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Honeywell Chemical Incidents
FINAL REPORT: Final Investigation Report
Location: Baton Rouge, LA
Accident Occurred On: 07/20/2003
Final Report Released On: 08/08/2005
Accident Type: Release
Company Name: Honeywell

statistics

Total # of Recommendations
30
Total # of Open Recommendations
3
Total # of Closed Recommendations
27
Total % of Open 10 vs. Closed 90

investigation information

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Accident Description
On July 20, 2003, there was a release of chlorine gas from the Honeywell refrigerant manufacturing plant in Baton Rouge, Louisiana. The accident resulted in the hospitalization of four plant workers and required residents within a half-mile radius to shelter in their homes. On July 29, 2003, a worker was fatally injured by exposure to antimony pentachloride when a gas cylinder released its contents to the atmosphere. On August 13, 2003, two plant workers were exposed to hydrofluoric acid, and one was hospitalized.
Investigation Status
The final report on the three incidents was approved by the Board on August 8, 2005, and released at a news conference in Baton Rouge on August 10.


 

Recommendations

American Society for Nondestructive Testing (ASNT)
2003-13-I-LA-28

Communicate the findings and recommendations from the July 20 incident to your membership. Emphasize the need to evaluate test methods for appropriateness in the given equipment.

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.
 

American Society of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE)
2003-13-I-LA-22

Develop guidance on the effective design and maintenance of HVAC systems and other necessary control room components designed to protect employees and equipment in the event of a release of hazardous materials.

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Baton Rouge Fire Department
2009-13-I-LA-23

Evaluate and update as necessary community notification procedures to include timely notification of residents in the event of a chemical release. Conduct periodic refresher training with staff on the requirements in the procedures.

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.
 

Chemical and Metal Industries (C&MI)
2003-13-I-LA-27

Develop formal procedures for disposition of nonconforming materials received from customers. Ensure that procedures include positive identification prior to shipment.

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.
 

East Baton Rouge Parish Office of Homeland Security and Emergency
2003-13-I-LA-24

Conduct an awareness campaign to educate residents on the proper response during a chemical release. Include instructions on the way residents (including those outside the affected area) can obtain information during an emergency.

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.
 

Honeywell Baton Rouge Facility
2003-13-I-LA-1

Revise inspection and testing procedures to include effective methods for detecting and preventing leaks in coolers that use chlorine. These procedures should include the use of appropriate NDT methods.

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.
 

2003-13-I-LA-2

Analyze layers of protection installed to prevent possible consequences of failure of heat exchangers that use chlorine, and implement corrective actions as appropriate. Examples of additional measures include installing monitors on the coolant stream to detect the presence of chlorine, and determining the feasibility of operating the coolant stream at a pressure high enough to prevent the entry of chlorine in the event of a leak.

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.
 

2003-13-I-LA-3

To address ongoing issues regarding layers of protection and leaks in heat exchangers, revise procedures for performing process hazard analyses for equipment that contains hazardous materials such as chlorine to, at a minimum: - Require an evaluation of the effects of leaks in heat exchangers.

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.
 

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2003-13-I-LA-4

To address ongoing issues regarding layers of protection and leaks in heat exchangers, revise procedures for performing process hazard analyses for equipment that contains hazardous materials such as chlorine to, at a minimum: - Consider the layers of protection necessary to prevent a catastrophic incident and require recommendations to be implemented when existing protection is inadequate.

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.
 

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2003-13-I-LA-5

Revise the incident investigation procedure to ensure that odors inside positive pressure control rooms are investigated, the causes identified, and the appropriate corrective actions implemented. Address causes of the releases as well as entry of the material into the building.

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.
 

2003-13-I-LA-6

Survey units that handle chlorine, and evaluate the effectiveness of shutdown systems for detecting and preventing the release of chlorine. At a minimum, ensure that shutdown systems and procedures are integrated to stop all potential sources of chlorine.

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.
 

2003-13-I-LA-7

Conduct training to emphasize that MOC evaluations must consider whether emergency shutdown procedures need to be changed when there are changes in material inventory.

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.
 

2003-13-I-LA-8

Conduct a hazard analysis (such as a job safety analysis) in the ton-cylinder area, incorporate appropriate findings into unit operating procedures, and train personnel accordingly.

