CSB Investigations Research Articles

Building design and selection for protection of critical assets

Abstract Mission Critical Buildings (MCB) are buildings that must remain operational in the event of a crisis to minimize risks due to asset damage, business interruption, and personnel impact. MCBs in processing facilities face operational hazards including explosions, fragments, fires, and toxic events. In the CSB's investigation report of the Philadelphia Energy Solutions Refinery incident, a recommendation was included for the API to update its standard to “require protection of critical safeguards and associated control system components from fire and explosion hazards, including radiant heat and flying projectiles.” This recommendation, if implemented, would require facilities to ensure MCBs are Multi‐hazard Resistant Buildings (MRBs) able to withstand a range of potential impacts. This paper details the key design characteristics of MRBs to protect critical assets in industrial processing facilities such as critical safeguards and control systems; emergency response equipment; people critical to operations and emergency response; or people located in buildings near processing units. Key concepts of protective building design are introduced, including the response of different building materials to hazards common in processing facilities. These concepts are then examined to illustrate how building response translates to human and equipment vulnerability.

US Chemical Safety Board issues delayed reports

The US Chemical Safety and Hazard Investigation Board (CSB) in December concluded three long-stalled accident investigation reports. The board also released a study concluding that over the last 2.5 years, 224 incidents occurred in the US that were serious enough to trigger a CSB investigation. The incidents killed 31 people and caused 126 serious injuries; 101 of the events resulted in over $1 million in damages. Also in December, the US Senate confirmed a new CSB member, Catherine J. K. Sandoval , and elevated CSB member Stephen Owens to chair the safety board. The CSB now has three members, short of its legally set level of five. The 25-year-old board’s charge is to investigate and determine the root cause of significant chemical accidents; recommend improvements to operations of refineries, chemical plants, laboratories, and other facilities; and boost federal and state regulatory oversight of these sites. An accumulation of unfinished investigations

Systemic accident analysis models: A comparison study between AcciMap, FRAM, and STAMP

Nowadays, different accident causation models are used to explain how accidents happen, whereas most of them were developed long time ago. There is an argument that significant changes have occurred in the industry and traditional models may have limitations in identifying causes of accidents in modern industry within complex socio‐technical environment. Consequently, new accident models based on systems theory have been introduced, but they are mainly used by academic researchers. Among systemic accident models, Systems‐Theoretic Accident Model and Processes (STAMP), Functional Resonance Accident Model (FRAM), and AcciMap methods have been identified as the most frequently cited models.This article presents a case study‐based comparison of these three models. STAMP and FRAM are used to analyze the Chevron Richmond refinery accident, which is investigated by U.S. Chemical Safety and Hazard Investigation Board (CSB). CSB investigation team developed an AcciMap of the accident.The results are compared and differences are discussed. In conclusion, STAMP is likely to be more instrumental and comprehensive in identifying contributing factors and generating recommendations. © 2018 American Institute of Chemical Engineers Process Saf Prog 38: e12002, 2019

Chemical safety board investigation reports and the hierarchy of controls: Round 2

Twenty‐five reports of the US Chemical Safety Board over the period December 2009–May 2016 were analyzed for evidence of examples related to inherent safety, passive, and active engineered safety, and procedural safety. These measures were also analyzed for their contribution to incident prevention and consequence mitigation, as well as their applicability to specific elements of the PSM system recommended by the Canadian Society for Chemical Engineering. This work represents the continuation of a previous study that performed a similar analysis for 60 CSB reports written during the period 1998–2010. The update provided here further illustrates the significant value of CSB investigation reports in demonstrating lessons learned and in training and educational efforts.Procedural safety was identified as the most common risk control measure cited in CSB reports, while the efficacy of inherent safety principles in incident prevention and mitigation has been consistently recognized by the CSB in its investigations. Risk reduction efforts aimed at incident prevention were found to be cited more often than those aimed at consequence mitigation. Active engineered safety measures were determined to be common among mitigation efforts due to the prevalence in the process industries of emergency alarms and fire suppression systems. © 2018 American Institute of Chemical Engineers Process Saf Prog 37: 459–466, 2018

