Health and Safety Investigation in Vinyl Choride Monomer Explosion - Case Study Example

Case Study: Health and Safety Investigation Name: Lecturer: Course: Date: Table of Contents Table of Contents 2 Introduction 3 Health and Safety Concerns 4 Consequences of the accidents 7 Relevant Legislation with respect to the case study 8 Evaluation of the Health and Safety Concerns 11 Conclusion 13 References 14 Introduction Fire safety consists of precautions to ensure prevention of reduction of the possibility of fire outbreak that may cause injuries, deaths and property loss as well as alert those occupying the building that there is a presence of uncontrolled fire in case of an incident, allow those occupying the building to evacuate the affected areas and survive and to reduce damage to property (Ennals 2002). This report examines a case study of an incident where manufacturing facilities experience problems with safeguards that are designed to thwart accidental discharge of flammable contents, which are responsible for fire explosions. In the case study, Formosa Plastics Corporation located in Illiopolis, Illinois, which manufactures polyvinyl chloride suffered from a fire explosion on April 23, 2004 resulting to five deaths and three severe injuries (U.S. Chemical Safety and Hazard Investigation Board 2007). The fire explosion destroyed an estimated 50 to 75 percent of the manufacturing plant and the warehouse after PVC resins that had been stored in the warehouse were ignited. The fuel for the explosion was identified as vinyl chloride monomer (VCM) used as a raw material in the manufacture of PVC. Investigations by the United States Chemical Safety and Hazard Investigation Board (CSB) found that the explosion happened after an operator had drained a fully pressurised and heated PVC reactor. It was also believed that an operator who was cleaning an adjacent reactor may have opened the bottom valve on, hence releasing highly flammable content that was responsible for the fire explosions (Long et al. 2007). Health and Safety Concerns A significant health and safety issue in manufacturing PCV is the exposure of plant operators to VCM, which is highly flammable. The main cause of the incident can be outlined as human error. The explosion was caused when an operator at Formosa-IL made an error by dumping contents of an operating PVC reactor when he opened the wrong valve (Long et al. 2007). At the company, the PVC reactors were set in groups of four. Control panel was installed for each two reactors. The two reactors responsible for the explosion (D310 and D306) were placed in the same position in the groups of four reactors (Fig 1). Figure 1: Layout of reactor building (U.S. Chemical Safety and Hazard Investigation Board 2007) The drain valve control panels and the reactor bottom were positioned at the lower level. Each reactor was given a number. The control panels were also given numbers with indicator bulbs that showed the drain and the bottom positions of the valves. Such layout of equipment is prevalent in chemical industries and can create a likelihood of human error (Long et al. 2007). Human error was therefore the main cause of the explosion, injuries, fatalities and destruction of property. In any case, studies have showed that human error is both unpredictable and inevitable. In which case, it is only inevitable when individuals are placed in positions that stress their human weaknesses and which do not support their strengths (Long et al. 2007). Based on this premise, it can be analysed that several factors contributed to human error as the company failed to evaluate and implement factors that could prevent high-risk situations and make error less likely. Several root causes were responsible for the fire explosion at Formosa Plastics Corporation. First, Borden Chemical, which had initially owned the plant, had failed to address the possibility of human error. For instance, it had failed to implement the recommendations of the 1992 process hazard analysis (PHA) that suggested that the reactor bottom valve be changed to reduce likely misuse. In 1999, Borden had identified serious consequences for opening the reactor bottom valve. However, it accepted the interlock and training as the most suitable safeguard. Formosa Plastics Corporation, which had bought the plant from Borden Chemical, also failed to address the likelihood for human error. For instance, after an incident in 2003 at Baton Rouge plant of the FPC, Formosa failed to acknowledge that a similar incident could happen at its new facility in Illiopolis, Illinois (Long et al. 2007). Additionally, the management at Formosa failed to implement counteractive measures that were established in the investigation of similar explosion at Formosa-IL in February 2004. Formosa Plastics