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Tesoro says CSB lacks jurisdiction to investigate acid leak

On Feb. 12, two Tesoro workers were injured in an acid leak at a refinery in Martinez, Calif. News accounts say that the workers were airlifted to the University of California, Davis, medical center, treated for first- and second-degree burns, and released.

The incident occurred mere weeks after the U.S. Chemical Safety & Hazard Investigation Board released a draft report on a 2010 fire at a Tesoro refinery in Anacortes, Wash., that killed seven workers. (For more on what’s going on with that draft report, see my colleague Jeff Johnson’s story, Regulatory Overhaul Stumbles.)

CSB investigators deployed to Martinez as well and made it onto the site initially. Then Tesoro barred the investigators from further access. “We’ve certainly faced our share of jurisdictional challenges, but I can’t think of another refinery or chemical plant that has taken a position that injuries aren’t serious enough for us to investigate and that we lack jurisdiction,” CSB managing director Daniel M. Horowitz told the Contra Costa Times.

Yesterday, CSB board members responded to Tesoro in writing, including some details of what the agency already learned about the incident:

We point out that our investigation team has determined already that approximately five gallons a minute was leaking until isolated. Acid splashing on worker’s unprotected faces or other parts of the body, resulting in first and second-degree burns requiring air evacuations to a hospital burn unit, treatment, and subsequent significant lost time at work, absolutely constitute serious injuries. …

Our draft report on the 2010 accident at Tesoro’s Anacortes refinery which killed seven workers on January 30, 2014, found a multitude of shortcomings in Tesoro’s plant safety culture. The CSB is interested in examining safety culture issues stemming from the February 12 incident, providing another legal ground for our inquiry.

At the Martinez facility, despite your counsel’s efforts to block our access, we have proceeded in our investigation and have determined that a mechanical integrity failure occurred on equipment connected to a 100,000 gallon process vessel containing flammable hydrocarbons and concentrated sulfuric acid, resulting in the sprayed acid, and that operators being sprayed by acid and caustic during routine sampling activities is a common occurrence.

We have also learned that protective equipment required by procedure for sampling was not provided for the workers at the time – operators did not have ready access to face shields and acid suit jackets at the Martinez facility.

Furthermore, some workers have made the assertion to us and to their union representatives that they have been fearful for their jobs at times when they wished to express safety concerns. We therefore seek further access and renewed cooperation with your company in order to determine all the facts.

Whatever happens with CSB, Tesoro certainly can’t bar the California Division of Occupational Safety & Health from the site. The Washington state Department of Labor & Industries cited Tesoro for 40 willful and five serious labor code violations and fined it $2.39 million for the Anacortes explosion.

Dow worker death likely due to reaction of trimethylindium with cleaning fluid

On Oct. 9, 2013, an explosion and fire at a Dow Chemical electronic materials facility in North Andover, Mass., led to the death of production operator Carlos A. Amaral, 51. According to a statement released by Dow and dated the end of January, the company’s investigation into the incident concluded that:

• An employee sustained injuries as a result of the overpressure of a small stainless steel manufacturing vessel during an operation associated with a Trimethylindium (TMI) manufacturing batch.
• An undesired and unexpected reactive chemical event occurred within the vessel as the employee was transporting the vessel from the glove box to the next manufacturing unit for further processing.
• The overpressure resulted in a release of reacted and unreacted materials and a fire.

The most highly probable cause of the unplanned event was the ingress of cleaning liquid from the cavity space of the ball valve into the crude TMI. Due to the nature of the event, it is impossible to completely validate this conclusion.

I asked Jeremy Cole, business communications manager at Dow Electronic Materials, whether Dow is changing anything regarding cleaning or other handling of the reaction vessel. He said yes, but so far he has declined to provide additional details.

The federal Occupational Safety & Health Administration is investigating the incident, because Massachusetts does not have its own occupational safety and health program. OSHA currently lists the case as open.

