Emergency planning and response and preventive maintenance are two of the Chemical Safety Board’s (CSB) newest “Most Wanted Safety Improvements.”

In talking about inadequate or poor emergency planning or response, CSB board members found that topic is a recurring finding in their investigations.

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“As a 50-year veteran of the chemical industry I know far too well the importance of a robust emergency response program,” said CSB Board Member Manuel “Manny” Ehrlich, who will serve as the champion for this issue. “I have responded to and investigated numerous chemical incidents in my career and look forward to sharing the important safety information in CSB reports and safety videos.”

To date, 12 CSB investigations and 46 resulting recommendations look to address deficiencies found in a community’s, facility’s or emergency responder’s response to an incident at a chemical facility. The CSB’s recommendations department found the majority of CSB’s recommendations on this issue can end up categorized in the following areas:
• Training for emergency responders, including hazardous materials training
• Local emergency planning, and community response plans and teams
• Use of community notification systems
• Use of an incident command system and the National Incident Management System
• Conducting emergency response exercises
• Information sharing between facilities, emergency responders and the community

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Despite the CSB’s recommendations over the years, emergency responders continue to suffer fatalities due to poor emergency planning or response. In a classic case, 12 emergency responders died as a result of the 2013 ammonium nitrate explosion and fire at the West Fertilizer Company located in West, TX.

Preventive maintenance also falls in that most wanted category since there is a paucity of adequate mechanical integrity programs, delayed or deferred preventive maintenance, and the aging infrastructure of equipment at chemical facilities. These issues have been a recurring root cause of incidents investigated by the CSB.

The CSB investigated 11 incidents and currently has 21 open recommendations aimed at addressing gaps at a number of levels, including: Facility, corporate, regulatory programs and industry standards.

The intent of the board’s recommendations is to promptly identify equipment upgrades, ensure replacements do not suffer from delay and equipment is not made to operate longer than it should.

“It is imperative that facilities institute a comprehensive preventive maintenance schedule for their equipment,” said CSB Chairperson Vanessa Allen Sutherland, who will serve as the champion for this issue. “Too many CSB investigations have highlighted a lack of timely inspections and scheduling of proper maintenance.”

Of the 11 investigations identified, a majority of them occurred at refineries.

The CSB’s investigation into the catastrophic failure of a 40-year-old heat exchanger at the Tesoro Refinery in Anacortes, WA, found the fatal explosion and fire was the result of damage to the heat exchanger, a mechanism known as “high temperature hydrogen attack,” or HTHA, which severely cracked and weakened carbon steel tubing led to a rupture. Tesoro used an inspection strategy that relied on design operating conditions rather than verifying actual operating parameters, and the CSB determined inspections for this type of damage are unreliable, as the microscopic cracks can end up localized and difficult to identify.

Another refinery investigation in where a lack of preventive maintenance was a root cause is the 2012 accident at the Chevron Refinery in Richmond, California, where a catastrophic pipe failure led to a massive fire.

Testing determined the pipe failed due to thinning caused by sulfidation corrosion, a common damage mechanism in refineries.

The CSB’s investigation of the incident found Chevron repeatedly failed over a 10-year period to upgrade piping in its crude oil processing unit, which was extremely corroded and ultimately ruptured on August 6, 2012.

The CSB found a failure by Chevron to identify and evaluate damage mechanism hazards, which if acted upon, would likely have identified the possibility of a catastrophic sulfidation corrosion-related piping failure.

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