CSB sued for lack of reporting rule

Several nonprofit organizations sued the U.S. Chemical Safety Board earlier this month for failing to establish a national reporting system to collect data on air pollution emissions from accidents by U.S. companies. The CSB reporting system is required by the Clean Air Act of 1990, which created the board. CSB is an independent federal agency responsible for investigating industrial, chemically related accidents and determining their root cause. Several hundred accidents annually meet the criteria for CSB investigations—a fatality among workers or the public, serious injuries, or substantial property damage—although the agency only has the resources to investigate a few. CSB has in the past recognized the importance of the reporting requirement and proposed a regulation in 2009. In that proposal, the board identified a host of improvements that would come from the regulation. It noted, for instance, that timeliness, completeness, and accuracy of chemical incident reports would be improved. Also,

Erratum: Dangerously close: The CSB's investigation into the fatal fire and explosion in west, Texas

Erratum: Dangerously close: The CSB's investigation into the fatal fire and explosion in west, Texas

Dangerously close: The CSB's investigation into the fatal fire and explosion in west, Texas

This article will focus on the fatal explosion and fire which occurred on April 17, 2013, at West Fertilizer in West, Texas, resulting in 15 fatalities, more than 260 injuries, and widespread community damage. The deadly fire and explosion occurred when about 30 tons of fertilizer grade ammonium nitrate exploded after being heated by a fire at the storage and distribution facility. The US Chemical Safety Board deployed an investigative team to examine the incident and conducted a thorough root cause investigation of the massive fire and explosion. © 2016 American Institute of Chemical Engineers Process Saf Prog 35: 312–316, 2016

Insights into process safety incidents from an analysis of CSB investigations

Insights into process safety incidents from an analysis of CSB investigations

CSB investigation of Chevron Richmond refinery pipe rupture and fire

The U.S. Chemical Safety and Hazard Investigation Board (CSB) investigated a pipe rupture of a high temperature light gas oil line at the Chevron Richmond Refinery in Richmond, CA. The CSB found technical, regulatory, and Chevron organizational factors causal to the incident. This article is a summary of the technical and organizational analysis presented in the CSB final investigation report on the Chevron Richmond Refinery incident. © 2015 American Institute of Chemical Engineers Process Saf Prog 34: 355–359, 2015

CSB investigation finds refinery explosion resulted from high-temperature hydrogen attack

CSB investigation finds refinery explosion resulted from high-temperature hydrogen attack

Smaller companies struggle with process safety

Abstract The majority of accidents investigated by the US Chemical Safety and Hazards Investigation Board (CSB) occurred at smaller companies. Some of these companies do not fully recognize the hazards of the processes they operate, they are not aware of regulatory requirements, and they do not understand the value of these regulations. While small company accidents lack the visibility of large company accidents, they are devastating to the company, its employees, the community, and its customers.This article presents a brief review of some CSB investigation reports for small company accidents and summarizes the specific reasons for these accidents. I include specific recommendations for small companies and other recommendations for larger companies, regulators, and industry groups to support smaller companies in their struggle to implement process safety management (PSM). My conclusions and recommendations are based on the lessons learned from the CSB incident reports and my own personal experience that has been focused on helping small companies prevent accidents. © 2012 American Institute of Chemical Engineers Process Saf Prog, 2012

CSB–investigation digest

Process Safety ProgressVolume 30, Issue 4 p. 401-402 CSB Digest CSB–investigation digest First published: 21 September 2011 https://doi.org/10.1002/prs.10489AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume30, Issue4December 2011Pages 401-402 RelatedInformation

