert
produced gases outside the building, to a process
released hydrogen in the area and mix it with air
lids that did not seal to manufacture EM 652
ventilation system, or other safe location
in the building
–
• • •
The AB Specialty Silicones production building did not have a
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hydrogen or flammable gas detection system with alarms to
neither were specifically intended for
Installed two LEL gas detector systems for a trial
AB Specialty Silicones gas detection system timeline
AB Specialty Silicones Actions
warn employees of a hazardous atmosphere
Gas Detection System
evaluation – the EM 652 process Found both detector sensors unresponsive / failed and concluded failure due to silicone exposure Had not replaced detector, established a sensor maintenance program, or implemented design changes to address silicone contacting the sensors
Around October 2018 Around March 2019 As of May 3, 2019
Date
• •
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applications use automatic alarming detectors to warn of
asserted no hydrogen gas detection system will work in
There are numerous gas detection technologies, each
sensors life cycle to be about 2 months, while another
Staff proposes a recommendation to AB Specialty
Gas Detection System (continued)
An AB Specialty Silicones manager estimated the
Others in industry with similar environments and
with advantages and disadvantages
hazardous atmospheres
a silicone environment
Silicones
• • • •
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detectors and alarms to
AB Specialty Silicones
alert of the hazardous
Did not provide gas
Emergency Preparedness
conditions Batch ticket warns of XL 10 reactivity and its ability to generate hydrogen
• •
Workers Trained on process • emergencies Recognized the • process upset Did not recognize • immediate hydrogen hazard created by the upset Did not evacuate the • building
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Double Initial Procedure Program
initial practice to prevent employees from charging the
In March 2019, AB Specialty Silicones experienced a
As a result, AB Specialty Silicones proceduralized its
wrong materials to batch processes and as a part of
In 2014 AB Specialty Silicones developed a double
near-miss event involving two chemicals stored in
double initial practice and retrained all production
the FDA’s cosmetic good manufacturing practice
similar 55-gallon blue metal drums
compliance requirement
workers
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Double Initial Procedure Program
(continued)
• Procedural controls used in industry including the double initial procedure are low on the hierarchy of controls, more likely to fail than are engineering controls and safeguards There was insufficient evidence to determine the specific • reason for the program failure on May 3, 2019: 1) operator was fatally injured and 2) batch ticket in use, which would have included the employees’ initials, was never recovered
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An organization’s safety culture is determined by the
quality and implementation of safety management
Process Safety Culture
programs Improving an organization’s process safety culture only starts with management; it requires the involvement of all Characteristics of a weak process safety culture exhibited at AB Specialty Silicones, specific to EM 652 include: Lack of engineering controls to minimize employee exposure to known hydrogen risk; Not performing a thorough hazard analysis following its 2014 drum explosion; and Heavy reliance on procedural
• • • - - -
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on process safety, are critical to prevent reactive chemical
Effective safety management systems, primarily focused
Safety Management System
incidents AB Specialty Silicones did not have a safety management system that addressed process safety to control reactive hazards Industry publications including OSHA PSM Standard, the EPA RMP Rule, and the Center for Chemical Process Safety provide guidance on developing process safety management systems to control reactive hazards Staff proposes two recommendations to AB Specialty Silicones
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Regulatory Coverage of Reactive Hazards
In 1996 the EPA promulgated its RMP Rule
In 1992, OSHA promulgated the PSM Standard
(29 CFR 1910.119) to manage chemical process
safety and to help prevent major incidents
(40 CFR 68) The AB Specialty Silicones EM 652 operation is not regulated by OSHA’s PSM Standard, nor the EPA’s RMP Rule because the chemicals used at the facility are not listed for coverage by either regulation
• • •
Regulatory Coverage of Reactive Hazards
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that found many reactive chemicals that could contribute
to catastrophic incidents are not covered by the OSHA
In 2002, the CSB published a Reactive Hazard Study
PSM Standard or EPA RMP Rule based on their
Staff proposes a reiteration of two previous
(continued)
respective existing selection criteria
recommendations:
- OSHA (2001-01-H-R1) and EPA (2001-01-H-R3) -
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This Concludes the Staff Presentation
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