CSB Investigators Say Chlorine Leak Resulted from Improper Safety Practices, Failure to Follow Written Procedures

June 17, 2004

In preliminary findings, investigators from the U.S. Chemical Safety and Hazard Investigation Board (CSB) say that last November’s chlorine release at the DPC Enterprises Glendale facility resulted from the failure to shut off a chlorine transfer line when safety alarms sounded. The alarms indicated the near-depletion of an essential chemical in a safety device called a scrubber, but the CSB found it was common practice to allow chlorine to flow even after the alarms sounded, in violation of the company’s own written procedures.

The chlorine release began while operators were transferring liquid chlorine from a railroad tank car to a tanker truck. As the tanker truck was filled with liquid chlorine, chlorine vapors were directed into the scrubber to prevent them from being vented into the atmosphere. The scrubber works by a chemical process where chlorine vapors are absorbed by a water solution with up to 20% caustic soda (sodium hydroxide), forming liquid bleach, a saleable byproduct.

CSB investigators said the company regularly ran the concentration of caustic soda in the scrubber down to less than 0.5% – a level “that left a limited safety margin.” The CSB found that on the day of the accident, November 17, 2003, the caustic concentration was allowed to drop to zero. The depleted solution could no longer absorb chlorine vapors, which then vented to the atmosphere. Furthermore, shutting off the transfer operation did not stop the release, as the over-chlorinated bleach solution broke down in a series of chemical reactions, generating chlorine gas.

Up to 3,500 pounds of chlorine were released in the incident. Authorities instructed more than 4,000 people to evacuate from the immediate area in Glendale and bordering Phoenix, using a reverse-911 call system. Fourteen people, including ten police officers, suffered chlorine inhalation symptoms and required evaluation at a hospital.

CSB Board Member John Bresland, who accompanied investigators to the accident site, said in prepared remarks for the meeting, “Companies which manage or produce chlorine have the responsibility of handling it safely. Chlorine gas is highly toxic by inhalation, and the CSB takes accidents that involve the release of chlorine very seriously. Fortunately in this case, no one was critically injured.”

CSB lead investigator John Murphy said, “Our investigation, while preliminary, shows that DPC had written procedures requiring transfer operations to be shut down when alarms indicated that the scrubber solution was in danger of becoming too weak to absorb chlorine. With the transfer halted, the procedures directed operators to use a chemical test to determine the exact caustic concentration in the scrubber solution. However, we found that it was common practice for plant operators to continue transferring chlorine after the safety alarms sounded while they conducted their analyses. On the day of the accident the narrow margin of safety ran out.”

Investigator Mike Morris said, “When operators went to the scrubber to sample the solution, they heard a rumbling sound. They activated the emergency shut off system, which worked as designed, halting the transfer operation and stopping the chlorine flow into the scrubber. By then a series of chemical reactions was underway and operators had no means to stop it. Chlorine continued to be released.”

Investigators said the large multi-agency emergency response, with the Glendale Fire Department in command, was largely effective.

The CSB is an independent federal agency charged with investigating industrial chemical accidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in safety management systems.

The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA.

OSHA Cites Steel Fabricator for Exposing Workers to Safety and Health Hazards

OSHA has cited Irby Steel for exposing workers to serious safety and health violations at the company's Gulfport steel fabricating plant. The agency is proposing $113,750 in penalties.

OSHA cited the company for 30 serious safety violations, with proposed penalties of $93,800. Included in the citations were failing to have a lockout-tagout program that would render machinery inoperable during maintenance or repair; exposing workers to injuries from defective forklifts, cranes, tools, machinery and electrical equipment; and failing to provide safety training for employees.

The company also received nine serious health violations, with proposed penalties of $19,950. Among the cited items were: using unapproved material as a gas line, which exposed workers to hazards of fire and explosion; failing to provide hearing protection and annual testing for employees working in areas where noise was above the permissible levels; failing to label and properly store chemicals; and lack of a first-aid program.

The company, a division of Struthers Industries, Inc., has 15 days to contest the OSHA citations and proposed penalties before the independent Occupational Safety and Health Review Commission.

OSHA Cites Company for Exposing Workers to "Caught and Crush" Hazards

OSHA has cited Krehling Industries Inc. for failing to protect workers from "caught and crush" hazards at the company's Naples plant.

OSHA's investigation found that a Krehling employee was caught between machinery and a pallet while adjusting a machine switch on Dec. 18, 2003, sustaining severe rib, lung and shoulder injuries.

OSHA issued two willful citations, with proposed penalties of $110,000, for failing to apply lockout devices that would isolate all energy sources and render machinery inoperable during servicing or repair, and for failing to guard machinery parts so they could not come in contact with employees. The company had been cited previously for similar violations.

The agency also cited the company for eight serious violations, with proposed penalties of $25,500, including failure to properly guard other machinery, properly store chemicals and lower the forks of a forklift before leaving it unattended. The agency issues a serious citation when there is substantial probability that death or serious physical harm could result and the employer knew or should have known of the hazard.

Krehling Industries has 15 working days to contest the OSHA citations and proposed penalties before the independent Occupational Safety and Health Review Commission.

RAND-NIOSH Study Says New Approach Needed to Protect Emergency Responders in Terrorist Attacks and Disasters

 The report, funded by the National Institute for Occupational Safety and Health (NIOSH), was issued by the RAND Corporation and NIOSH.

