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IRFinal-3. 3/29/20042/26/2004 Japan 3rd NRIFD Symposium

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The USA Chemical Safety and Hazard Investigation Board, Its Investigation of Reactive Hazards and the Status of the Report’s

Recommendations to Industry and Government1 Isadore (Irv) Rosenthal1, PhD

I. Abstract The paper opens with a brief description of the origin, authorities and responsibilities of the USA Chemical Safety and Hazard Investigation Board (CSB or Board). The discharge of the Board’s responsibilities is illustrated by its broad investigation of the chemical safety risks posed by the class of reactive hazards. This report, “IMPROVING REACTIVE HAZARD MANAGEMENT” (Reactive Report), was issued in October 2002 and its conclusions and recommendations have had significant impacts on how stakeholders now view the adequacy of industry and government management of reactive hazards. The major thrusts of the Reactive Report’s ‘Recommendations’, directed to government agencies and other stakeholders, are presented and followed by a discussion of the congruence between the Report’s Objectives and Conclusions and the status of responses to the reports recommendations. The positive impacts that the CSB Report has already had on activities by professional societies, government and industry related to reactive hazards are then reviewed. The paper concludes with observations on the current issues facing the CSB and the author’s expectation in regard to future developments on reactive hazards issues raised by the CSB Report.

II. Introduction

The number and severity of U.S. process safety chemical accidents demonstrate the need for the USA Chemical Safety and Hazard Investigation Board (CSB or Board). For example, among just the 15,430 chemical-handling facilities required to file risk management plans with the U.S. Environmental Protection Agency (EPA) in 1999, 1,205 of these facilities reported 1,970 accidents over the five-year period from 1994 through 1999. These incidents resulted in a total of 1,897 injuries, 33 deaths to workers/employees and evacuation or sheltering in place of over 200,000 members of the public2. These EPA Risk Management Program (RMP) regulated facilities are just a relatively small fraction of the facilities that can experience major accidental chemical releases. Reactive hazards3 are a problem throughout the industrialized world and the EU has recognized this as well by the attention it pays to reactive hazards in the Seveso II directive and its sponsorship of efforts such as HarsNet4. The vision of this group is to “Help reduce the frequency and consequences of reactive chemical incidents”. The financial impact of such accidents is also very significant. A recent paper estimated direct insurance company payouts related to chemical release accidents at about $1 billion per year. Taking into account indirect losses and losses not covered by insurance companies, overall effects could be conservatively estimated at $3 to 5 billion annually5. As the CSB report on,”Improving Reactive Hazard Management” (Reactive Report) shows, a significant fraction of chemical release and process accidents continue to involve reactive hazards. III. Synopsis of the history, responsibilities and authorities of the CSB6 Following the catastrophic incident at the Union Carbide facility in Bhopal, India in 1984 and a series of domestic incidents7 in 1987-1989, the U.S. Congress authorized new chemical accident provisions through the Clean Air Act Amendments of 19908. In addition to new regulatory approaches required of the U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) and EPA, Congress mandated an independent Chemical Safety Board. 1 Senior Fellow, Risk Mgmt and Decision Processes Center, The Wharton School of the University of Pennsylvania, 558 Jon M. Huntsman Hall, 3730 Walnut Street’,

Philadelphia, PA, 19104. Though the author served on the five person board governing the U.S. Chemical Safety and Hazard Investigation Board”, the views expressed in

this paper are his and do not necessarily express the views of any other member of the Board or agency.

