Accident: Kuraray Pasadena Release and Fire
Location: Location: Pasadena, TX
Accident Occured On: 05/19/2018 | Final Report Released On: 12/21/2022
Accident Type: Hot Work - Explosion and Fire
Investigation Status: Released December 21, 2022.
An explosion at Kuraray America on May 19, 2018, injured 21 workers at the EVAL facility in Pasadena, Texas. The facility manufactures ethylene vinyl-alcohol copolymers, sold as EVAL. Kuraray America is a Tokyo-based specialty chemical manufacturer.
Develop and implement an emergency pressure-relief system design standard to ensure that each of these safety systems will discharge to a safe location. Include a requirement to periodically evaluate the site’s emergency pressure-relief systems and make appropriate modifications to ensure that each of these systems discharge to a safe location such that material that could discharge from these safety systems will not harm people.
Implement a site-wide system to evacuate nonessential personnel during upset conditions and exclude nonessential workers from being near equipment during transient operating modes, such as startup.
Develop and implement a system requiring a periodic evaluation of the adequacy and effectiveness of any safeguard used to mitigate or otherwise lower the risk of process safety hazards. This safeguard protection analysis should be based on the requirements of Cal/OSHA’s Process Safety Management for Petroleum Refineries regulations or an appropriate equivalent methodology.
Develop and implement a policy detailing how to effectively address recommendations generated from company process safety management systems, including audits, incident investigations, management of change, and process hazard analysis that is consistent with existing OSHA guidance. Include a periodic training requirement for managers and other employees involved with evaluating and managing proposed recommendations to help ensure proposed safety improvements are effectively evaluated and appropriately implemented.
Review the Center for Chemical Process Safety guidance on recognizing catastrophic incident warning signs and then develop and implement a program for the EVAL Plant that incorporates warning signs into its safety management system.
Clarify the lower equipment design pressure of the EVAL Reactor 2 within the operator training systems, written procedures, and in the control system interface.
Develop and implement a program to ensure that the company’s EVAL Plant nightly operating instructions do not conflict with its written operating procedures. Ensure that employees use the management of change system when changes to the written operating procedures are desired. Additionally, develop and implement a written procedure and conduct training on how to perform the EVAL Reactor methanol flush operation.
Strengthen the EVAL Plant’s operator training program by 1) including the known activities, such as bringing ethylene back into the unit, upset conditions like the reactor’s High-High-Pressure alarm, and providing guidance or otherwise clarifying when nonessential personnel should be excluded from being in the unit; 2) including alarm setpoints and actions that operators should take in response to specific process alarms, such as high pressure inside an EVAL Reactor; 3) including directions on when operators should use the emergency open valve; and 4) including safe operating limits, the consequence of deviating beyond the safe operating limits, and the predetermined steps operators need to take to return the process to a safe condition.
Complete the alarm management efforts at the EVAL Plant and implement a continual program to meet or be lower than the alarm rate performance targets established in ISA 18.2.
Improve the EVAL Plant’s safety management system by 1) controlling when chilled liquid is circulated through the heat exchanger during startup; 2) enhancing recognition of liquid ethylene accumulation and response to low-temperature conditions inside an EVAL Reactor through alarms, written procedures, and operator training; 3) implementing a system to manage abnormal operating conditions effectively by, at a minimum, including appropriate technical representation, performing a hazard analysis of temporary or troubleshooting operations, and providing management oversight of any abnormal condition; 4) updating the written startup procedures to include guidance on the appropriate operator actions to take in response to process alarms; 5) using control system guidance to aid operator response to abnormal or upset conditions to keep the process within the safe operating limits; and 6) removing the physical and procedural controls used at the EVAL Plant to restrict board operators from accessing or using the emergency open valve, and updating the written procedures and operator training to provide guidance on when to open the emergency open valve.
Modify the EVAL Plant’s safe operating limits program to prevent operating under conditions that rely upon equipment design safety factors, such as the American Society of Mechanical Engineers (ASME) code material safety factors.
Acquire the services of an independent third party to perform a comprehensive assessment of its EVAL Plant’s process safety management systems. In addition to meeting the requirements outlined in Appendix B of this report, this comprehensive assessment should evaluate whether existing policies meet minimum federal process safety regulatory requirements and apply the Center for Chemical Process Safety model to verify both the suitability of these systems and their effective, consistent implementation.