Feb. 26 update–Some more information from Dow’s Cole:

the following is the facility’s action plan:
• Prior to TMI production restart, the facility will consider alternate cleaning processes that use cleaning materials that do not react with TMI. If an alternate cleaning process is not feasible, the facility will define a means to confirm the absence of cleaning materials in void spaces and the vessel prior to addition of raw materials.
• The facility will consider modifications to the manufacturing process to increase the tolerance of intrusion of small amounts of cleaning materials as well as variability of raw materials.
• The facility will conduct a review of its Process Hazard Analyses and determine whether any improvements are recommended. Improvements will be captured in appropriate process documentation.

Tesoro refinery fire caused by weakened steel

Last week, the U.S. Chemical Safety & Hazard Investigation Board released its draft report about a 2010 fire at a Tesoro refinery in Anacortes, Wash., that killed seven workers. The fire occurred when a naphtha heat exchanger ruptured, the report says. The cause of the rupture was high temperature hydrogen attack, which occurs when hydrogen atoms diffuse into carbon steel and react with the carbon to form methane. The methane accumulates in the steel and causes stress and fissures. CSB found that curves established by the American Petroleum Institute to predict high temperature hydrogen attack are inaccurate. “CSB has learned of at least eight recent refinery incidents where HTHA reportedly occurred below the carbon steel Nelson curve,” the report says.

Here’s CSB’s video about the incident:


The CSB found several indications of process safety culture deficiencies at the Tesoro Anacortes Refinery. Refinery management had normalized the occurrences of hazardous conditions, including frequent leaks from the [naphtha hydrotreater unit] heat exchangers, by using steam to mitigate leaks, ineffectively correcting heat exchanger design issues, commonly requiring additional operators during [naphtha hydrotreater unit] heat exchanger startups, and exceeding the staffing levels that procedures specified.


The refinery process safety culture required proof of danger rather than proof of effective safety implementation. For years, technical experts used design data to evaluate the B and E heat exchangers for HTHA susceptibility. Data for actual operating conditions were not readily available, and these technical experts were not required to prove safety effectiveness in reaching their conclusion that the B and E heat exchangers were not susceptible to HTHA damage.

CSB noted several similarities between the Tesoro fire and a Chevron refinery fire in Richmond, Calif., in 2012:

  • The Chevron “incident was also the result of a metallurgical failure caused by a well-known damage mechanism called sulfidation corrosion, and Chevron process safety programs failed to identify the hazard before the major incident that endangered the lives of 19 Chevron employees.”
  • “Mechanical integrity programs at both Tesoro and Chevron emphasized inspection strategies rather than the use of inherently safer design to control the damage mechanisms that ultimately caused the major process safety incidents.”
  • “Rather than performing rigorous analyses of damage mechanisms during the PHA process, both companies simply cited non-specific, judgment-based qualitative safeguards to reduce the risk of damage mechanisms.”

One of the recommendations CSB makes in its Tesoro report is that Washington state implement a “safety case” approach to regulation, in which companies develop their own process safety requirements that are closely overseen by state regulators. The agency made the same recommendation to California in its Chevron report, but that report fell to a divided vote by CSB board members, with board members Beth Rosenberg and Mark Griffon wanting CSB to study regulatory options further. An expected vote on the Tesoro report last week was delayed. What happens from here is an open question. Given criticism of CSB that the agency is taking too long already to complete its investigations, holding reports for further study seems untenable. The federal budget passed last month allotted CSB “$11 million for fiscal 2014, slightly less than previous years and below the Administration’s request of $11.5 million.”

Feb. 5, 2014: Title changed to reflect the fact that although I saw the heat exchangers as a bundle of tubes inside a larger tube, CSB tells me that engineers view the outer structure as a shell, not a tube. In any case, weakened steel from high temperature hydrogen attack was still the problem.

Prosecuting companies rather than executives for wrongdoing

The last couple of weeks have been alarming ones for U.S. industrial accidents. Aside from the chemical spill and subsequent drinking water disaster in West Virginia, “Two people died and 10 were injured Monday morning in Omaha, Nebraska, when the second floor of an animal feed plant collapsed. In Madill, Oklahoma, two workers died when a large industrial furnace exploded at a steel plant Monday afternoon,” Reuters reports.