Better planning, training, coordination and management procedures are needed to protect emergency responders at the scene of terrorist attacks and disasters, according to the study. It proposes a new approach that would make protecting the health and safety of emergency responders – including police, firefighters and ambulance crews – a key priority in coordinating the overall response to terrorist attacks and major disasters.

Currently, each agency that sends emergency responders to an incident takes responsibility for safeguarding its own workers. Because terrorist attacks and major disasters often draw emergency responders from several departments in nearby communities – with different operating procedures, communications systems and response plans – coordinating efforts to protect workers is difficult, the report says.

"At the scene of major disasters, responder safety is a collective responsibility for the multiple response agencies and organizations involved," said NIOSH Director John Howard, M.D. "We look forward to working with our many partners to make this new report an important resource for planning and preparation."

The study recommends enhanced preparedness planning to assure that all emergency responders to an event can be protected within the Incident Command System, the standard overarching management structure used in disaster response and called for under the newly established National Incident Management System. This would prevent different departments from wasting valuable time trying to come up with ways to protect workers on a case-by-case basis at each emergency scene.


Other recommendations in the report call for:

  • Developing a cadre of highly trained disaster safety managers who can lead coordination between agencies. Drawn from local response organizations, these people would know their localities and be quickly available. They would also have the broad-based understanding of disaster situations and crosscutting expertise in safety management that is needed to supervise multi-agency safety efforts.
  • Incorporating safety and health issues more realistically into joint disaster exercises and training, to make sure that safety management is more than just a training footnote.
  • Preparing in advance the types of expertise and other assets needed to protect responder safety. This would help insure that safety-related reinforcements will be able to be used quickly and efficiently in an ongoing operation.
  • Developing common standards and guidelines for responder training, hazard assessment, responder credentialing and protective equipment to assure that responders have the knowledge and tools needed to accomplish their missions safely.

The importance of protecting emergency responders was underscored by the Sept. 11, 2001, attack on the World Trade Center. The difficulties of managing emergency responder safety in the New York City attack led to ad hoc arrangements to coordinate worker safety efforts. While the efforts provided important examples of coordinated approaches to safety management, the ad hoc arrangements took days to organize and their effectiveness suffered because they had not been included in preparedness planning, researchers found.

The report says leadership to make the needed changes should come from all levels of government. For example, an effective planning effort will require a combination of federal, state and local officials to develop national standards. And as in the National Incident Management System, cooperation between officials at all levels of government is needed to put many of the changes in effect.

Funding for the study was provided by NIOSH, which is part of the U.S. Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services.

The project included extensive involvement of emergency responders from organizations that responded to the Sept. 11 attacks on the World Trade Center and the Pentagon, or to major natural disasters such as the Northridge earthquake and Hurricane Andrew.

The report is the third in a series of RAND-NIOSH studies on protecting emergency responders.

OSHA to Host Hispanic Safety and Health Summit in Orlando

OSHA and the Hispanic Alliance for Progress, in partnership with the U.S. Hispanic Chamber of Commerce, will host a national Hispanic Safety and Health Summit Thursday, July 22, 2003 in Orlando, Fla.

The event will bring together representatives from government, community and faith-based organizations, non-profits, industry, academia and organized labor to share practical safety and health information and success stories, and discuss gaps in communication, training and outreach for Hispanics workers in the United States.

The summit will include presentations by senior officials, labor union leaders, and industry representatives. Highlights include workshops offering the latest information on initiatives to reduce injuries, illnesses, and fatalities among the Hispanic workforce.


National Federation of Independent Business Aligns with OSHA

OSHA and the National Federation of Independent Business (NFIB) have joined forces to enhance safety and health throughout the nation's small and independent businesses.

OSHA and the NFIB signed a formal Alliance that will make health and safety information and compliance assistance resources available to all employers, with a particular focus on small and independent businesses, and also helps communicate the need for the implementation of safety and health management systems programs in the workplace.

"Small and independent businesses represent the vast majority of all employers in our country," said OSHA Administrator John Henshaw. "By working with NFIB, we can reach more business owners, managers, and workers to promote workplace safety and health. This is a tremendous opportunity to make a difference in the lives of thousands of workers."

Added Jack Faris, NFIB President and CEO: "We have been working toward this Alliance for some time now, and NFIB is very pleased that OSHA is showing an even deeper commitment to a cooperative approach to improving workplace safety. Helping small business understand the value of safety will make the workplace even safer for employees and more profitable for their employers."

Together, OSHA and NFIB will develop and promote accessible and user-friendly tools to encourage and help small business owners create and implement effective safety and health management programs in the workplace. Key to this agreement is the testing and development of safety and health resources for small businesses.

NFIB and OSHA will disseminate safety and health information through both organization's websites, and print and electronic media, publications, and safety newsletters, in addition to developing new electronic assistance tools. Representatives of OSHA and NFIB will participate in forums, roundtable discussions or stakeholder meetings to help forge innovative solutions in the workplace.

Both organizations will also speak, exhibit and appear at conferences, local meetings or other events that address small business issues, including the NFIB Congressional Small Business Summit.

The National Federation of Independent Business is a small business advocacy group. Founded in 1943, NFIB represents the consensus views of its 600,000 members in Washington, D.C., and each state capital.