Chemical Safety Board To Issue Two Safety Bulletins

December 15, 2000

(Washington, DC - December 15, 2000): The U.S. Chemical Safety and Hazard Investigation Board (CSB) today announced a plan to issue two special Safety Bulletins arising out of Board accident investigations.

One bulletin will focus on safely assessing and controlling hazards associated with changes in chemical processes, commonly known as "Management of Change." Management of Change is a central feature of the Process Safety Management standard of the U.S. Occupational Safety and Health Administration (OSHA).

Ineffective Management of Change likely contributed to three serious accidents investigated by the Board:

1. a fire at the Puget Sound Refining Company (Equilon) in Anacortes, Washington;

2. a fire and explosion during specialized operations at a petroleum well in Bienville Parish, Louisiana; and

3. a runaway reaction and fire at a Condea Vista chemical plant in Baltimore, Maryland. All three incidents occurred during the fall of 1998, the first year of the Boards operations.

CSB Safety Bulletins are informational publications on significant topics in chemical safety, usually stemming from Board investigations or hazard studies. The intended audience includes plant managers, engineers, and operators; safety professionals; and trade and labor groups.

According to CSB Director of Investigations and Safety Programs Bill Hoyle, "A Safety Bulletin is a new product for the agency, one which gets right to the heart of our mission to prevent chemical accidents. By distilling the messages from multiple events, we hope to draw heightened attention to the common, preventable causes of chemical accidents. In some cases, Safety Bulletins will reach a wider audience than individual accident reports."

A second bulletin will draw attention to the hazards associated with hydroxylamine, a potentially explosive substance used in semiconductor manufacturing and other applications. On February 19, 1999, a hydroxylamine explosion destroyed the Concept Sciences plant in Allentown, Pennsylvania, killing five. The blast left the U.S. without any domestic sources of hydroxylamine. Several firms have recently expressed interest in initiating production.

Commenting on the move, Board Member Andrea Taylor said: "We arrived at this decision after a lengthy review process, including an independent assessment by an outside safety engineering firm. In the first year or so of the Board's existence, more cases were initiated than could readily be completed, given the available resources. Issuing the bulletins will draw these four cases to a meaningful conclusion."

The Board contracted earlier this year with General Physics Corporation, a Maryland engineering firm, to review case files for all five investigations. The consultants evaluated the resources needed to complete each investigation, the obstacles to producing high-quality scientific reports, and the accident prevention value of the finished products. All of the cases studied had been initiated under former Board Chairman Paul L. Hill, Jr., who stepped down on January 12, 2000.

"Until this year," Taylor noted, "the Board functioned with a skeleton investigations staff. We have now refocused our resources in a fairly dramatic way, putting the majority of our budget into investigations and recruiting a number of seasoned accident investigators and safety professionals. Over the next several years, we will build the capacity to conduct three to five major accident investigations per year. Well-trained teams will be dispatched to each accident site, and once deployed we will wrap each case up as expeditiously as possible.

"The Safety Bulletins will be a valuable product from the early cases. We think these bulletins can play a constructive role in preventing future lapses in good practice that can lead to accidents. Effective Management of Change procedures are an important component of good safety programs, as recognized by OSHA and many other organizations. Obviously not everyone is getting this message, however, and that's where the bulletins can help," Taylor said.

Taylor said she expects the CSB to publish the two safety bulletins by the early spring of 2001. An outreach effort to publicize the bulletins will be undertaken, Taylor added. A fifth case, involving a December 1998 explosion at Michigan-based Independence Fireworks, will also be closed. CSB observations on this case will be shared with other agencies and organizations.

The CSB is an independent federal agency whose mission is to ensure the safety of workers and the public by preventing chemical incidents. The CSB is a scientific investigatory organization, not an enforcement or regulatory body. The Board determines the root causes of accidents, issues safety recommendations, and performs special studies on chemical safety issues.

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