July, 2003

This is a repeating event

200320JulAll DayHoneywell Toxic Releases 2003Honeywell Baton Rouge (US-LA) Origin: CSB Lessons:Operating Procedures,Operational Readiness,Risk AssessmentIndustry:ManufacturingCountry:United StatesLanguage:ENLoC:Deterioration,Operator error

Summary

On July 20, a chlorine cooler at the Baton Rouge plant failed, leaking chlorine into the Genetron 143a refrigerant (G-143a) coolant system. The coolant system itself then failed, releasing chlorine to the atmosphere, which overwhelmed operators located both inside and outside the control room and caused them to leave the area. Seven plant workers were injured. The entire plant was evacuated, and authorities were notified. Because chlorine had been released to the atmosphere, the East Baton Rouge OHSEP initiated its community notification system and issued a shelter-in-place advisory for residents within a 0.5-mile radius. The release lasted approximately 3.5 hours, largely because:
• Operators were forced to evacuate the area before they could diagnose the problem and isolate the source of the leak.
• Chlorine entered the control room and damaged process control equipment.
• Unit emergency shutdown procedures did not completely isolate the chlorine supply.

During the July 20 chlorine release, all units at the Baton Rouge plant were shut down. Chlorine had corroded the process control system, which needed to be replaced. Work at the facility during the days that followed consisted mainly of maintenance, shipping activities, and the return of process equipment to a safe, normal state. On July 29, an operator working in the ton-cylinder area of the plant was preparing empty 1-ton refrigerant cylinders for offsite testing. During this procedure, he removed a plug from a 1-ton cylinder he likely believed to be empty. The cylinder was actually full, and its contents were released. The operator was engulfed in a cloud later determined to be contaminated antimony pentachloride; he died the following day, July 30.

Following the July 20 and 29 incidents at the Baton Rouge facility, the president of the Honeywell Specialty Materials group ordered a review of all facility operations prior to restarting operations. While Honeywell was investigating the two incidents and reviewing overall plant safety systems, plant activities were limited to maintenance and inspection. During the July 20 chlorine release, the plant’s G-22 unit was rapidly shut down using emergency procedures. Some equipment, such as an HF vaporizer, was left in an abnormal shutdown state (i.e., it contained liquid hydrogen fluoride). For the next few weeks, operations personnel started returning equipment to normal conditions. On August 12, operators began using a venturi stick to remove liquid hydrogen fluoride from a vaporizer in the G-22 process. This activity resulted in an HF release on August 13 that injured one employee and exposed one operator.

KEY ISSUES:
• HAZARD ANALYSIS
• NONROUTINE SITUATIONS
• OPERATING PROCEDURES

ROOT CAUSES:
1. The Honeywell Baton Rouge plant management systems did not protect against failures in the chlorine cooler.
2. The consequences of chlorine entering the coolant system were not fully evaluated.

1. Honeywell had no program to identify and address potential hazards in the ton-cylinder area.
2. Honeywell and C&MI have no systematic processes for positively verifying the contents of cylinders rejected by C&MI.
3. The Honeywell systems for segregating and storing 1-ton cylinders did not include procedures for identifying and handling abnormal cylinders.

1. Honeywell had no procedures for identifying and planning for nonroutine job situations.


Image Credit: CSB

Origin

CSBUS Chemical Safety Board

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