Aug 10, 2005
CSB States Three Honeywell Baton Rouge Accidents in 2003 Were Avoidable; Final Report Finds Inadequate Hazard Analyses, Work Practices Common to All
Baton Rouge, Louisiana, August 10, 2005 - The U.S. Chemical Safety and Hazard Investigation Board (CSB) today released a final report on its investigation of three incidents that occurred at the Honeywell International, Inc., plant in Baton Rouge, Louisiana, in 2003. Each involved toxic releases and in one case, the death of a worker.
The Board's report - released at a news conference in Baton Rouge held by CSB Chairman Carolyn Merritt and Lead Investigator Lisa Long - revealed management system deficiencies at the plant that were common to all three incidents. The company's hazard analyses did not provide an adequate review of all equipment, procedures, and likely accident scenarios, the report said, noting that potentially dangerous "non-routine" situations at the plant were not always recognized as such. The Board said work practices at the plant did not always strictly follow written operating procedures.
The incidents involved were a July 20, 2003, chlorine release which injured eight Honeywell employees and caused neighbors to shelter-in-place; the July 29, 2003, death of worker Delvin S. Henry, caused by the release of a toxic mixture containing lethal antimony pentachloride from a mislabeled cylinder; and the August 13, 2003, release of highly toxic and corrosive hydrogen fluoride (HF) which splashed onto a worker causing a burn.
Chairman Merritt said, "Our Chemical Safety Board investigation shows these incidents resulted from the failure to identify potential hazards, to recognize non-routine situations, and to ensure adherence to written procedures." Chairman Merritt added, "These incidents at the Honeywell Baton Rouge facility in the summer of 2003 should not have happened and would not have happened had better procedures, hazard analyses, and design of critical equipment been put in place at the plant."
Lead Investigator Long highlighted findings and root causes for each incident, saying, "The common thread in these incidents can be found in weaknesses in some management systems at Honeywell that could have identified potential problems in each of the three seemingly different incidents. We believe our investigation highlights these areas and forms the basis for needed change at the plant and possibly elsewhere."
The CSB Investigation Report included these findings and root causes:
July 20, 2003: Eight Honeywell employees were injured, four of them hospitalized, when a hole developed in a chlorine cooler tube used in the production of refrigerants; the gas escaped from the hole and entered the refrigerant coolant system. This system in turn developed a leak, releasing chlorine to the atmosphere less than 25 feet from the plant's control room, overwhelming operators inside and outside the room. The chlorine entered the control room through holes and gaps in the room's ventilation system ductwork. A shelter-in-place was advised for neighbors within a half-mile radius by local authorities. The released chlorine quickly corroded the plant's electronic control system forcing the shutdown of the plant.
The CSB found a dangerous condition developed because the plant's management systems - including safety plans, procedures, and designs - did not protect against failures in the chlorine cooler. The CSB found the "consequences of chlorine entering the coolant system were not fully evaluated." The report cited as a contributing cause the inadequate design and maintenance of the control room, which should have been able to provide short-term protection against the infiltration of chlorine.
July 29, 2003: With all plant units shut down following the July 20 chlorine release, plant activities primarily consisted of maintenance, shipping, and returning equipment to normal conditions. This included continuing to process large previously-used one-ton refrigerant cylinders stored on the plant grounds for off-site testing so they could be reused. An operator, preparing what he likely believed to be an empty refrigerant cylinder, removed a plug at one end. In fact, the CSB determined the cylinder contained 3,228 pounds of what was later determined to be a mixture containing toxic antimony pentachloride. The operator was sprayed with the liquid and engulfed in a cloud, causing severe internal and external injuries from which he died the following day.
The CSB found the cylinder had been improperly relabeled as a refrigerant at a Denver facility owned by Chemical and Metal Industries, Inc. (C&MI). The CSB found Honeywell had no program to identify and address potential hazards in the ton-cylinder area, and said neither the company nor C&MI had a systematic process for positively verifying the contents of cylinders.
August 13, 2003: Honeywell had been investigating the two prior incidents and reviewing overall plant safety systems, while returning some equipment to normal conditions. On August 13 one employee was burned and another exposed to highly toxic hydrogen fluoride (HF) during an attempt to remove the substance from the plant's system. The CSB found that operators used a suction device called a venturi stick. HF flowing through the device into the sewer suddenly increased in pressure causing the venturi stick -- which was secured only by a rope -- to jump up, splashing an operator who was subsequently treated for a burn.
The CSB found Honeywell "had no procedures for identifying and planning for non-routine job situations." Investigators noted that since HF is highly hazardous, more specific procedures and job planning were necessary to ensure the operation was safe.
The CSB issued numerous safety recommendations.
The Board's recommendations to Honeywell included revising equipment inspection and testing procedures to prevent leaks in coolers that use chlorine, and to establish standards and procedures for designing and maintaining critical control rooms to protect them from toxic gases. The Board recommended the plant revise and improve its procedures to better identify chemical process hazards.
The Board recommended C&MI ensure positive identification of contents of containers prior to shipping them.
The Baton Rouge Fire Department was asked by the CSB to evaluate and conduct internal training on its community notification procedures. The CSB additionally recommended that the East Baton Rouge Parish Office of Homeland Security and Emergency Preparedness conduct an awareness campaign to educate residents on how to respond to chemical releases.
Chairman Merritt said, "The Board anticipates that Honeywell will implement the CSB's recommendations and improve its management systems to prevent incidents like this from happening here or at other sites with similar operations. It is also our hope that Honeywell will use its standing in the industrial community to share information about this event and how it could have been prevented with chlorine producers and users."
The entire report, including findings and all recommendations, will be published at www.CSB.gov.
The CSB is an independent federal agency charged with investigating industrial chemical accidents. The agency's board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in safety management systems.
The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Please visit our website, www.CSB.gov. For more information, contact Sandy Gilmour 202-261-7614, cell 202-251-5496 or Lindsey Heyl, 202-261-3614, cell 703-303-7499.