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The U.S. Chemical Safety and Hazard Investigation Board (CSB) is an independent Federal agency similar to the National Transportation Safety Board (NTSB). The CSB mission is to investigate and promote the prevention of major chemical incidents at industrial facilities. CSB is a scientific investigatory organization. It has the legal authorities required to enter facilities, conduct interviews and collect other information required in order to conduct a thorough accident investigation. However, the CSB cannot levy fines nor is it an enforcement body. Furthermore, the Boards investigative findings cannot be used as evidence in civil litigation. The purpose, structure, authorities, and responsibilities of the CSB were spelled out by the U.S. Congress in section 112(r)(6) of the 1990 clean air act amendments9. In essence, the language in section 112(r)(6) directs the Board to:

Conduct root cause investigations of accidental chemical releases that affected or could have affected members of the public and report on the investigations findings

“Issue periodic reports to the Congress and pertinent Federal, State and Local agencies” on “the safety of chemical production, processing, handling and storage”. These Reports should ”recommend measures to reduce the likelihood or consequences of accidental releases” and may include recommendations to EPA and OSHA on regulatory measures to prevent or minimize the consequences of accidental releases.

Establish reporting requirements for chemical incidents within its jurisdiction. “Conduct research and studies with respect to the potential for accidental releases whether or not an

accidental release has occurred”. The CSB began operations in January 1998. Modeled after the National Transportation Safety Board, the statute authorizing the CSB provides for five Board Members, including a Chairperson, who are nominated by the President by and with the advice and consent of the U.S. Senate. Members of the Board are appointed on the basis of technical qualification, professional standing, and demonstrated knowledge in the fields of accident reconstruction, safety engineering, human factors, toxicology, or air pollution regulation. The CSB is governed by majority vote of its Board members who serve a 5-year term. At present, the Board has an operating budget of approximately $8.5 million and a staff of about 40 people. To date the Board has completed 20 investigations and studies, including the hazard investigation report titled ”Improving Reactive Hazard Management,” which is the main subject of this paper. All of these reports and studies can be viewed on the CSB website.10 IV. The CSB Report; “Improving Reactive Hazard Management” (CSB Reactive Report)

a. Background

1. Nature of CSB hazard investigations

Findings and recommendations from a field investigation of an accident often reflect very specific aspects of the facility’s manufacturing operations, which typically use specialized procedures, equipment, and technologies. However, occasionally in the course of conducting incident investigations, the Board may be alerted to significant safety problems related to a common hazard that could affect a large number of facilities. In such cases, CSB may choose to conduct a ‘hazard investigation’ or ‘safety study’ with broad industry-wide applicability. Findings from such an investigation can lead to a variety of recommendations, including proposals for regulatory action, as was the case with the CSB report on “Improving Reactive Hazard Management”.11

2. Morton, NAPP and other reactive incidents relevant to initiation of the CSB Reactive Report The Morton International plant in Paterson, New Jersey, experienced an explosion on April 8, 1998, which seriously injured nine workers. The explosion and subsequent fire were caused by a runaway chemical reaction in a 2,000-gallon reactor used to produce a yellow fuel dye (Automate Yellow 96). A vigorous exothermic reaction occurred shortly after the two chemicals used to make the dye were mixed. The temperature in the reactor began to rapidly increase, causing the further exothermic decomposition of the dye and eventually over-pressurizing and rupturing the kettle. The reactor contents were released to the air and distributed into the surrounding urban area. The chemicals released included toxic ortho-nitrochlorobenzene. Fallout occurred as far as 0.5 mile from the plant, and residents of a 10 square block area were required to

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shelter in place. Local authorities issued a health advisory to residents shortly after the incident, though the magnitude of human exposure is unknown. The plant was repaired, but the company discontinued the production of Automate Yellow 96. The CSB issued a final Morton accident investigation report12 on the August 16, 2000 and one of the recommendations made to both OSHA and the EPA in the CSB Report Morton implicitly committed the CSB to an investigation of reactive hazards13

3. OSHA concerns about reactive hazards covered under PSM prior to the CSB Reactive Report Even before the CSB issued its report on its investigation of the Morton14 accident, Stakeholders and OSHA were already concerned with the issue of whether the provisions in its Process Safety Management15 (PSM) regulation adequately covered reactive hazards. This concern was generated in large part by a series of accidents due to reactive hazards, some of which are listed in Table 1 and in particular to the NAPP16 accident which resulted in five deaths and triggered a petition17 to OSHA asking for tighter regulation of reactive hazards under the PSM or by other means. Public pressure on regulatory bodies was focused more on OSHA than EPA18.

