U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD INVESTIGATION REPORT CHLORINE RELEASE July 20, 2003 (7 Injured) CONTAMINATED ANTIMONY PENTACHLORIDE EXPOSURE JULY 29, 2003 (1 Killed) HYDROGEN FLUORIDE RELEASE August 13, 2003 (1 Exposed, 1 Injured) HONEYWELL INTERNATIONAL, INC. BATON ROUGE, LOUISIANA KEY ISSUES: • HAZARD ANALYSIS • NONROUTINE SITUATIONS • OPERATING PROCEDURES REPORT NO. 2003-13-I-LA AUGUST 2005 Contents EXECUTIVE SUMMARY ........................................................................................................................11 1.0 INTRODUCTION .........................................................................................................................11 1.1 Background....................................................................................................................................11 1.2 Investigative Process......................................................................................................................11 1.3 Honeywell International, Inc. ........................................................................................................12 1.4 Honeywell Baton Rouge Plant.......................................................................................................12 2.0 JULY 20 CHLORINE RELEASE .................................................................................................14 2.1 Background....................................................................................................................................14 2.1.1 Process Description...........................................................................................................14 2.1.2 Chlorine ............................................................................................................................17 2.1.3 Industry Trade Associations .............................................................................................19 2.2 Incident Description.......................................................................................................................20 2.2.1 Chlorine Release...............................................................................................................20 2.2.2 Incident Response.............................................................................................................21 2.2.3 Community Impact ...........................................................................................................23 2.3 Incident Analysis ...........................................................................................................................26 2.3.1 Mechanical Integrity .........................................................................................................26 2.3.1.1 Cooler History...............................................................................................27 2.3.1.2 Post-Incident Testing.....................................................................................28 2.3.1.3 Analysis.........................................................................................................29 2.3.2 Hazard Analysis................................................................................................................30 2.3.3 Management of Change and Chlorine System Shutdown ................................................33 2.3.4 Design and Maintenance of Positive Pressure Control Rooms.........................................34 2 2.3.5 Previous Incidents of Chlorine in Omni Control Room ...................................................38 2.3.6 Community Notification Systems.....................................................................................39 2.4 Regulatory Analysis.......................................................................................................................42 2.4.1 OSHA Process Safety Management .................................................................................42 2.4.2 EPA Risk Management Program......................................................................................44 2.5 Key Findings..................................................................................................................................44 2.6 Root and Contributing Causes .......................................................................................................46 2.6.1 Root Causes ......................................................................................................................46 2.6.2 Contributing Causes..........................................................................................................47 2.7 Recommendations..........................................................................................................................49 3.0 JULY 29 CONTAMINATED ANTIMONY PENTACHLORIDE EXPOSURE .........................52 3.0 Background....................................................................................................................................52 3.1.1 Antimony Pentachloride Use ............................................................................................52 3.1.2 Honeywell El Segundo Facility ........................................................................................54 3.1.3 Antimony Pentachloride ...................................................................................................54 3.1.4 Refrigerant Cylinder Operation ........................................................................................55 3.2 Incident Description.......................................................................................................................56 3.3 Reconstructive Analysis.................................................................................................................60 3.3.1 Cylinder Contents Analysis ..............................................................................................60 3.3.2 1-Ton Cylinder Mislabeling..............................................................................................61 3.4 Incident Analysis ...........................................................................................................................64 3.4.1 Refrigerants vs. Contaminated Antimony Pentachloride..................................................64 3.4.2 Hazard Analysis................................................................................................................64 3.4.3 Standard Operating Procedures.........................................................................................65 3.4.4 Experience/Training..........................................................................................................66 3 3.5 Regulatory Analysis.......................................................................................................................67 3.5.1 U.S. Department of Transportation...................................................................................67 3.5.2 Occupational Safety and Health Administration ..............................................................69 3.6 Key Findings..................................................................................................................................69 3.7 Root Causes ...................................................................................................................................70 3.7.1 Root Causes ......................................................................................................................70 3.8 Recommendations..........................................................................................................................72 4.0 AUGUST 13 HF RELEASE..........................................................................................................73 4.1 Background....................................................................................................................................73 4.1.1 Hydrogen Fluoride............................................................................................................73 4.1.2 Hydrogen Fluoride Use.....................................................................................................74 4.1.3 Venturi Stick Operation ....................................................................................................75 4.2 Incident Description.......................................................................................................................76 4.3 Incident Analysis ...........................................................................................................................77 4.3.1 Nonroutine Job Planning ..................................................................................................77 4.3.2 Hazard Analysis................................................................................................................78 4.3.3 HF Handling Practices and Guidelines.............................................................................79 4.3.3.1 API Recommended Practices ........................................................................79 4.3.3.2 HFIPI Guidelines...........................................................................................79 4.3.3.3 Industry Best Practices..................................................................................80 4.3.4 Use of PPE........................................................................................................................81