At this point it’s unclear what prosecutions, if any, will result from the incidents. I recently read a story about the 2008 financial crisis, “Why have no high-level executives been prosecuted?” by U.S. District Judge Jed S. Rakoff. I was struck by the similarities to what’s happened following the BP oil spill in the Gulf of Mexico and Sheharbano (Sheri) Sangji’s death from a lab fire at the University of California, Los Angeles. Prosecutors charged the organizations and some personnel–BP oil rig supervisors for manslaughter and a vice president for obstruction, a UCLA professor for labor code violations–but not top management. From the financial crisis piece:

The final factor I would mention is both the most subtle and the most systemic of the three, and arguably the most important. It is the shift that has occurred, over the past thirty years or more, from focusing on prosecuting high-level individuals to focusing on prosecuting companies and other institutions. It is true that prosecutors have brought criminal charges against companies for well over a hundred years, but until relatively recently, such prosecutions were the exception, and prosecutions of companies without simultaneous prosecutions of their managerial agents were even rarer. …

But if your priority is prosecuting the company, a different scenario takes place. Early in the investigation, you invite in counsel to the company and explain to him or her why you suspect fraud. He or she responds by assuring you that the company wants to cooperate and do the right thing, and to that end the company has hired a former assistant US attorney, now a partner at a respected law firm, to do an internal investigation. The company’s counsel asks you to defer your investigation until the company’s own internal investigation is completed, on the condition that the company will share its results with you. In order to save time and resources, you agree.

Six months later the company’s counsel returns, with a detailed report showing that mistakes were made but that the company is now intent on correcting them. You and the company then agree that the company will enter into a deferred prosecution agreement that couples some immediate fines with the imposition of expensive but internal prophylactic measures. For all practical purposes the case is now over. You are happy because you believe that you have helped prevent future crimes; the company is happy because it has avoided a devastating indictment; and perhaps the happiest of all are the executives, or former executives, who actually committed the underlying misconduct, for they are left untouched.

I suggest that this is not the best way to proceed. Although it is supposedly justified because it prevents future crimes, I suggest that the future deterrent value of successfully prosecuting individuals far outweighs the prophylactic benefits of imposing internal compliance measures that are often little more than window-dressing. Just going after the company is also both technically and morally suspect. It is technically suspect because, under the law, you should not indict or threaten to indict a company unless you can prove beyond a reasonable doubt that some managerial agent of the company committed the alleged crime; and if you can prove that, why not indict the manager? And from a moral standpoint, punishing a company and its many innocent employees and shareholders for the crimes committed by some unprosecuted individuals seems contrary to elementary notions of moral responsibility.

I don’t have enough data to say whether the same pattern holds for prosecutions in occupational health and safety. Certainly some company leaders have been charged–Black Mag gunpowder plant owner Craig Sanborn was convicted last fall of negligent homicide and manslaughter and sentenced to 10-20 years in prison for a 2010 explosion that killed two employees. But who, exactly, gets prosecuted for industrial incidents may be something that warrants closer attention.

Friday chemical safety round up

Chemical health and safety news from the past few weeks:

  • In January’s Process Safety Beacon, corrosion under insulation, “which occurs due to water under insulation or fireproofing”
  • AIChE’s Spring Meeting and 10th Global Congress on Process Safety will be held in New Orleans at the end of March
  • BioRAFT’s is hosting a seminar at the end of January on Student Involvement in Improving the Culture of Safety in Academic Laboratories, looks like in collaboration with the University of Minnesota
  • The Chemical Safety & Hazard Investigation Board’s proposal for a new regulatory approach to refinery safety was derailed when two board members voted against the recommendation
  • A California hazardous waste transporter was sentenced to serve 120 days in jail and three years’ probation on six felony charges of unlawful storage, transportation, and disposal of hazardous waste; he was also fined $7,500 and ordered to pay $228,000 in restitution
  • And BNSF Railway is to pay $140,000 for a 2012 spill of phenol, cresylic acid, and other corrosive chemicals near the port of Los Angeles
  • A clinical pharmacist at California Pacific Medical Center is suing UI Pharmaceuticals for injuries she claims she suffered when unpacking a box of sodium chlorite vials destined for a clinical trial
  • Lake Tahoe fireworks violate the Clean Water Act, according to a lawsuit
  • California’s Department of Toxic Substances Control is hoping for a funding increase of $4.5 million “to fix the state’s hazardous waste tracking system, its permitting program and the way it collects money from polluters who have walked away from contaminated land“
  • U.S. spent nuclear fuel storage in pools remains safe, members of the Nuclear Regulatory Commission say
  • Germany finds an average of 2,000 tons of buried WWII munitions annually
  • The export and destruction of the most dangerous materials in Syria’s chemical weapons stockpile has begun