Table 1 Reactive Incidents

≈ Heat of Reaction Are Chemical(s) Consequences

Facility ≈∆H cal/g PSM listed? Deaths Injury

Morton Intl.19 ≈170 No 0 9 (4/8/1998) NAPP Tech.20 ≈190 No 5 4 (4/21/1995) Condea Vista21 ≈120 No 0 5 (10/13/1998) Terra Industries22 ≈40023 No 4 18 (12/13/1994)

Phillips Pasadena24 ≈300 Yes 2 2 (6/23/1999) Concept Sciences25 ≈1200 Yes? 5 8 (2/19/1999) (Process Coverage Disputed26)

Georgia Pacific27 ≈180 Yes 1 7 (9/10/1997) (Not as reactive)

Bartlo Packaging28 ≈190 No 3 17 South (5/8/199

-----------End of Table 1-------- Examination of Table 1 reveals, that by and large the processes experiencing this series of ‘reactive’ accidents were not governed by the provisions of the PSM (covered). Processes are covered under PSM if the substance(s) being processed is specifically listed or is a member of a listed class and the amount being processed is above PSM specified threshold amounts Reactive hazards are covered as such under the OSHA PSM on the basis of two criteria:

• Is the substance listed in the standard as a ‘reactive’ hazard?29 • Is the amount of the covered substance to be ‘processed’ greater than the coverage threshold

amount specified in the standard? None of the hazards leading to the eight ‘reactive’ accidents listed in Table 1 were covered as reactive hazards under the OSHA standard.

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Over the next several years, OSHA developed and discussed a number of alternative approaches with its stakeholders and developed a draft Advance Notice of Proposed Rulemaking (ANPR) late in 1999. The ANPR was never issued, but informally shared with some stakeholders. Responses to the draft ANPR from chemical industry trade associations were not positive,30 and at least one important group suggested that the OSHA proposals would add a significant regulatory burden for industry with little return in added safety. OSHA removed the issue of reactive hazards from its high priority action list in 2002. b. Discussion of the Reactive Report’s contents To facilitate reader understanding of this paper’s discussion of the contents of the CSB report “Hazard Investigation: Improving Reactive Hazard Management”, the Report’s Objectives, Findings, Conclusions and Recommendations have been reproduced in Appendix verbatim1. The Report’s contents, as well as its Objectives, Findings, Conclusions and Recommendations need to be read in order to fully understand the Report. This paper can only try to provide some insight into some major aspects of the report for those who may not have the opportunity for the careful study the Report merits. Clearly any attempt to do this introduces unavoidable elements of subjectivity This paper will attempt to summarize and analyze two important aspects of the CSB Report:

- Congruence: How well did the Report address its stated ‘Objectives’? - What are the essential thrusts of the Report’s ‘Recommendations’?

1. Congruence: Did the Report ’Findings’ and ‘Conclusions’ address the Board’s ‘Objectives’?

This question will be addressed by seeing how well the Report’s Conclusions, which of course are built on and embody the Report’s important findings, address the first four of the Board’s Objectives31. In Table 2, the author has assigned each of the Report’s 13 Conclusions32 to the Report Objective to which he feels it is most pertinent. The Objectives have been given Roman numbers (they were not numbered in the Report) to facilitate discussion of our analysis.

Table 2: Congruence of Report’s Conclusions and Objectives2

I. Determine the impacts of reactive chemical incidents.

1. Reactive incidents are a significant chemical safety problem. 7. Existing sources of incident data are not adequate to identify the number, severity, and causes of reactive

incidents or to analyze incident frequency trends. 8. There is no publicly available database for sharing lessons learned from reactive incidents.