Corporation also depended on written guidelines to control hazard with likely catastrophic consequences. The company also lacked written guidelines for matching risks with safeguards. It also lacked comprehensive written standards for managing interlocks at its PVC plant. With regard to emergency preparedness, the company’s employees were also not prepared for large VCM release. Further, worker actions at the time of the fire explosion showed that they were poorly prepared for major release of VCM. The facility emergency response procedures had requirements that were conflicting. Additionally, workers who had been assigned with critical response duties did not receive necessary training. Further, workers had not practiced a response to a large VCM release for over a period of ten years (Long et al. 2007). In all, two major health and safety concerns are identified from the case study: Containment – the company had to address whether flammable materials are stored in suitable containers and accessed securely to avoid any spillage, or to contain any spillage. Separation – the company had to address whether flammable materials are stored safely and away from other industrial processes or general storehouses or warehouses. Consequences of the accidents The fire explosion at Formosa Plastic Corporation resulted to huge plumes of acrid smoke that was sent into the nearly community. As a consequence, more than 150 residents in the nearby community were evacuated by the emergency responders. The plant suffered extensive damage. The fire explosion destroyed some 75 percent of the facility. For instance, the reactor’s building roof was blown off. Additionally, the insulation of the piping and asbestos paneling was torn across the site of the plant. Offices used by shift employees were also heavily damaged by the explosion (Long et al. 2007). Concerning environmental impact, the surrounding air and runoff water was tested for hazardous substances. Findings from the on-site samples revealed that there was a need to continual corrective activities and monitoring to make sure that the local environment and community were free from danger from the site. However, results from the off-site sampling did not indicate concentration of hazardous substances that could be a matter of concern to the environment and public health. Nevertheless, some of the soil sample from the off-site indicated levels of dioxin that were above the suggested background level of 1 part per trillion. However, none of the samples were above the action level of 1 part per trillion (EPA 2004). The 3,000 gallon recovery tanks for VCM were knocked over buy the explosion that also lifted multi-ton dryers off their supports, further destroying the engineering and safety offices as well as the laboratory. The fire further extended to the PVC warehouse near the reactor building, which was destroyed sending a large plume of smoke to the nearby community. Concerning human loss, four operators were killed in the explosion. This comprised two who were at the time of explosion stationed near the top of the reactor and two others who were stationed at the lower level. Two weeks after the explosion, a filth operator who had been hospitalized succumbed to injuries. Two workers and the shift supervisors were also hospitalized while four workers received treatment at the site. Relevant Legislation with respect to the case study In jurisdiction such as the United States where the fire explosion occurred at Formosa Plastic Corporation, several legislations are available that could have prevented the occurrence of the incident. The Occupational Safety and Health Act 1970 comprises to the main federal law that safeguards occupational health and safety within the private sector. Its primary aim is to ensure that the working conditions offered to the employees by the employer are free from hazards such as unsanitary conditions, exposure to toxic materials or fire and mechanical hazards. The Acts is found in U.S. Code at title 29 Chapter 1. In the case study, Occupational Safety and Health Act is relevant as it provides that employees should have been protected from toxic and flammable materials that could present danger (SHRM 2013). According to the Act, an employer is an individual engaged in a business and who employs other individuals. Based on this legislation, Formosa Plastics Corporation is an employer as it was involved in the manufacture and sale of PVC as well as employed other individuals involved in the manufacture. Occupational Safety and Health Act 1970 is applicable to employers in different fields such manufacturers who employ workers (U.S. Chemical Safety and Hazard Investigation Board 2007). Section 5 of Occupational Safety and Health Act 1970 stipulates the general duties of the employers, which