Fires and explosions:

  • A heat exchanger at a Mitsubishi Materials plant in Japan exploded during cleaning, possibly from exposing a chemical to air, killing five workers and injuring twelve others
  • Fire gutted two chemical factories in India. In one, “while methanol was being unloaded from a tanker, a spark occurred which set afire 12 drums loaded with chemicals. This in turn blasted two reactors.” In the other, “the packing unit of Hetero Pharma in Polepally SEZ went up in flames reportedly due to electric short circuit.” No one was hurt in either.
  • A fire at a Malaysian chemical company reportedly started when a bottle of “nitrite acid” exploded
  • “Cleaning solvents used to sterilize equipment caused a chemical reaction that spawned a flash fire” at Amgen, injuring two workers
  • Leaking nitric acid was reportedly the cause of a fire at Avantor Performance Materials in Kentucky
  • An acetone leak led to a fire at a U.S. Paint warehouse in Missouri; one worker was injured
  • Some sort of explosion in an enclosure used for filling or analysis of gas cylinders at an Air Liquide site in Pennsylvania caused extensive damage to equipment, but no one was injured
  • A fire at ERG Environmental Services in Michigan may have started during the transfer of hazardous materials
  • A pyrophoric metallic compound left in a hood ignited, causing a fire at Isle Chem Research and Development in New York
  • A contractor installing some sort of compressed gas line in a Malaysian school lab suffered serious burns in an explosion believed to be caused by a leak from a gas cylinder

Leaks, spills, and other exposures:

  • The co-owner of a New York lumber company died from chemical exposure after something reacted in a drum
  • For up-to-date info on the 4-methylcyclohexanemethanol spill affecting West Virginia’s drinking water, see the West Virginia Gazette, both its news stories and its Sustained Outrage blog
  • 100 gal of “sodium hydroxide chlorine” spilled at a dairy processing plant in North Carolina
  • Diethyl ether and cyclohexane leaked from Ohio’s Kraton Polymers into a nearby creek
  • An ammonia leak shut down a Cargill pork plant in Iowa; two workers were taken to the hospital
  • Nitric acid + sulfuric acid + something organic caused an exploding waste incident at Karlsruhe Institute of Technology, in Germany; one student was hit by flying glass and may have a lung embolism from breathing fumes and one firefighter suffered a “chemical eye injury”
  • Chlorine dioxide released at Mentor Biologics in Wisconsin; three workers were treated for exposure
  • Uncontained mercury, lead paint, and asbestos dust forced he San Francisco State University’s science building to close temporarily

Not covered (usually): meth labs; incidents involving floor sealants, cleaning solutions, or pool chemicals; transportation spills; things that happen at recycling centers (dispose of your waste properly, people!); and fires from oil, natural gas, or other fuels

How freight company Saia trains and monitors its drivers


Credit: Saia

As seen in a variety of rail and truck incidents, chemical manufacturing sites are not the only places where hazardous chemicals can be a concern. Those chemicals often must transported safely to another facility. For trucking operations, safe transportation “starts with hiring the right drivers, training them correctly, and then monitoring them for performance,” says Karla Staver of Saia LTL Freight.

Saia won an American Chemistry Council Responsible Care Partner Award last year. As a company, Saia tries to keep in mind that its employee’s families share the roads with the shipments the company hauls, says Staver, who is Saia’s director of safety and claims prevention.

When hiring, Saia couples road tests with extensive background checks that look at an applicant’s driving record and which companies they’ve already driven for. “Our top candidates have at least a year’s worth of experience,” she says.