II. Examine how industry, OSHA, and EPA currently address reactive chemical hazards. 5.(b) Improving reactive hazard management requires that both regulators and industry address the hazards from

combinations of chemicals and process-specific conditions rather than focus exclusively on the inherent properties of individual chemicals3.

9. Neither the OSHA PSM Standard nor the EPA RMP regulation explicitly requires specific hazards, such as reactive hazards, to be examined when performing a process hazard analysis. Given that reactive incidents are often caused by inadequate recognition and evaluation of reactive hazards, improving reactive hazard management involves defining and requiring relevant factors (e.g., rate and quantity of heat and gas generated) to be examined within a process hazard analysis.

10. The OSHA PSM Standard and the EPA RMP regulation do not explicitly require the use of multiple sources when compiling process safety information.

11. Publicly available resources33 are not always used by industry to assist in identifying reactive hazards.

2 Roman numerals are assigned to the CSB Reactive Report’s five Objectives since they were not numbered in the Report. The Table uses same Arabic numerals used in the

CSB Report to identify each of the Report’s 13 Conclusions.

3 Conclusion 5 covers two diverse points, the second of which is split out as 5(b) and assigned as pertinent to Objective II because it implies that industry and government

should, but do not adequately consider process-substance interactions

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13. Current good practice guidelines on how to effectively manage reactive hazards throughout the life cycle34 of a chemical manufacturing process are neither complete nor sufficiently explicit.

14. Given the impact and diversity of reactive hazards, optimum progress in the prevention of reactive incidents requires both enhanced regulatory and non-regulatory programs

III. Determine the differences, if any, between small, medium, and large companies with regard to reactive

chemical policies, practices, in-house reactivity research, testing, and process engineering. IV. Analyze the appropriateness of, and consider alternatives to, industry and OSHA use of the National

Fire Protection Association (NFPA) instability rating system for process safety management. 2. The OSHA PSM Standard has significant gaps in coverage of reactive hazards because it is based on a

limited list of individual chemicals with inherently reactive properties. 3. NFPA instability ratings are insufficient as the sole basis for determining coverage of reactive hazards in the

OSHA PSM Standard. 4. The EPA Accidental Release Prevention Requirements (40 CFR 68) have significant gaps in coverage of

reactive hazards. 5. Using lists of chemicals is an inadequate approach for regulatory coverage of reactive hazards. Improving

reactive hazard management requires that both regulators and industry address the hazards from combinations of chemicals and process-specific conditions rather than focus exclusively on the inherent properties of individual chemicals.

V. Develop recommendations for reducing the number and severity of reactive chemical incidents.

_______End of Table 2_______

After examining the results of the Table 2 exercise, the author makes the following observations in regard to what he believes can be concluded from the work done in the Reactive Hazard Investigation in regard to the issues raised in the Report’s Objectives:

• The available data on ‘Reactive” accidents does not allow one to arrive at even a good semi-quantitatively estimate of their incidence rate though clearly the available information on notorious accidents such as Seveso, Bhopal, Phillips, Toulouse and less notorious incidents like those listed in Table 1, indicate that they are of considerable significance.

• OSHA, EPA and Industry Practitioners focus on individual unstable individual substances and often do

not appropriately take into account the significant reactive hazards presented by combinations of ‘stable’ substances

• Many facilities do not adequately use available data to identify and characterize reactive hazards and

OSHA, EPA, and Trade associations have not done a good job in addressing this failure.

• The process hazard analyses called for in the PSM, RMP and Trade Association guidelines do not have appropriate guidance and requirements in regard to analyzing and assessing the impact of processing conditions on the likelihood and magnitude with which reactive hazards are expressed.

• The Report’s conclusions do not comment on differences between small, medium and large companies with regard to reactive chemical policies, practices, reactivity research, testing, and process engineering.