includes maintaining conditions of adopting practices that can protect workers who are at work. It also requires that employers should be familiar with the standards that are relevant to their establishment and that employees should use personal protective equipment while at work. According to section 8 of the Occupational Safety and Health Act 1970, all employers have to report within eight hours when an employee dies from a work-related incident, or when at least three employees are hospitalized due to a work-related incident. In the case study four employees died in the fire explosion while four others were hospitalized (Long et al. 2007). Section 8 of the Occupational Safety and Health Act 1970 also gives OSHA an authority to inspect and regulated the workplace covered by the Act, such as manufacturing facilities. Employers are also required to communicate with employees on hazards at the workplace. In which case, employers must have written guides on how to operate safely within the manufacturing plant (SHRM 2013). Section 11(c) of the Act restricts employers from discriminating or retaliating against employees show have exercised their rights under the Act, including presenting complaints to OSHA or seeking that the facility be inspected (SHRM 2013). Further, Section 18 of the Act allows states to encourage their own occupational safety and health plans on condition that they will be effective in ensuring safety at workplace. For instance, in places such as Illinois where Formosa Plastic Corporation is situated, the provincial and state codes are based on use and occupancy of buildings. In general, the owner of the building is required to prepare the safety plan. On the other hand, buildings that have elaborate emergency systems need the assistance of a fire protection consultant (Anon n.d). Concerning EPA regulations, manufacture and use of VCM is restricted under the Risk Management Plan, Clean Air Act and the National Emissions for Hazardous Air Pollutants (NESHAP), which the company had to comply with. At the time of the fire incident, EPA regulated the manufacture of PVC under 40 CFR 63 Subpart J of the NESHAP for Polyvinyl Chloride and Copolymers Production. The regulation required that facilities that manufactured PVC using more than 10,000 pounds of vinyl chloride should use the “maximum achievable control technology” (MACT) to reduce emissions (SHRM 2013). Evaluation of the Health and Safety Concerns In evaluating the health and safety concerns, several policy-level interventions are often established basing on the evidence concerning the underlying risks and how the risks can best be controlled. Hence, they imply the expectations on how the requirements for safety should be implemented and the impact of implementing them on the hazards associated with fatalities, injuries or property damage. Evaluation of health and safety concerns therefore concerns their effectiveness and implementation basing on whether the policy was implemented as intended by the regulatory agency or the employer and whether measures were implemented resulting in decreased health effects and hazards (LaMontagne 2001). Based on the facts of the case study, several factors were responsible for the human error and which made the fire explosion likely. The company failed to implement OSHA PSM standards which required facilities that use highly hazardous chemicals to evaluate the facility after every five years to know whether the reactors are in safe working conditions. While the assessment was carried out in 1992, partial validation was conducted in 1999. However, revalidation was not done in 1999 or before the 2004 fire explosion incident. The management of the company had also relied on the reactor bottom valve as the main safeguard to prevent dumping or accidental transfer of contents of the operating reactor despite the fact that the interlock could be easily bypassed. Aside from the reactor bottom valve, additional safety equipment that could easily be bypassed was identified. These included wooden blocks necessary for prevention of inadvertent activation of the deluge system. Since the management wanted that authorised personnel could use blocks during maintenance, since the blocks were uncontrolled, they were susceptible to misuse including failure to remove them during maintenance. Other than a toggle switch that disabled VCM gas detection system, no other signal existed to inform workers that the system had been disabled (The Keil Centre 2002). The design of the bypass was supposed to be secure, effective and reliable. However, the company’s bypasses did not have physical controls necessary to make them secure hence any one could access the bypasses and use them. Additionally, failure to present bypass condition indication implied that the