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.
 

2003-13-I-LA-9

Revise plant procedures on receiving cylinders to require that weights be recorded on incoming materials and suspicious materials be isolated so that hazardous materials are handled appropriately.

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.
 

2003-13-I-LA-10

Revise the personal protective equipment matrix to include requirements for specific activities, such as draining HF equipment. Refer to the HFIPI guidelines as appropriate.

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.
 

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2003-13-I-LA-11

Develop and implement a program for the identification and management of hazards in nonroutine situations. Ensure that this program covers the following: - Situations where employees are unable to follow standard operating procedures, such as properly purging equipment.

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.
 

2003-13-I-LA-12

Develop and implement a program for the identification and management of hazards in nonroutine situations. Ensure that this program covers the following: - Circumstances where there is no specific formal procedure for handling a highly hazardous chemical.

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.
 

2003-13-I-LA-13

Develop and implement a program for the identification and management of hazards in nonroutine situations. Ensure that this program covers the following: - Operations following an emergency shutdown.

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.
 

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Honeywell International, Inc.
2003-13-I-LA-14

Develop and implement corporate standards to ensure positive pressure control rooms, including the HVAC systems, are designed and maintained to prevent the short-term entry of hazardous materials. Implement corporate standard changes at the Baton Rouge facility, and other Honeywell facilities as appropriate.

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.
 

2003-13-I-LA-15

Develop and implement procedures for positively identifying material rejected by contractors such as C&MI so that hazardous materials are handled appropriately.

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.
 

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2003-13-I-LA-16

Develop and implement corporate standards for safely handling hydrogen fluoride.

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.
 

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2003-13-I-LA-17

In light of the findings of this investigation report, conduct a comprehensive audit of fluorine-based manufacturing facilities in your Specialty Materials group facilities. Ensure that the audit addresses: Thoroughness of hazard analysis and adequacy of safeguards.

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.
 

2003-13-I-LA-18

In light of the findings of this investigation report, conduct a comprehensive audit of fluorine-based manufacturing facilities in your Specialty Materials group facilities. Ensure that the audit addresses: Recognition and management of nonroutine situations.

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.
 

2003-13-I-LA-19

In light of the findings of this investigation report, conduct a comprehensive audit of fluorine-based manufacturing facilities in your Specialty Materials group facilities. Ensure that the audit addresses: Adherence to standard operating procedures.

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.
 

2003-13-I-LA-20

In light of the findings of this investigation report, conduct a comprehensive audit of fluorine-based manufacturing facilities in your Specialty Materials group facilities. Implement the recommendations from the audit and communicate the findings to the work force.

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.
 

2003-13-I-LA-21

Communicate the findings and recommendations of this report to your employees at fluorine-based manufacturing facilities in your Specialty Materials group.

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.
 

Hydrogen Fluoride Industry Practices Institute (HFIPI)
2003-13-I-LA-25

Conduct a survey of members to determine best industry practices for HF handling activities, such as draining equipment, use of open systems, and nonroutine work. Develop best practices guidance as appropriate and communicate it to your members.

Status: Open - Acceptable Response or Alternate Response
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

2003-13-I-LA-26

Communicate the findings and recommendations from the August 13 incident to your membership.

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.
 

International Brotherhood of Teamsters Local #5
2003-13-I-LA-29

Work with Honeywell to communicate the findings and recommendations of this report to your members employed at the Honeywell Baton Rouge Facility.

Status: Closed - Unacceptable Action/No Response Received
Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.
 

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U.S. Department of Transportation (DOT)
2005-6-I-LA-1

Expand the scope of DOT regulatory coverage to include chlorine railcar unloading operations. Ensure the regulations specifically require remotely operated emergency isolation devices that will quickly isolate a leak in any of the flexible hoses (or piping components) used to unload a chlorine railcar. The shutdown system must be capable of stopping a chlorine release from both the railcar and the facility chlorine receiving equipment. Require the emergency isolation system be periodically maintained and operationally tested to ensure it will function in the event of an unloading system chlorine leak.

Status: Open - Acceptable Response or Alternate Response
Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.
 

 
 

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