Improving Reactive Hazard Management

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Accident Description

Accident: Improving Reactive Hazard Management

Location: Location: ,

Accident Occurred On: 08/01/2000 | Final Report Released On: 10/08/2002

Accident Type: Reactive Incident

Investigation Status: On September 17, 2003, the CSB released data on the complete set of 167 serious reactive incidents that formed the basis of the investigation.

In August 2000, following its investigation of a serious reactive incident at Morton International, the Board initiated a comprehensive review of reactive hazards nationwide. The purpose of the investigation was to develop recommendations to reduce the number and severity of such incidents.

Final Reports

FINAL REPORT: Final Investigation Report

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Recommendations

American Chemistry Council (ACC)

2001-01-H-8

Expand the Responsible Care Process Safety Code to emphasize the need for managing reactive hazards. Ensure that: · Member companies are required to have programs to manage reactive hazards that address, at a minimum, hazard identification, hazard evaluation, management of change, inherently safer design, and adequate procedures and training. · There is a program to communicate to your membership the availability of existing tools, guidance, and initiatives to aid in identifying and evaluating reactive hazards.

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.

Recommendation Status Change Summary

2001-01-H-9

Develop and implement a program for reporting reactive incidents that includes the sharing of relevant safety knowledge and lessons learned with your membership, the public, and government to improve safety system performance and prevent future incidents.

Status: Closed - Reconsidered/Superseded

Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.

Recommendations Status Change Summary

2001-01-H-10

Work with NIST in developing and implementing a publicly available database for reactive hazard test information. Promote submissions of data by your membership.

Status: Closed - Reconsidered/Superseded

Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.

Recommendations Status Change Summary

2001-01-H-11

Communicate the findings and recommendations of this report 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.
American Industrial Hygiene Association (AIHA)

2001-01-H-24

Communicate the findings and recommendations of this report 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.
American Society of Safety Engineers (ASSE)

2001-01-H-23

Communicate the findings and recommendations of this report 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.
Center for Chemical Process Safety (CCPS)

2001-01-H-6

Publish comprehensive guidance on model reactive hazard management systems. At a minimum, ensure that these guidelines cover: · For companies engaged in chemical manufacturing: reactive hazard management, including hazard identification, hazard evaluation, management of change, inherently safer design, and adequate procedures and training. · For companies engaged primarily in the bulk storage, handling, and use of chemicals: identification and prevention of reactive hazards, including the inadvertent mixing of incompatible substances.

Status: Closed - Exceeds Recommended Action

Closed - Exceeds Recommended Action (C - ERA) - Action on the recommendation meets and surpasses the objectives envisioned by the Board.
Chemical and Metal Industries (C&MI)

2001-01-H-7

Communicate the findings and recommendations of this report to your membership.

Status: Closed - Exceeds Recommended Action

Closed - Exceeds Recommended Action (C - ERA) - Action on the recommendation meets and surpasses the objectives envisioned by the Board.
Environmental Protection Agency (EPA)

2001-01-H-3

Revise the Accidental Release Prevention Requirements, 40 CFR 68, to explicitly cover catastrophic reactive hazards that have the potential to seriously impact the public, including those resulting from self-reactive chemicals and combinations of chemicals and process-specific conditions. Take into account the recommendations of this report to OSHA on reactive hazard coverage. Seek congressional authority if necessary to amend the regulation.

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.

Recommendation Status Change Summary

2001-01-H-4

Modify the accident reporting requirements in RMP* Info to define and record reactive incidents. Consider adding the term "reactive incident" to the four existing "release events" in EPA's current 5-year accident reporting requirements (Gas Release, Liquid Spill/Evaporation, Fire, and Explosion). Structure this information collection to allow EPA and its stakeholders to identify and focus resources on industry sectors that experienced the incidents; chemicals and processes involved; and impact on the public, the workforce, and the environment.

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 Association of Fire Fighters (IAFF)

2001-01-H-18

Communicate the findings and recommendations of this report 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.
National Association of Chemical Distributors (NACD)

2001-01-H-16

Expand the existing Responsible Distribution Process to include reactive hazard management as an area of emphasis. At a minimum, ensure that the revisions address storage and handling, including the hazards of inadvertent mixing of incompatible chemicals.