Once hired, drivers get instruction on topics such as forklift use, hazardous materials, and hazard communication standards. They then spend a week working with a driver trainer. Staver characterizes driver trainers as “top drivers within the company who have expressed an interest in helping train.” The trainers focus on defensive driving techniques, such as being aware of traffic behavior and leaving appropriate space cushions. “We have had drivers that we brought on who don’t make it through that week because they didn’t meet our expectations of safety performance,” Staver says.

Saia then continues to monitor its drivers long term, Staver says. The company has both city and long-haul drivers. “City drivers we see frequently, and they’re a little bit easier to score, such as by how much brake do they bring back every day or are there any issues with customers,” Staver says.


Credit: Saia

Long-haul drivers are harder to evaluate. Saia has installed camera systems in its trucks that save a recording of 10 seconds prior to certain trigger events, such as a hard-braking situation. The company gets an email alert and then can look at the recording and assess the event for the root cause, such the driver following another vehicle too closely, getting cut off, or avoiding debris on the road, Staver says.

When the company piloted the system, they put it in 10 trucks in the Los Angeles area. The company found that generally its drivers were performing better than expected. “We were, frankly, shocked at the statistics that we got back,” Staver says. Nevertheless, there were a few drivers that needed correction. The videos themselves became coaching tools. “It was great to turn it around to the driver and say ‘tell me what you see,’” she says.

For hazardous materials, drivers are taught how understand bills of lading and to recognize whether shipments are appropriately labeled and sturdily packaged, as well as how to block and brace materials in trailers and what placards to use on the outside. “If there is a release, they are trained on the sequence of emergency events that needs to happen,” Staver says. “Drivers are not first responders,” she adds. “We teach them to notify and find a safe harbor, including don’t park by a drain or a creek.” On the back of company badges is an 800 number to reach in-house safety professionals who are available around the clock and have more extensive hazardous materials training and experience. Saia also contacts with emergency response vendors that can be called in as necessary to handle chemical releases as necessary.

How McKinsey makes training mandatory

From a New York Times profile of McKinsey & Co. CEO Dominic Barton and his efforts to change the company’s rules and culture regarding personal investment after insider trading scandals:

At McKinsey’s London office last fall, a recently hired associate sat at a computer for an orientation session. The associate worked at McKinsey as a business analyst several years earlier and then left the firm for a nongovernmental organization. During her first stint, she simply signed a form confirming that she understood McKinsey’s investing rules. This time, though, she had to walk through a 45-minute interactive program.

When McKinsey first introduced this tutorial, six employees refused to complete it, saying it was a sign that the firm was turning into a “nanny state.” They left the firm. To push recalcitrant employees to complete the test, McKinsey cuts off their email access until they comply.

The story says that all McKinsey consultants–not just new ones–have to complete tutorials such as the one described and senior partners in particular weren’t to too happy about it. Barton persevered.

People v Patrick Harran continues

University of California, Los Angeles, chemistry professor Patrick Harran had another court status check today. The result is another status check scheduled for March 19. The continued delay in scheduling a trial is due at least in part to the fact that Harran’s attorneys are trying to get the case dismissed through the California Court of Appeal. Harran faces trial on four counts of felony violations of the state labor code relating to the 2009 death of Sheharbano (Sheri) Sangji from injuries sustained in a fire in Harran’s lab.

The Los Angeles County District Attorney’s office filed the charges against Harran and the UC governing body on Dec. 27, 2011. UC settled with the district attorney on July 27, 2012, in exchange for implementing a prescribed safety program and a law scholarship in Sangji’s name. Judge Lisa B. Lench heard testimony in Harran’s preliminary hearing in November and December, 2012, then ruled on April 26, 2013, that there was enough evidence for a trial. On Aug. 26, 2013, Judge George G. Lomeli ruled against additional defense motions to dismiss the case.