Imperial sugar refinery combustible dust explosion investigation

Abstract On February 7, 2008, at about 7:15 p.m., a series of sugar dust explosions at the Imperial Sugar manufacturing facility in Port Wentworth, GA, resulted in 14 worker fatalities. Thirty‐six workers were treated for serious burns and injuries—some caused permanent, life‐altering conditions. The explosions and subsequent fires destroyed the sugar packing buildings, palletizer room, and silos, and severely damaged the bulk train car loading area and parts of the sugar refining process areas.The Imperial Sugar manufacturing facility housed a refinery that converts raw cane sugar into granulated sugar. A system of screw and belt conveyors and bucket elevators transported granulated sugar from the refinery to three 105‐foot tall sugar storage silos. Granulated sugar was then transported through conveyors and bucket elevators to specialty sugar processing areas and granulated sugar packaging machines. Sugar products were packaged in a four‐story building surrounding the silos that contained packaging machines for the sugar products. Granulated sugar was also bulk shipped in railcars and tanker trucks in the bulk sugar loading area.The U.S. Chemical Safety and Hazard Investigation Board (CSB) determined that the first dust explosion occurred in the enclosed steel belt conveyor located below the sugar silos. Steel cover panels installed on the belt conveyor less than a year before the explosion allowed explosive concentrations of sugar dust to accumulate inside the enclosure. An unknown source ignited the sugar dust, causing a violent explosion. The explosion lofted sugar dust that had accumulated on the floors and elevated horizontal surfaces, propagating more dust explosions through the buildings. Secondary dust explosions occurred throughout the packing buildings, parts of the refinery, and the bulk sugar loading buildings. The pressure waves from the explosions heaved thick concrete floors and collapsed brick walls, blocking stairwell and other exit routes. The resulting fires destroyed the packing buildings, silos, palletizer building and heavily damaged parts of the refinery and bulk sugar loading area.The CSB investigation identified the following incident causes: Sugar and cornstarch conveying equipment was not designed or maintained to minimize the release of sugar and sugar dust into the work area. Inadequate housekeeping practices resulted in significant accumulations of combustible granulated and powdered sugar and combustible sugar dust on the floors and elevated surfaces throughout the packing buildings. Airborne combustible sugar dust accumulated above the minimum explosible concentration inside the newly enclosed steel belt assembly under silos 1 and 2. An overheated bearing in the steel belt conveyor most likely ignited a primary dust explosion. The primary dust explosion inside the enclosed steel conveyor belt under silos 1 and 2 triggered massive secondary dust explosions and fires throughout the packing buildings. Accumulated sugar dust and spilled sugar fueled the secondary explosions and fires. All 14 fatalities were the result of these secondary events. This article presents the CSB investigation and discusses important management practices to prevent similar combustible dust explosions. Published 2011 American Institute of Chemical Engineers Process Saf Prog, 2011

BAYER ACCUSED OF SKIRTING SAFETY

A DECISION TO HASTEN the restart of a pesticide production process and bypass safety controls led to a tragic accident on Aug. 28, 2008, at the Bayer CropScience plant in Institute, W.Va., concludes the Chemical Safety & Hazard Investigation Board (CSB), in a report released on Jan. 20. The accident destroyed a key pesticide manufacturing unit, killed two workers, required 40,000 people living near the plant to shelter in place, and revealed gross inadequacies in Bayer’s accident emergency response operations. Workers at the Bayer plant were under pressure to resume production of the pesticides methomyl and Larvin after a lengthy maintenance shutdown, according to the CSB investigation. As a result, they failed to evaluate new computer programs, inspect safety equipment, and conduct safety process checks. Most critical, the report says, was the intentional overriding of an interlock system that was designed to prevent a runaway reaction inside a residue treater pressure vessel. Late at ...

Oversights and omissions in process hazard analyses: Lessons learned from CSB investigations

Abstract Although process hazard analyses have been voluntarily used in the chemical processing industries for over 30 years and required by U.S. regulation for certain processes involving highly hazardous chemicals since the early 1990s, failing to apply or continued misapplication of these techniques allow process hazards to remain either undetected or unappreciated. Using findings from past CSB investigations as examples, this article discusses some problems observed in process hazard analyses that diminished their overall effectiveness and prevented them from fully identifying and/or evaluating process hazards. Some practical solutions are presented for making process hazard analyses more effective. Published 2010 American Institute of Chemical Engineers Process Saf Prog 2010