The absence of any opinion or comment on the last point is surprising, since it is a common belief among practitioners that ‘large’ companies handle reactive hazards well on their own, ‘small’ companies do not and they need help. 2. Major thrusts of the Report’s ‘Recommendations’ Appendix 1 contains the full text of the Board’s recommendations. The recommendations are addressed to specific pertinent stakeholders that the Board believes are affected by deficient management of reactive hazards and are able to take steps to help address such deficiencies. To facilitate discussion of both the Board’s Reactive Report recommendations and responses to these recommendations, the paper has prepared the ad hoc synopsis of Board recommendations shown in Table 3.

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Examination of Table 3 shows that by and large the thrusts of the Board’s recommendations address the issues that the Report concludes affect “the number and severity of reactive incidents” as called for in Objective 5 of the Report. The responses to the Board’s recommendations will be discussed in the next section of the paper after the reader has had the opportunity of reviewing Table 3

Table 3

Major CSB Reactive Report Recommendations (Ad Hoc Condensation)

To OSHA

1. Extend PSM coverage of reactive hazards to include combinations as well as individual substances taking process conditions into consideration. Use objective criteria and process considerations to:

a. Define covered combinations of substances b. Increase the number of individual substances covered

2. Require better collection and dissemination of literature information relevant to reactive hazards 3. Require PSM covered facilities to address explicit aspects of reactive hazards when they do presently

required process hazard analyses 4. Collect and make available better information on the nature, impacts and incidence of accidents

caused by reactive hazards To EPA

1. Extend RMP coverage of reactive hazards to include combinations as well as individual substances taking process conditions into consideration. Follow the approach used by OSHA.

2. Modify the accident reporting requirements in RMP*INFO to collect and make available better information on the nature, impacts and incidence of accidents caused by reactive hazards

To National Institute of Standards and Technology (NIST) 1. Develop and implement a publicly available database containing reactive hazard test data and

information gathered from the literature, academia, business and government sources. To Center for Chemical Process Safety (CCPS)

1 Publish comprehensive guidance on model reactive chemical management systems for companies primarily in the processing of reactive hazards and also for companies engaged primarily in the storage of reactive substances.

To Industry trade associations: American Chemistry Council (ACC), Synthetic Organic Chemical Manufacturers Association (SOCMA) and also with some modification to National Association of Chemical Distributors (NACD)

1. Improve the Responsible Care Program in regard to the management of reactive hazards and collect better information on reactive incidents and lessons learned from incidents

2. Work with NIST in developing and implementing a publicly available database for reactive hazard test information

To International Association of Firefighters, Paper Allied-Industrial, Chemical & Energy Workers International Union (PACE); The United Steelworkers of America; Union of Needle-trades, Industrial, and Textile Employees (UNITE); United Food and Commercial Workers International Union; American Society of Safety Engineers (ASSE); American Industrial Hygiene Association (AIHA)

1. Communicate the findings and recommendations of this report to your membership.

--------------------End of Table 3-----------------

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V. Some developments related to issuance of the CSB Reactive Report

a. Status of responses to the Board’s Reactive Report Recommendations

Table 3 contains the paper’s ad hoc synopsis of the Board’s Reactive Report’s recommendations to stakeholders. The purpose of this synopsis, as noted, is to facilitate discussion of the major thrusts of the Board’s recommendations and the status of the responses received by the CSB on its recommendations. In essence the Report’s major recommendations call for actions in four areas: 1. Make better use of information in the literature and/or testing to screen for and identify substances that

could pose a significant reactive hazard in a facility’s intended operations 2. Perform Process hazard analyses that explicitly evaluate scenarios that could lead to accidents associated

with intended facility operations involving reactive hazards 3. Take measures to improve the collection and availability of better information on the nature, impacts and

incidence of accidents caused by reactive hazards 4. Make your stakeholders aware of the CSB Reactive Report As of February 6th, 2004, there have been few formal responses to the Board by the organizations to whom the Board’s recommendations were made. Early in November, OSHA did respond to the Board and outlined a number of initiatives it proposed to take in regard to recommendations 1 to 3, but the Board35 did not feel the OSHA response was acceptable. OSHA’s response stated that it would revise its PSM guidance and compliance Directives to indicate the need to better address recommendation items 1 and 2, but that it had not decided whether to amend the PSM per se, and it declined to act on item 3. OSHA also indicated that it would take other actions such as:

