Accident: Honeywell Chemical Incidents
Location: Location: Baton Rouge, LA
Accident Occurred On: 07/20/2003 | Final Report Released On: 08/08/2005
Accident Type: Release
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.
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.
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.
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.
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.
Develop formal procedures for disposition of nonconforming materials received from customers. Ensure that procedures include positive identification prior to shipment.
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.
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.
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.
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.
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.
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.
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.
Conduct training to emphasize that MOC evaluations must consider whether emergency shutdown procedures need to be changed when there are changes in material inventory.
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.
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.
Revise the personal protective equipment matrix to include requirements for specific activities, such as draining HF equipment. Refer to the HFIPI guidelines as appropriate.
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.
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.
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.
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.
Develop and implement procedures for positively identifying material rejected by contractors such as C&MI so that hazardous materials are handled appropriately.
Develop and implement corporate standards for safely handling hydrogen fluoride.
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.
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.
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.
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.
Communicate the findings and recommendations of this report to your employees at fluorine-based manufacturing facilities in your Specialty Materials group.
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.
Communicate the findings and recommendations from the August 13 incident to your membership.
Work with Honeywell to communicate the findings and recommendations of this report to your members employed at the Honeywell Baton Rouge Facility.