condition could go undetected. This could compromise the equipment’s safety. Concerning the policies, although the company had certain procedures for using emergency air supply in a bid to bypass the bottom valve interlock, this process was not generally accepted or recognised as a ‘best practice” for controlling safety interlocks. Although “plant-wide” philosophy had been implemented in 1992 to control the interlock, none had been adopted at the time of the incident in 2004 (Long et al. 2007). Concerning emergency preparedness, actions of workers during the fire explosion showed they had been poorly prepared for incidences of cataclysmic release of VCM. For instance, workers had failed to rehearse in more than 10 years. However, the facility had CCM alarm system that monitored airborne VCM concentration, and which sounded alarm requiring all personnel to evacuate the building. This was effective. Concerning communication, workers operating at the lower level had no way of communicating with those on the upper level who had access to status information of the reactor. This could have contributed to a scenario where the blaster operator could know the status of the reactor (Long et al. 2007). Conclusion This report concludes that the Formosa Plastics Corporation failed to adopt actions and designs that could improve health and safety culture in the organization resulting to vulnerabilities to human errors. It is therefore considered that using organizational safety guidelines is essential in ensuring workplace safety. Investigations into the main cause of the explosion revealed that it resulted due to an operator draining a full pressurized and heated PVC reactor after accidentally opened the bottom-side valve on a reactor that was still in operation causing the release of highly explosive vinyl chloride monomer (VCM). Human error was therefore the main cause of the explosion, injuries, fatalities and destruction of property. In all, two major health and safety concerns are identified from the case study. This included containment, as the company had failed to address whether flammable materials are stored in suitable containers and accessed securely to avoid any spillage, or to contain any spillage. Second is separation, as the company had failed to address whether flammable materials are stored safely and away from other industrial processes or general storehouses or warehouses. Based on this premise, it can also be conclude that several factors contributed to human error. This is since the company failed to evaluate and implement factors that could prevent high-risk situations and make error less likely. The management has also failed to address the possibility of human error through its failure to implement the recommendations of the 1992 process hazard analysis (PHA) that suggested that the reactor bottom valve be changed to reduce likely misuse. Additionally, the management at Formosa failed to implement counteractive measures. Formosa Plastics Corporation also depended on written guidelines to control hazard with likely catastrophic consequences. The company also lacked written guidelines for matching risks with safeguards. It also lacked comprehensive written standards for managing interlocks at its PVC plant. The company also had poor emergency preparedness. References Anon n.d. Occupational Safety and Health, viewed 5 Jan 2014, http://eprints.nottingham.ac.uk/382/1/OSH.pdf Ennals, R 2002, “Partnership for Sustainable Healthy Workplaces,” Ann Occup Hyg, Vol. 46 No. 4, pp423-428. EPA 2004, Formosa Plastics Corporation Site, viewed 5 Jan 2004, http://www.epa.state.il.us/community-relations/fact-sheets/formosa-plastics/formosa-plastics-2.html LaMontagne, A 2001, Improving Occupational Health & Safety Policy Through Intervention Research, viewed 5 Jan 2014, http://www.safeworkaustralia.gov.au/sites/SWA/about/Publications/Documents/549/AppendixA.pdf Menckel, E & Westerholm P, 1999, Evaluation in Occupational Health Practice, Butterworth-Heinemann, Oxford Long, L, Lay, J, Leskin, K, McClure, R & Smith, A 2007, Investigation Report: Vinyl Chloride Monomer Explosion, U.S. Chemical Safety Board, Washington, DC SHRM 2013, Occupational Safety and Health Act (OSHA) of 1970, viewed 5 Jan 2014, http://www.shrm.org/LegalIssues/FederalResources/FederalStatutesRegulationsandGuidanc/Pages/OccupationalSafetyandHealthAct(OSHA)of1970.aspx The Keil Centre 2002, Evaluating the effectiveness of the Health and Safety Executive's Health and Safety Climate Survey Tool, viewed 5 Jan 2014, http://www.hse.gov.uk/research/rrpdf/rr042.pdf U.S. Chemical Safety and Hazard Investigation Board 2007, Investigation Report Report No. 2004-10-I-IL March 2007: Vinyl Chloride Monomer Explosion, viewed 5 Jan 2014, http://www.csb.gov/assets/1/19/Formosa_IL_Report.pdf Read More