1. Making the CCPS book on “Practices for Managing Reactive Hazards” available to employees, employers and other interested persons free of charge,

2. Foster efforts in its “Alliance Program” with trade, business, labor, government and professional organizations,

3. Participate in the Reactivity Management Roundtable (RMR) which is discussed below in this paper. NIST has not indicated how it would act on the recommendation that specifically asked it to

“Develop and implement a publicly available database for reactive hazard test information. Structure the system to encourage submission of data by individual companies and academic and government institutions that perform chemical testing”.

EPA appears to have taken action36 on the recommendation made to it in regard to item 2, but it has not apparently notified the Board of its action. No action would be expected in regard to recommendation (1) on improving coverage of reactive hazards under RMP, until OSHA acts, given that the Board suggested and there is general agreement that EPA should follow OSHA’s lead in this matter. Based on the response to queries the author made to the CSB, Trade Associations such as ACC and SOCMA who were asked to modify their association programs such as “Responsible Care” and to increase attention to items 1 to 3 also have not formally responded to the Board.

b. The impact of the CSB Report on issues related to reactive hazards. As was evident in the paper’s discussion of responses to the Board’s recommendations, there was reluctance by significant stakeholders to accept some of the recommendations with the greatest potential to reduce accidents due to reactive hazards. This is not unusual. One needs to remember that in spite of strong societal reactions to the horror of the Bhopal accident, these feelings did not translate into preventive actions immediately. While there were significant actions by industry and government, it took multiple domestic chemical accidents in the late 1980s, including many reactive incidents, before passage of the Clean Air Act Amendments of 1990 resulted in actions that:

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• Prompted OSHA Process Safety Management (PSM) regulations (1992), • Led to EPA’s Risk Management Program (RMP) regulations (1996), and • Established the Chemical Safety Board (1998).

However, in spite of the obviously less than complete agreement on implementing the Board’s recommendations, the Reactives report has had important impacts in other ways. This section of the paper will discuss three examples of such impacts. 1. Regulatory action on reactive hazards in New Jersey

As the CSB Reactive Report was being developed, the State of New Jersey was engaged in a required re-examination and regulatory reauthorization of its “Toxic Catastrophic Prevention Act Program (TCPA). The original program was enacted in 1986, in part in reaction to the Bhopal accident. It was aimed primarily at reducing the frequency and impact of accidental chemical process releases on the public. In this sense it was more closely related to the EPA RMP regulation than to the OSHA PSM regulation which focused on worker impacts. When the TCPA was revisited by the New Jersey Department of Environmental Protection (NJDEP) in 1998, the full repercussions of the NAPP and Morton accidents, both of which occurred in NJ had apparently not fully registered. However, as shown by the following extract from a NJDEP notice37 of a proposed March17, 2003 public hearing on the re-adoption of a modified TCPA program, these accidents and the CSB Reactive Report had changed the climate of opinion. The issue of reactive hazards was now of paramount concern:

“Significant Proposed Program Changes

The most significant program change is the Department’s proposal to list certain reactive hazard substances as extraordinarily hazardous substances at N.J.A.C. 7:31-6.3, thus making them subject to the TCPA rules at listed threshold quantities. Investigations of the accidents at two New Jersey companies, NAPP Technologies in 1995 and Morton International in1998, identified reactive substances as contributors to the root cause of these accidents and raised concerns about reactive hazards to a national level. In addition, as reported in its October, 2002 publication, the United States Chemical Safety and Hazard Investigation Board concluded that of 167 incidents that occurred between 1980 and 2001, over 50% involved reactive hazards. Reactive hazards are not currently regulated under the State’s TCPA rules or the federal ARP program. The Department is proposing to add reactive hazard substances to the EHS list at Table I, Part D at N.J.A.C. 7:31-6.3.”