On Oct. 24, 2013, Harran’s attorneys filed a “petition for writ of mandate, prohibition, or other appropriate relief” with the California Court of Appeal. The petition covers similar territory as the demurrer motion from last August: The defense argues that UC was the employer and Harran merely a supervisor. California Labor Code section 6425(a) makes it a crime for “Any employer and any employee having direction, management, control, or custody of any employment, place of employment, or of any other employee” to willfully violate an occupational safety or health standard in such a way that causes death or permanent or prolonged impairment of the body of an employee. Nevertheless, Harran’s attorneys write, the specific occupational safety and health regulations Harran is charged with violating reference either employer or no one at all (Title 8, sections 5191(f)(4), 3203(a)(6), 3383(a), and 3383(b)). Other regulations do call out supervisors. From the petition:

In the regulatory scheme, Cal/OSHA thus specifically identifies supervisors as the party legally responsible for certain acts when it deems necessary. In other circumstances, it simply prescribes duties of employers, and leaves to the employer how to divide responsibility for internal implementation of the safety standards. There is no principled justification to disregard the expressed policy preferences of the administrative body charged with promoting workplace safety in this state.

So far, the Court of Appeal has not done anything with the petition. Until it does, the case cannot proceed.

Performing the ‘rainbow’ flame test demo safely

Less than a month after the Chemical Safety & Hazard Investigation Board released its video warning against using methanol for flame test demonstrations, we have this:

A teacher’s chemistry experiment exploded during a demonstration at Beacon High School in Manhattan on Thursday, creating a fireball that burned two 10th graders, one severely, according to Fire Department and school officials. The incident happened about 9 a.m., as Anna Poole, a science teacher at the public school, gave a lesson on how electrons react to different chemicals and give off different colors, according to students and school officials.

Local news reports all say that it was a flame test demo and that the teacher was using methanol, but those stories either don’t attribute the information or use unnamed sources. I contacted the New York City Fire Department, Department of Education, and Special Commissioner of Investigation for the schools, but none of them has been willing to confirm any details of the incident.

But several years of tracking chemistry incidents means that when I hear about students injured in a fire in a high school science class, my first thought is that it was a methanol-based flame test experiment. There is a safer way to do flame tests, by soaking wood sticks in metal salt solutions (chlorides, NOT nitrates) and holding the sticks in a flame. The National Science Teachers Association has detailed instructions here (h/t to @Lewis_lab for the link).

Local coverage of the incident:

  • New York Times – Chemistry lab fire injures 2 at a Manhattan high school, School experiment that burned boy was focus of federal warning
  • New York Post – Two high school kids burned in lab accident, Safety lapses eyed in Beacon School Chemistry Fire
  • New York Daily News – Two Beacon School students injured when science experiment erupts in fireball, Beacon chemistry teacher faulted by safety expert after students burned in experiment

Update: The New York Times had a Jan. 8 story that the fire department has cited the high school for eight code violations involving hazardous chemical storage and safety equipment.

For more discussion, also see Chemjobber: Another accident with the “rainbow flame” experiment, Placeholder for Beacon School incident, FDNY finds code violations

Friday chemical safety round up

Chemical health and safety news since Thanksgiving:

Instead of tweet, a quote from a comment on Chemjobber’s post about high school chemistry demonstration accidents

Yesterday I went and filled out the paperwork to teach Chemistry at the community college across the street as an adjunct. I was required to watch a 25 minute CD on safety. The sound did not work on the CD. I went and told the person that I was filling out the paperwork about the problem the CD

She said “Oh, dont worry about it”.

  • Remember that Nitrile gloves do not provide universal protection!
  • ‘Tis the season for Christmas tree fires; here’s a nice graphic on holiday decor safety. Also, there are some lovely chemistrees out in the twitterverse!
  • December’s AIChE Process Safety Beacon covers the hazards of strong oxidizers
  • Miss BioRaft’s webinar on “Proactive EHS Management and Communications”? Here’s the recording.
  • In OSHA news, whistleblowers can now file complaints online and the Labor Department would like public comment on agency standards to improve chemical safety
  • Rising caseload, fewer Labor Department judges triggers painful mix for suffering laborers
  • OSHA no match for workplace dangers that kill thousands
  • Routine labor violators receive billions in federal contracts
  • Don’t we want to reveal the good news about workplace safety?
  • High bladder cancer rate shrouds New York plant
  • Nuclear weapons clean-up disputes heat up in, South Carolina and Washington state
  • It will take an international effort and an Italian port to get Syria’s chemical weapons out to the U.S. MV Cape Ray for destruction

Skipping the incidents for time reasons, will start fresh with those in January. Happy holidays!

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