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MGPI Processing, Inc. Toxic Chemical Release
FINAL REPORT: MGPI Case Study
Location: Atchison, KS
Incident Occurred On: 10/21/2016
Final Report Released On: 01/03/2018
Incident Type: Release

statistics

Total # of Recommendations
5
Total # of Open Recommendations
5
Total # of Closed Recommendations
0
Total % of Open 100 vs. Closed 0

investigation information

Image
Incident Description
On October 21, 2016, a chemical release occurred at the MGPI Processing plant in Atchison, Kansas. MGPI Processing produces distilled spirits and specialty wheat proteins and starches. The release occurred when a chemical delivery truck, owned and operated by Harcros Chemicals, was inadvertently connected to a tank containing incompatible material. The plume generated by the chemical reaction led to a shelter-in-place order for thousands of residents. At least 120 employees and members of the public sought medical attention.
Investigation Status
The CSB's final investigation was released on 1.3.2018.


 

Recommendations

Atchison County Department of Emergency Management
2017-01-I-KS-5

Coordinate planning and training activities to ensure emergency responders within Atchison County are prepared for future incidents involving hazardous materials. The Atchison County Local Emergency Planning Committee should do the following:

a) Review facility Risk Management Plans as they are submitted or revised and conduct pre-planning at Risk Management Program covered facilities and all other facilities within the county that, based on annual Tier II reporting forms, store large amounts of hazardous chemicals.

b) Conduct a full-scale hazardous materials exercise that involves an offsite chemical release scenario within the next three years. The exercise should include participants from local emergency response organizations, hospitals, schools, and fixed facilities. Identify and resolve coordination or communication issues identified during the exercise.

c) Increase participation in state and regional emergency response training and programs. Work with the Kansas Department of Emergency Management to submit a Hazardous Materials Emergency Preparedness (HMEP) grant proposal to assist in funding additional training and pre-planning activities within the county.

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.
 

Harcros Chemicals
2017-01-I-KS-3

Establish a refresher training program to ensure drivers know the location of various CTMV emergency shut-off devices, when to use them, and the effectiveness of those devices to stop the flow of chemicals during emergencies. The refresher training program should include drills for drivers to simulate the activation of all shut-off devices in defined incident scenarios (e.g., inadvertent mixing, chemical releases, etc.) during unloading operations. Establish a process to evaluate the effectiveness of the refresher training program.

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.
 

2017-01-I-KS-4

Establish a process whereby the respiratory hazards associated with chemical unloading at customer sites are evaluated. The evaluations should, at a minimum, determine whether drivers need emergency escape respirators in the event of an accidental reaction and/or release of chemicals. If the results of the evaluations indicate that respiratory protection is needed, provide the equipment and training for such protection as appropriate. The equipment and training should be provided in accordance with OSHA’s Respiratory Protection Standard (29 C.F.R § 1910.134). The equipment should also be stored in an area that allows for immediate access.

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.
 

MGPI Processing, Inc.
2017-01-I-KS-1

Commission an independent engineering evaluation of the Mod B building and ventilation system and, based on the results of that evaluation, implement design changes and controls to protect occupants from a chemical release. At a minimum, the evaluation should assess the effectiveness of the building ventilation system, indoor and outdoor sources of chemicals, air intake locations, contaminant control methods such as filtration and removal, contaminant monitoring devices, and automation. The engineering evaluation of the ventilation system should consider airborne contaminants during normal operations as well as spills, releases, and chemicals produced from unintended reactions and inadvertent mixing.

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.
 

2017-01-I-KS-2

Conduct an evaluation of the Mod B chemical transfer equipment (e.g., fill lines, transfer valves, transfer piping, tanks and other associated equipment) and install appropriate engineering safeguards to prevent and mitigate an unintended reaction, chemical release, or spill during bulk unloading. Where feasible, install safeguards, such as alarms and interlocks, to prevent personnel from opening the incorrect chemical transfer valves during deliveries. In addition, install mitigation measures to automatically shut down the transfer of chemicals into the facility based on process deviations or abnormal conditions (e.g., pressure, temperature, flow or level indications; gas detection).

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.
 

 
 

Related Video

Mixed Connection, Toxic Result
1/3/2018 2:52:00 PM
CSB safety video detailing key lessons from investigation into 2016 chemical release at MGPI processing facility in Atchison, Kansas. read more

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Related News

MGPI_Video
Chemical Safety Board Releases New Safety Video, “Mixed Connection, Toxic Result,” Detailing Key Lessons from CSB Investigation into 2016 Chemical Release at MGPI Processing Facility in Atchison, Kansas
1/3/2018
Today the U.S. Chemical Safety Board (CSB) released a safety video about the October 21, 2016, toxic chemical release at the MGPI Processing facility in Atchison, Kansas, which resulted in over 140 reported injuries, and approximately 11,000 citizens forced to evacuate or shelter-in-place.
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Chemical Safety Board Deploying to Site of Chemical Release in Atchison, Kansas
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An investigative team from the U.S. Chemical Safety Board (CSB) has deployed to the scene of a chemical release that led to a shelter-in-place order for thousands of residents and at least 85 members of the public seeking medical attention in Atchison, Kansas.
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