Accident: Wacker Polysilicon Chemical Release
Location: Location: Charleston, TN
Accident Occurred On: 11/13/2020 | Final Report Released On: 06/15/2023
Accident Type: Chemical Manufacturing - Fire and Explosion
Investigation Status: The CSB's investigation was released on June 15, 2023.
On Friday November 13, 2020, at approximately 10:04 a.m. EST, seven workers were exposed to a release of hydrochloric acid during a maintenance activity at the Wacker Polysilicon North America facility in Charleston, Tennessee. One of the workers was fatally injured, and three other workers sustained serious injuries. .
Develop and publish a safety product on Safe Work Practices, including detailed and practical guidelines for evaluating simultaneous operations (SIMOPs). The guidelines, at a minimum, should:
a. Address the content found in CCPS’s website resource for implementing Safe Work Practices; and
b. Discuss guidelines for a SIMOPs life cycle, including:
1. methods to identify SIMOPs;
2. methods to conduct a SIMOPs hazard assessment;
3. safeguards and controls pertaining to SIMOPs;
4. preparation for SIMOPs; and
5. SIMOPs execution.
In developing this safety product, consider the findings presented in the CSB report titled Fire During Hot Work at Evergreen Packaging Paper Mill and this CSB report, titled Equipment Fracture and Fatal Hydrogen Chloride Release at Wacker Polysilicon North America.
Amend the International Building Code (IBC) to address conditions that may require multiple means of egress from elevated equipment platforms used for accessing equipment containing materials that pose physical and health hazards, such as the one used at Wacker in this incident. Specify the minimum number of egress points to increase the likelihood of worker escape in the event of a hazardous material release.
Revise NFPA 101 Life Safety Code, NFPA 55 Compressed Gases and Cryogenic Fluids Code, or NFPA 400 Hazardous Materials Code to address conditions which may require multiple means of egress from elevated industrial structures containing hazardous materials posing physical and health hazards, regardless of their combustibility, burn rate, or likelihood of explosion. The guidance should address egress situations for workers on unwalled, elevated structures in the presence of materials posing physical and health hazards. Specify the minimum number of egress points to increase the likelihood of worker escape in the event of a hazardous material release.
Promulgate a standard or modify existing standards to require employers to ensure the coordination of simultaneous operations (SIMOPs) involving multiple work groups, including contractors. Ensure that the requirements of this standard or standards apply to both general industry and construction activities and are not limited to activities occurring within confined spaces. Include in the standard requirements for Employers to ensure that the following activities occur:
a. Identification of potential SIMOPs;
b. Identification of potential hazardous interactions;
c. Evaluation and implementation of necessary safeguards to allow for safe SIMOPs;
d. Coordination, including shared communication methods, between the SIMOPs; and
e. Inclusion of emergency response personnel or services in the planning and coordination of the SIMOPs.
Develop a safety product providing guidance on the coordination of simultaneous operations (SIMOPs) involving multiple work groups, including contractors, that is not limited to confined space or construction. Provide guidance on the following activities:
Develop detailed maintenance procedures for torquing activities which:
a. Clearly communicate differing equipment torque specifications, such as those for bolts installed at PTFE-to-PTFE and PTFE-to-graphite connections through visual means such as annotated photographs, signage, physical differentiation, and other methods, as appropriate;
b. Include procedural requirements for all torquing activities conducted on equipment containing hazardous material to perform an engineering and risk analysis and implement safeguards as a result of the risk analysis, per American Society of Mechanical Engineers (ASME) PCC-1-2019 Guidelines for Pressure Boundary Bolted Flange Joint Assembly and ANSI/ASSP Z244.1-2016 The Control of Hazardous Energy Lockout, Tagout and Alternative Methods;
c. Ensure that terms such as “hot torque” are clearly defined and that employees and contractors are trained on these terms; and
d. Ensure that procedures and training conform to the mechanical integrity requirements of the Process Safety Management (PSM) standard found in 29 CFR 1910.119(j) and the Risk Management Program (RMP) rule found in 40 CFR 68.73.
Develop policy requirements to ensure torquing activities performed on equipment containing hazardous energy are performed safely, such as through de-inventorying equipment or restriction of nonessential personnel and ensuring that essential workers wear proper PPE. Document these requirements in procedures, such as Lock, Tag and Try; First Line Break – Return to Service; or other procedures as applicable. Ensure employees and contractors are trained on these procedures in accordance with the Process Safety Management (PSM) standard requirements found in 29 CFR 1910.119(f)(4) and 29 CFR 1910.119(g) and the Risk Management Program (RMP) rule found in 40 CFR 68.69(d) and 40 CFR 68.71.
Develop and implement a formalized Simultaneous Operations (SIMOPs) program addressing planned and/or permitted co-located work tasks including:
Ensure relevant staff are trained on execution of the SIMOPs program.
Install additional means of egress for the T230 desorption tower platforms and other multi-floor equipment structures on-site. After completing these installations, ensure workers are made aware of exit locations from the structure platforms through training, drills, or other techniques as appropriate.