Dust explosion incidents and regulations in the United States

Dust explosion incidents and regulations in the United States

CSB investigation of the explosions and fire at the BP texas city refinery on March 23, 2005

Abstract At approximately 1:20 p.m. on Wednesday, March 23, 2005 a series of explosions and fire occurred at the BP Texas City oil refinery during the start‐up of an isomerization (ISOM) process unit. Fifteen workers were killed and about 170 other people were injured. Many of those killed were working in or around office trailers located near a blowdown drum and stack open to the atmosphere. The U.S. Chemical Safety and Hazard Investigation Board (CSB) found that because of problems that began during the ISOM process unit start‐up, a sudden, geyser‐like release of flammable hydrocarbon liquid and vapor discharged from the atmospheric vent stack. This release created a flammable vapor cloud, which ignited, causing as many as five explosions and fire in and around the ISOM unit. CSB identified multiple possible ignition sources in and around the blowdown drum area, including idling vehicles; however, the exact ignition source remains unknown.CSB deployed a team of investigators to BP Texas City to conduct a root‐cause investigation immediately after the incident. This team examined blast patterns to determine the explosion origin; reviewed the design of the isomerization unit equipment; and examined plant safety and operating procedures, past accidents, maintenance procedures, and oversight and inspection. Investigators also reviewed the adequacy of applicable regulations and industry standards for the placement of temporary structures such as trailers in refineries. This article presents the preliminary findings from the CSB investigative team regarding the technical and underlying causes of the incident and discusses three urgent recommendations issued by the CSB stemming from the BP incident. © 2006 American Institute of Chemical Engineers Process Saf Prog, 2006

Lessons after Bhopal: CSB a catalyst for change

Lessons after Bhopal: CSB a catalyst for change

Management system failures identified in incidents investigated by the U.S. Chemical Safety and Hazard Investigation Board

Abstract A key mission of the US Chemical Safety and Hazard Investigation Board (CSB) is to determine the root causes of incidents, report the findings, and issue recommendations to prevent similar incidents from occurring. CSB investigators respond to a variety of events occurring in a wide range of workplaces, from chemical plants and refineries to food‐flavoring factories and steel mills.The details of each investigation are unique and the root causes are pertinent to each specific case. However, a common thread that emerges in CSB investigations is the inadequacy of management systems that might have prevented the incident from occurring. Examples of the systemic issues identified in CSB reports are: Lack of hazard review to predict and prevent incidents Insufficient investigation and follow‐up after previous incidents Inadequate training of staff Failure to implement effective mechanical integrity programs These issues are well recognized as elements of a process safety management (PSM) program, although many incidents investigated by the CSB occurred at facilities that are not regulated by OSHA's process safety management rule.1 Indeed, a number of these incidents occurred at facilities that are well outside society's definition of “chemical plants.”Please note that the opinions and conclusions expressed in this paper are those of the author, and do not necessarily represent the opinions of the Chemical Safety and Hazard Investigation Board. © 2004 American Institute of Chemical Engineers Process Saf Prog, 2004

CSB'S reactive chemical hazard investigation: Description and lessons learned

Abstract The U.S. Chemical Safety and Hazard Investigation Board (CSB) began operations as an independent federal agency in 1998. Its primary mission is to prevent chemical‐related incidents (fires, explosions, or toxic releases) in commercial or industrial settings by conducting incident investigations, reporting on causes, and issuing safety recommendations. This paper discusses some findings of the reactive chemical hazard investigation that originated from CSB's investigation of a runaway reaction at Morton International in 1998. As a result of this investigation, the Board made recommendations to promote the safe handling of reactive chemicals. Incident data sources were surveyed to determine the number and impact of reactive chemical incidents. Through site visits and surveys, the Board gathered information about reactive chemical hazard management for select small, medium, and large companies within the chemical industry. OSHA and EPA were also surveyed to determine current regulatory approaches for managing reactive chemical hazards and to identify future agency plans. This paper focuses on evidence that supports the Board's findings and recommendations on improving reactive chemical process safety.