Accident: LyondellBasell La Porte Fatal Chemical Release
Location: Location: La Porte, TX
Accident Occurred On: 07/27/2021 | Final Report Released On: 05/25/2023
Accident Type: Release
Investigation Status: The CSB's final report was released on May 25, 2023.
On July 27, 2021, a release of 100,000 pounds of acetic acid during a maintenance event at the LyondellBasell facility in La Porte, TX, resulted in fatal injuries to two contract employees and 30 other personnel being transported to medical facilities for evaluation and/or treatment.
Revise API Standard 599 Metal Plug Valves—Flanged, Threaded, and Welding Ends as follows:
a. State that there have been multiple incidents in which workers have inadvertently removed pressure-retaining components from plug valves while workers were attempting to remove the valve’s actuator or gearbox.
b. Recommend that facilities using plug valves establish written procedures detailing the correct way to remove the plug valve actuator or gearbox for each specific plug valve design at the facility.
c. For existing plug valves, require facilities to clearly mark all pressure-retaining components (for example, with paint, accompanying warning signs, etc.). Work with ASME and VMA to ensure a consistent methodology is specified across both API and ASME standards.
d. Require that new plug valves be designed, consistent with Prevention through Design principles, to prevent the inadvertent removal of pressure-retaining components when removing the actuator or gearbox. Evaluate past plug valve incidents, and the associated plug valve designs involved in those incidents, when formulating a new plug valve design. Work with ASME and VMA to ensure a consistent methodology is specified across both API and ASME standards.
Revise American Society of Mechanical Engineers (ASME) Standard B16.34 Valves—Flanged, Threaded, and Welding End as follows:
a. For existing plug valves, require facilities to clearly mark all pressure-retaining components (for example, with paint, accompanying warning signs, etc.). Work with American Petroleum Institute (API) and the Valve Manufacturers Association of America (VMA) to ensure a consistent methodology is specified across both API and ASME standards.
b. Require that new plug valves be designed, consistent with Prevention through Design principles, to prevent the inadvertent removal of pressure-retaining components when removing the actuator or gearbox. Evaluate past plug valve incidents, and the associated plug valve designs involved in those incidents, when formulating a new plug valve design. Work with API and VMA to ensure a consistent methodology is specified across both API and ASME standards.
Update LyondellBasell policy documents to require that procedures are developed for properly removing actuating equipment from plug valves. Require that the procedures clearly identify which non-pressure-retaining components are safe to remove and pressure-retaining components that shall not be removed, as well as ensure LyondellBasell personnel are trained on these procedures. Ensure that hazardous energy is controlled when performing these procedures, as required by 29 C.F.R. 1910.147. Require in the policy document that risk assessments for process safety are conducted before the actuating equipment removal work is authorized. Ensure that sufficient procedures and safeguards are in place to prevent worker exposure to process fluid.
Update LyondellBasell policy documents to require that LyondellBasell competent employee(s), as defined by 29 C.F.R. 1926.32(f), verify that contractors are competent, adequately trained, and qualified to perform the required work. To make this determination and to ensure work on process equipment is conducted in a safe manner, LyondellBasell competent employees may be required to oversee the work conducted by contractors on the process equipment. In the updated policy documents, include requirements to ensure that contract employees are informed of relevant process hazards and relevant details about the process equipment and are provided with equipment-specific procedures necessary to safely conduct their work.
Update Turn2 policy documents to require that Turn2 employees are provided with written, detailed procedures for safely conducting work on process equipment and are trained on the procedures before the work is authorized to be performed.
Work with ASME and API and develop a white paper to the Valve Manufacturers Association of America addressing the issue of plug valve design with a focus on the following:
a. Recommend as an industry good practice that facilities using plug valves establish written procedures detailing the correct way to remove the plug valve actuator or gearbox for each specific plug valve design.
b. For existing plug valves, recommend as an industry good practice for facilities to clearly mark all pressure-retaining components (for example, with paint, accompanying warning signs, etc.). Work with ASME and API to ensure a consistent methodology is specified to the industry.
c. Recommend new plug valves be designed, consistent with Prevention through Design principles, to prevent the inadvertent removal of pressure-retaining components when removing the actuator or gearbox. Evaluate past plug valve incidents, and the associated plug valve designs involved in those incidents, when formulating a new plug valve design recommendation. Work with ASME and API to ensure a consistent design is recommended to the industry.