Skip to Main Content

An independent federal agency investigating chemical accidents to protect workers, the public, and the environment.

Text Size AA
PRINT PAGE
Formosa Plastics Vinyl Chloride Explosion
Location: Illiopolis, IL
Accident Occurred On: 04/23/2004
Final Report Released On: 03/06/2007
Accident Type: Chemical Manufacturing - Fire and Explosion
Company Name: Formosa Plastics

statistics

Total # of Recommendations
8
Total # of Open Recommendations
0
Total # of Closed Recommendations
8
Total % of Open 0 vs. Closed 100

investigation information

Image
Accident Description
On April 23, 2004, five workers were fatally injured and two others were seriously injured when an explosion occurred in a polyvinyl chloride (PVC) production unit at Formosa Plastics in Illiopolis, Illinois, east of Springfield. The explosion followed a release of highly flammable vinyl chloride, which ignited. The explosion forced a community evacuation and lighted fires that burned for several days at the plant.
Investigation Status
The CSB's final report on this investigation was issued at a news conference in Springfield, Illinois, on March 6, 2007.


 

Recommendations

Center for Chemical Process Safety (CCPS)
2004-10-I-IL-8

Develop guidelines for auditing chemical process safety at newly acquired facilities. Emphasize the identification of major hazards, a review of the acquired facility's previous incident history and hazard analyses, the adequacy of management safety systems, and harmonization of the acquired facility's standards and practices with those of the acquiring company.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Environmental Protection Agency (EPA)
2004-10-I-IL-7

Ensure that the EPA's Enforcement Alert concerning PVC facilities includes the causes and lessons learned from this investigation. Emphasize the importance of analyzing human factors and the need to implement adequate safeguards to minimize the likelihood and consequences of human error that could result in catastrophic incidents.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Formosa Plastics USA
2004-10-I-IL-1

Review the design and operation of FPC USA manufacturing facilities and implement policies and procedures to ensure that: -Site-wide policies are implemented to address necessary steps and approval levels required to bypass safety interlocks and other critical safety systems. -Chemical processes are designed to minimize the likelihood and consequences of human error that could result in a catastrophic release. -Safety impacts of staffing changes are evaluated. -Risks identified during hazard analyses and near-miss and incident investigations are characterized, prioritized, and that corrective actions are taken promptly. -High-risk hazards are evaluated using layers of protection analysis (LOPA) techniques and that appropriate safeguards are installed to reduce the likelihood of a catastrophic release of material. -All credible consequences are considered in near-miss investigations. -Emergency procedures clearly characterize emergency scenarios, address responsibilities and duties of responders, describe evacuation procedures, and ensure adequate training. Ensure that periodic drills are conducted. -The siting of offices for administrative and support personnel is evaluated to ensure the safety of personnel should an explosion or catastrophic release occur.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2004-10-I-IL-2

Conduct periodic audits of each FPC USA PVC manufacturing facility for implementation of the items in Recommendation R1. Develop written findings and recommendations. Track and promptly implement corrective actions arising from the audit. Share audit findings with the workforce at the facilities and the FPC USA Board of Directors.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2004-10-I-IL-3

Design and implement a program requiring audits of newly acquired facilities that address the issues highlighted in this report. Document, track, and promptly address recommended actions arising from the audits.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2004-10-I-IL-4

Communicate the contents of this report to all employees of FPC USA PVC facilities.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

National Fire Protection Association (NFPA)
2004-10-I-IL-5

Revise NFPA 15, Standard for Water Spray Fixed Systems for Fire Protection, to provide additional design guidance for deluge systems designed to prevent or mitigate fires and explosions. Include information concerning the limitations of using deluge systems for this purpose.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Vinyl Institute
2004-10-I-IL-6

Issue a safety alert to your membership highlighting the need to identify design features that may render processes vulnerable to human error and to implement sufficient layers of protection to minimize the likelihood human error causing catastrophic releases of hazardous material. Include lessons from PVC industry industrial accidents (including those described in this report and others highlighted in The Encyclopedia of PVC and elsewhere) that involved human error.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

 
 

Related Video

Explosion at Formosa Plastics (Illinois)
3/6/2007 5:00:00 AM
A preventable human error leads to a vinyl chloride explosion, killing five. read more

Download QuickTime Video

Related News

DSCN39301
CSB Issues Final Report and Safety Video on Formosa Plastics Explosion in Illinois, Concludes That Company and Previous Owner Did Not Adequately Plan for Consequences of Human Error
3/6/2007
Springfield, Illinois, March 6, 2007 - The U.S. Chemical Safety Board (CSB) today issued its final report on the explosion and fire that destroyed the Formosa Plastics plant in Illiopolis, Illinois, on April 23, 2004, concluding that the accident occurred when an operator overrode a critical valve safety interlock on a pressurized vessel making polyvinyl chloride. Vinyl chloride liquid and vapor discharged into the plant and was ignited, resulting in a massive explosion.
read more
DSCN4018
CSB Investigation of Formosa Accident Continues; Agency Analyzing Evidence, Determining Root Causes
4/22/2005
Washington, DC, April 22, 2005 - CSB investigators are nearing completion of equipment testing and are focusing on the analysis of evidence to determine the root causes of the Formosa Plastics accident that occurred in Illiopolis, Illinois, on April 23, 2004, taking the lives of five workers and injuring others. The explosion forced a community evacuation and lighted fires that burned for several days at the plant.
read more
DSCN3930
CSB Continues Investigation of Formosa Plastics Explosion, Examines Functioning of Plant Fire Safety System for Vinyl Chloride
4/30/2004
Washington, DC, April 30, 2004 - Investigators from the U.S. Chemical Safety and Hazard Investigation Board (CSB) are continuing their field work on the April 23 accident at the Formosa Plastics plant in Illiopolis, Illinois, east of Springfield, and plan to enter the area where the explosion originated as soon as structural safety issues are resolved next week.
read more
 
 
© csb.gov. All rights reserved