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MFG Chemical Inc. Toxic Gas Release
FINAL REPORT: Final Investigation Report
Location: Dalton, GA
Accident Occurred On: 04/12/2004
Final Report Released On: 04/11/2006
Accident Type: Reactive Incident
Company Name: MFG Chemical

statistics

Total # of Recommendations
16
Total # of Open Recommendations
6
Total # of Closed Recommendations
10
Total % of Open 38 vs. Closed 62

investigation information

Image
Accident Description
On the evening of April 12, 2004, a chemical reactor overheated at the MFG Chemical manufacturing plant, releasing toxic allyl alcohol vapor. The resulting cloud sent 154 people to a local hospital and forced the evacuation of nearby residents. Vegetation and aquatic life near the plant were killed
Investigation Status
The CSB issued its final report on the accident at a news conference in Dalton, Georgia, on April 11, 2006.


 

Recommendations

City of Dalton, GA
2004-9-I-GA-8

Establish, equip, and train a hazardous materials response team. Work with the Whitfield County Emergency Management Agency to update the Emergency Operations Plan, clearly defining the roles and responsibilities of the response team.

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.
 

2004-9-I-GA-9

Revise fire department and police department procedures and training to clearly define facility and evacuation zone access control responsibilities when hazardous chemicals are involved or suspected in an emergency.

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.
 

Governor of the State of Georgia
2004-9-I-GA-12

Clearly designate and define the roles of the agencies responsible for ensuring compliance with all sections of the SARA Title III (Emergency Planning and Community Right-to-Know Act) including review of Local Emergency Response Plans and accompanying attachments, such as 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.
 

2004-9-I-GA-13

Designate a responsible agency and develop a system that will encourage and assist local authorities to obtain and use Risk Management Plans for those facilities that are required to develop this information to aid in the development of the site-specific emergency response plans.

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.
 

GP Chemical
2004-9-I-GA-5

Implement written procedures for tolling agreements using resources such as the CCPS book Process Safety in Outsourced Manufacturing Operations. Ensure that tolling agreements provide for: - Direct GPC involvement in new process development, including the detailed process hazard analysis and emergency planning, - Active participation in the first production run, 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.
 

Lyondell Chemical Company
2004-9-I-GA-6

Revise the applicable sections of the Allyl Alcohol Product Safety Bulletin, appendices, and web page, to emphasize the applicability of the EPA Risk Management Program regulation and OSHA Process Safety Management standard. Clearly identify the threshold quantity of allyl alcohol applicable to each regulation.

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.
 

2004-9-I-GA-7

Revise the customer site safety assessment process, clearly addressing both PSM and Risk Management Program applicability before shipping allyl alcohol to a new customer. Include a requirement to review the customer's program documents, including the (draft) RMP, and internal and external safety audit or assessment records. Require that appropriate Lyondell health, safety, and environmental personnel review the written customer safety assessment before approving the shipment of allyl alcohol.

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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MFG Chemical, Inc.
2004-9-I-GA-1

Develop written procedures that require a comprehensive hazard analysis of new processes, especially those involving reactive chemistry. Ensure the hazard evaluations address critical process controls, overpressure protection, alarms, and other equipment such as vent collection/containment devices to minimize the possibility and consequences of a toxic or flammable release.

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.
 

2004-9-I-GA-2

Provide EPA Risk Management Program regulation and OSHA Process Safety Management program training to affected personnel to ensure that the facility understands the scope and application of each regulation, and implements all requirements prior to receiving and using covered 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.
 

2004-9-I-GA-3

Create a comprehensive emergency response plan and provide equipment and training that is appropriate to the duties assigned to employees in the event of 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.
 

2004-9-I-GA-4

Implement written tolling procedures using resources such as the CCPS book Process Safety in Outsourced Manufacturing Operations. Ensure effective communication between the toller (MFG) and client throughout the process development, completion of a detailed process hazard analysis, creation of emergency procedures, and dissemination to all parties who would be involved in emergency response 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.
 

Synthetic Organic Chemical Manufacturers Association (SOCMA)
2004-9-I-GA-14

Revise the SOCMA website to simplify locating the link to the CSB website www.csb.gov, such as adding a link in "More Resources" on the SOCMA home page. Ensure that the CSB website and the report Hazard Investigation: Improving Reactive Hazard Management, Report No. 2001-01-H can be easily located using the SOCMA website search engine.

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.
 

2004-9-I-GA-15

Develop a ChemStewards Management System Guidance Module that addresses tolling, including the best practices described in the CCPS book Process Safety in Outsourced Manufacturing Operations, and emergency planning involving new products.

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.
 

2004-9-I-GA-16

Develop a formal training module for the ChemStewards Management System Tolling Guidance Module and provide appropriate training to SOCMA member companies. Include in the training program a discussion on the tolling issues identified in the MFG report.

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.
 

Whitfield County, GA
2004-9-I-GA-10

Establish a Local Emergency Planning Committee to assist the Whitfield County Emergency Management Agency to: - Develop site-specific agency emergency response plans and standard operating procedures, - Develop training programs and conduct drills for emergencies at fixed facilities, - Educate the community regarding proper protective actions, such as shelter-in-place and evacuation procedures.

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.
 

2004-9-I-GA-11

Work with the City of Dalton, representatives from local facilities, and relevant community representatives to review and revise the Emergency Operations Plan to: -Update the list of facilities handling hazardous chemicals, including those covered by the EPA Risk Management Program regulation, -Develop standard operating procedures addressing communication of emergency information, evacuation, and shelter-in-place, -Conduct community training and drills that involve operation of the emergency notification system and potential actions in the event of an emergency, -Implement an automated community emergency notification system.

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.
 

 
 

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