Accident: Formosa Plastics Vinyl Chloride Explosion
Location: Location: Illiopolis, IL
Accident Occured On: 04/23/2004 | Final Report Released On: 03/06/2007
Accident Type: Chemical Manufacturing - Fire and Explosion
Investigation Status: The CSB's final report on this investigation was issued at a news conference in Springfield, Illinois, on March 6, 2007.
On April 23, 2004, five workers were fatally injured and two others were seriously injured when an explosion occurred in a polyvinyl chloride (PVC) production unit at Formosa Plastics in Illiopolis, Illinois, east of Springfield. The explosion followed a release of highly flammable vinyl chloride, which ignited. The explosion forced a community evacuation and lighted fires that burned for several days at the plant.
Develop guidelines for auditing chemical process safety at newly acquired facilities. Emphasize the identification of major hazards, a review of the acquired facility's previous incident history and hazard analyses, the adequacy of management safety systems, and harmonization of the acquired facility's standards and practices with those of the acquiring company.
Ensure that the EPA's Enforcement Alert concerning PVC facilities includes the causes and lessons learned from this investigation. Emphasize the importance of analyzing human factors and the need to implement adequate safeguards to minimize the likelihood and consequences of human error that could result in catastrophic incidents.
Review the design and operation of FPC USA manufacturing facilities and implement policies and procedures to ensure that: -Site-wide policies are implemented to address necessary steps and approval levels required to bypass safety interlocks and other critical safety systems. -Chemical processes are designed to minimize the likelihood and consequences of human error that could result in a catastrophic release. -Safety impacts of staffing changes are evaluated. -Risks identified during hazard analyses and near-miss and incident investigations are characterized, prioritized, and that corrective actions are taken promptly. -High-risk hazards are evaluated using layers of protection analysis (LOPA) techniques and that appropriate safeguards are installed to reduce the likelihood of a catastrophic release of material. -All credible consequences are considered in near-miss investigations. -Emergency procedures clearly characterize emergency scenarios, address responsibilities and duties of responders, describe evacuation procedures, and ensure adequate training. Ensure that periodic drills are conducted. -The siting of offices for administrative and support personnel is evaluated to ensure the safety of personnel should an explosion or catastrophic release occur.
Conduct periodic audits of each FPC USA PVC manufacturing facility for implementation of the items in Recommendation R1. Develop written findings and recommendations. Track and promptly implement corrective actions arising from the audit. Share audit findings with the workforce at the facilities and the FPC USA Board of Directors.
Design and implement a program requiring audits of newly acquired facilities that address the issues highlighted in this report. Document, track, and promptly address recommended actions arising from the audits.
Communicate the contents of this report to all employees of FPC USA PVC facilities.
Revise NFPA 15, Standard for Water Spray Fixed Systems for Fire Protection, to provide additional design guidance for deluge systems designed to prevent or mitigate fires and explosions. Include information concerning the limitations of using deluge systems for this purpose.
Issue a safety alert to your membership highlighting the need to identify design features that may render processes vulnerable to human error and to implement sufficient layers of protection to minimize the likelihood human error causing catastrophic releases of hazardous material. Include lessons from PVC industry industrial accidents (including those described in this report and others highlighted in The Encyclopedia of PVC and elsewhere) that involved human error.