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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2001-01-H-17

Communicate the findings and recommendations of this report 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.
National Institute of Standards and Technology (NIST)

2001-01-H-5

Develop and implement a publicly available database for reactive hazard test information. Structure the system to encourage submission of data by individual companies and academic and government institutions that perform chemical testing.

Status: Closed - Reconsidered/Superseded

Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.
Occupational Safety and Health Administration (OSHA)
2001-01-H-1
(Superseded by 2021-02-I-WV-R13 from the Optima Belle report)

Amend the Process Safety Management Standard (PSM), 29 CFR 1910.119, to achieve more comprehensive control of reactive hazards that could have catastrophic consequences.

Broaden the application to cover reactive hazards resulting from process-specific conditions and combinations of chemicals. Additionally, broaden coverage of hazards from self-reactive chemicals. In expanding PSM coverage, use objective criteria. Consider criteria such as the North American Industry Classification System (NAICS), a reactive hazard classification system (e.g., based on heat of reaction or toxic gas evolution), incident history, or catastrophic potential.

In the compilation of process safety information, require that multiple sources of information be sufficiently consulted to understand and control potential reactive hazards. Useful sources include:

- Literature surveys (e.g., Bretherick's Handbook of Reactive Chemical Hazards, Sax's Dangerous Properties of Industrial Materials).

- Information developed from computerized tools (e.g., ASTM's CHETAH, NOAA's The Chemical Reactivity Worksheet).

- Chemical reactivity test data produced by employers or obtained from other sources (e.g., differential scanning calorimetry, thermogravimetric analysis, accelerating rate calorimetry).

- Relevant incident reports from the plant, the corporation, industry, and government.

- Chemical Abstracts Service.

Augment the process hazard analysis (PHA) element to explicitly require an evaluation of reactive hazards. In revising this element, evaluate the need to consider relevant factors, such as:

- Rate and quantity of heat or gas generated.

- Maximum operating temperature to avoid decomposition.

- Thermal stability of reactants, reaction mixtures, byproducts, waste streams, and products.

- Effect of variables such as charging rates, catalyst addition, and possible contaminants.

- Understanding the consequences of runaway reactions or toxic gas evolution.
Status: Closed - Reconsidered/Superseded

Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.

Recommendation Status Change Summary
2001-01-H-2

Implement a program to define and record information on reactive incidents that OSHA investigates or requires to be investigated under OSHA regulations. Structure the collected information so that it can be used to measure progress in the prevention of reactive incidents that give rise to catastrophic releases.

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.

Recommendation Status Change Summary
Paper, Allied-Industrial, Chemical and Energy Workers International Union (PACE)

2001-01-H-19

Communicate the findings and recommendations of this report 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.
Synthetic Organic Chemical Manufacturers Association (SOCMA)

2001-01-H-12

Expand the Responsible Care Process Safety Code to emphasize the need for managing reactive hazards. Ensure that: · Member companies are required to have programs to manage reactive hazards that address, at a minimum, hazard identification, hazard evaluation, management of change, inherently safer design, and adequate procedures and training. · There is a program to communicate to your membership the availa bility of existing tools, guidance, and initiatives to aid in identifying and evaluating reactive hazards.

Status: Closed - No Longer Applicable

Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).

Recommendation Status Change Summary

2001-01-H-13

Develop and implement a program for reporting reactive incidents that includes the sharing of relevant safety knowledge and lessons learned with your membership, the public, and government to improve safety system performance and prevent future incidents.

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.

Recommendation Status Change Summary

2001-01-H-14

Work with NIST in developing and implementing a publicly available database for reactive hazard test information. Promote submissions of data by your membership.

Status: Closed - Reconsidered/Superseded

Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.

Recommendation Status Change Summary

2001-01-H-15

Communicate the findings and recommendations of this report 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.
Union of Needletrades, Industrial, and Textile Employee (UNITE)

2001-01-H-21

Communicate the findings and recommendations of this report 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.
United Food and Commercial Workers International Union (UFCW)

2001-01-H-22

Communicate the findings and recommendations of this report 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.
United Steelworkers of America (USWA)

2001-01-H-20

Communicate the findings and recommendations of this report 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.