Accident: Bayer CropScience Pesticide Waste Tank Explosion
Location: Location: Institute, WV
Accident Occurred On: 08/28/2008 | Final Report Released On: 01/20/2011
Accident Type: Chemical Manufacturing - Fire and Explosion
Investigation Status: The CSB's final investigation report was reased at a public meeting in Institute, WV on 1.20.2011
Two workers were fatally injured when a waste tank containing the pesticide methomyl violently exploded, damaging a process unit at the Bayer CropScience chemical plant in Institute, West Virginia.
Review and revise, as necessary, all Bayer production unit standard operating procedures to ensure they address all operating modes (startup, normal operation, temporary operations, emergency shutdown, emergency operations, normal shutdown, and startup following a turnaround or emergency shutdown), are accurate, and approved.
Ensure that all facility fire brigade members are trained in the National Incident Management System, consistent with municipal and state emergency response agencies.
Evaluate the fenceline air monitor program against federal, state, and local regulations, and Bayer corporate policies, and upgrade and install air monitoring devices as necessary to ensure effective monitoring of potential releases of high-hazard chemicals at the perimeter of the facility.
Commission an independent human factors and ergonomics study of all Institute site PSM/RMP covered process control rooms to evaluate the human-control system interface, operator fatigue, and control system familiarity and training. Develop and implement a plan to resolve all recommendations identified in the study that includes assigned responsibilities, required corrective actions, and completion dates.
Revise the corporate PHA policies and procedures to require:
a. Validation of all PHA assumptions to ensure that risk analysis of each PHA scenario specifically examines the risk(s) of intentional bypassing or other nullifications of safeguards,
b. Addressing all phases of operation and special topics including those cited in chapter 9 of "Guidelines for Hazard Evaluation Procedures" (CCPS, 2008), and
c. Training all PHA facilitators on the revised policies and procedures prior to assigning the facilitator to a PHA team.
Ensure all PHAs are updated to conform to the revised procedures.
In light of the findings of this report and the serious potential hazards to workers and the public from chemicals used and stored at the Bayer Institute site (such as phosgene, MIC, and methomyl), conduct a comprehensive Risk Management Program (RMP) inspection of the complex. Coordinate with the Occupational Safety and Health Administration, as appropriate.
Establish a Hazardous Chemical Release Prevention Program to enhance the prevention of accidental releases of highly hazardous chemicals, and optimize responses in the event of their occurrence. In establishing the program, study and evaluate the possible applicability of the experience of similar programs in the country, such as those summarized in Section 5.3 of this report. As a minimum:
a. Ensure that the new program:
1. Implements an effective system of independent oversight and other services to enhance the prevention of accidental releases of highly hazardous chemicals
2. Facilitates the collaboration of multiple stakeholders in achieving common goals of chemical safety; and,
3. Increases the confidence of the community, the workforce, and the local authorities in the ability of the facility owners to prevent and respond to accidental releases of highly hazardous chemicals.
b. Define the characteristics of chemical facilities that would be covered by the new Program, such as the hazards and potential risks of their chemicals and processes, their quantities, and similar relevant factors;
c. Ensure that covered facilities develop, implement, and submit for review and approval:
1. Applicable hazard and process information and evaluations.
2. Written safety plans with appropriate descriptions of hazard controls, safety culture and human factors programs with employee participation, and consideration of the adoption of inherently safer systems to reduce risks
3. Emergency response plans; and,
4. Performance indicators addressing the prevention of incidents and chemical incidents.
d. Ensure that the program has the right to evaluate the documents submitted by the covered facilities, and to require modifications, as necessary
e. Ensure that the program has right-of-entry to covered facilities, and access to requisite information to conduct periodic audits of safety systems and investigations of chemical releases;
f. Establish a system of fees assessed on covered facilities sufficient to cover the oversight and related services to be provided to the facilities including necessary technical and administrative personnel; and,
g. Consistent with applicable law, ensure that the program provides reasonable public participation with the program staff in review of facility programs and access to:
1. The materials submitted by covered facilities (e.g., hazard evaluations, safety plans, emergency response plans);
2. The reviews conducted by program staff and the modifications triggered by those reviews;
3. Records of audits and incident investigations conducted by the program;
4. Performance indicator reports and data submitted by the facilities, and;
5. Other relevant information concerning the hazards and the control methods overseen by the program.
h. Ensure that the program will require a periodic review of the designated agency activities and issue a periodic public report of its activities and recommended action items
Work with the Kanawha and Putnam counties Emergency Response Directors to prepare and issue a revision to the Kanawha Putnam County Emergency Response Plan and Annexes to address facility emergency response and Incident Command when such functions are provided by the facility owner.
In light of the findings of this report and the serious potential hazards to workers and the public from chemicals used and stored at the Bayer Institute site (such as phosgene, MIC, and methomyl), conduct a comprehensive Process Safety Management (PSM) inspection of the complex. Coordinate with the Environmental Protection Agency, as appropriate.
Revise the Chemical National Emphasis Program and the targeting criteria to:
a. Expand the coverage to all OSHA regions,
b. Include in the targeting criteria from which potential inspections are selected all establishments that have submitted certifications of completions of actions in response to previous PSM citations;
c. Require NEP inspections to examine the status of compliance of all previously cited PSM program items for which the company has submitted certifications of completion to OSHA.
Work with the Director of the Kanawha-Charleston Health Department to ensure the successful planning, fee collection, and implementation of the Hazardous Chemical Release Prevention Program as described in Recommendation 2008-08-WV-R6, above, including the provision of services to all eligible facilities in the State.
Revise the Fire Department Evaluation Administrative Section Matrix addressing the periodic inspection of local fire departments to include a requirement for inspectors to examine and identify the status of National Incident Management System fire department personnel training.