Washington, D.C. December 21, 2022 – Today the U.S. Chemical Safety and Hazard Investigation Board (CSB) released its final investigation report and incident animation for the 2018 fire that injured 23 workers at the Kuraray America, Inc. EVAL plant in Pasadena, Texas.
The CSB’s report explains the events leading up to the incident, including how the incident occurred during the startup of a chemical reactor system following a scheduled maintenance shutdown – also referred to as a turnaround. High pressure conditions developed inside the reactor and activated the reactor’s emergency pressure relief system, discharging flammable ethylene vapor through piping into an area where a number of contractors were working. Over 2,300 pounds of ethylene were released in approximately three minutes. The work being done by the nearby contractors included welding, which most likely ignited the flammable vapor.
Among the 23 workers injured during the incident, two were life-flighted from the facility, one of whom remained in critical condition for several days because of burn injuries. As many as 19 others were transported to the hospital by emergency responders for various injuries.
The CSB’s animation depicts the incident and the events leading up to it.
The CSB determined that the cause of the incident was Kuraray’s emergency pressure relief system design that discharged flammable ethylene vapor from the reactor through horizontally aimed piping into the air in an area near workers. If Kuraray’s emergency pressure relief system had been designed to discharge the vapor to a safe location, the flammable ethylene gas should not have harmed any workers.
CSB Chairperson Steve Owens said, “Kuraray could have prevented the injuries to these workers by ensuring that the flammable ethylene gas discharged from its system was directed to a safe location. Kuraray also should have evacuated these workers from the area when the reactor’s high-pressure alarm sounded, since it was signaling a serious problem with the reactor.”
The CSB’s investigation report details a chain of process safety management failures that led to the build-up of excessive pressure inside the reactor. The emergency pressure relief system discharge design is just one of the 17 safety issues identified by the CSB in the report. The additional 16 safety issues are:
- Presence of Nonessential Workers During Startup and Upset Conditions
- Hazardous Location
- Recognized and Generally Accepted Good Engineering Practices
- Process Hazards Analysis Safeguards
- Process Hazard Analysis Recommendations
- Warning Signs
- Equipment Design
- Operating Procedures
- Operator Training
- Abnormal Operating Conditions
- Safety Interlock Disabling
- Alarm Management
- Process Alarm Response
- Safe Operating Limits
- Environmental Permit Limits
- Safety Management System Self-Assessment Audits
The CSB is making several safety recommendations to the company, including a call for Kuraray America to develop and implement a standard to ensure that these safety systems discharge to a safe location.
CSB Board Member Sylvia Johnson said, “The CSB’s final report and safety recommendations aim to take the valuable lessons learned from our investigations and implement necessary changes to improve workplace safety throughout this facility and across the industry.”
The CSB is an independent federal agency charged with investigating incidents and hazards that result, or may result, in the catastrophic release of extremely hazardous substances. The agency’s core mission activities include conducting incident investigations; formulating preventive or mitigative recommendations based on investigation findings and advocating for their implementation; issuing reports containing the findings, conclusions, and recommendations arising from incident investigations; and conducting studies on chemical hazards.
The agency's board members are appointed by the president subject to Senate confirmation. The Board does not issue citations or fines but makes safety recommendations to companies, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA.
Please visit our website, www.csb.gov. For more information, contact Communications Manager Hillary Cohen at Hillary.Cohen@csb.gov