Note: Author has used italics for emphasis in the above quotation. The New Jersey Department of Environmental Protection (NJDEP) now evidently felt that the revision of the TCPA should address the issues raised in the CSB reactive report and should cover reactive hazards and processes similar to those that were involved in the reactive accidents at NAPP and Morton. In order to accomplish this, the NJDEP felt they needed to cover reactive hazards posed by both individual substances and also mixtures of substances that were being intentionally transformed physically or chemically. The NJDEP proposed38 and then accomplished this in its adopted regulation published August 4, 2004 by:

1) Preparing a list of substance(s) that would be covered as reactive hazards based on historical and technical considerations 2) Defining a class of reactives (mixtures or individual substances) whose members met three requirements:

• The facility planned to ‘intentionally’ chemically or physically transform the substance(s) itself or admixed with other substances

• The substance(s) had one or more of the specified functional groups, • The amount of energy (-∆H) released using prescribed procedures exceeded 100

Calories/gram of the mixture over a specified temperature range. The prescribed procedures allowed ∆H to be determined by acceptable calorimetric tests, calculations or literature data

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2.) The CSB/EPA/OSHA Roundtable on Reactive Hazards

On June 10th 2003, the CSB, OSHA and EPA sponsored a Roundtable discussion focused on the following Question:

“If OSHA and EPA were to accept the CSB recommendation on broadening regulatory coverage of reactive hazards under the PSM and RMP standards using objective criteria, what methodology would you recommend they should use to achieve this broadened coverage”.

The Roundtable attendees (about 50 persons) represented a cross section of industry, labor and government with some academic and public interest group participation as well. The rules established for the Roundtable mandated that there would be no attribution of the remarks or presentations made during the Roundtable. Four papers were presented, one by a labor representative, two by employees of chemical companies and one by an academic. The papers were asked to address the question posed above. After the papers were presented, the Roundtable was opened for general discussion. As might be expected, answers to the posed question were diverse. They ranged from:

1) Requiring that all substances to be processed undergo a hazard analysis that was thorough enough to uncover any reasonably possible hazard due to reactivity

To: 2) Basing coverage on a list of covered materials with specified functional groups that also

exhibited rapid, high energy release under specified conditions.

To the author, the latter approach does not appear to be different in kind from that proposed by the NJDEP (see below) and is in a sense a limited class approach. The discussions in the afternoon were far ranging. Some parties felt the problem could be addressed almost entirely by trade association action to improve industry voluntary guidelines, others felt that a new OSHA standard designed specifically for reactive hazards was needed, a few felt that an enhanced HAZCOM standard was an important tool and some were proponents of better OSHA enforcement of an enhanced General Duty Clause, etc. There was also an interesting, widely held set of opinions to the effect that, while reactive hazards may not be a serious problem for the ‘better’ firms, OSHA needed to reach out to ‘small’ firms, variously characterized as, ‘lacking technical expertise’, ‘resources’, ‘time’, etc. It appeared to the author, that the only area of near agreement was that OSHA needed to find an approach for dealing with reactive hazards that was better than their present ‘simple’ list approach. As a long time observer of the regulatory scene, I sensed some movement away from rigid positions that existed before the CSB Reactive Report was issued.

3 The AIChE Reactive Management Roundtable Shortly after the CSB/EPA/OSHA held their Roundtable on reactive hazards, a group of American Institute of Chemical Engineers (AIChE) members, many of whom were present at this Roundtable organized a meeting in conjunction with the AIChE Design Institute for Emergency Relief Systems (DIERS) committee in Las Vegas to discuss the issue of improving the Management of Reactive hazards. There were about 40 persons present at the meeting, and they spent the day discussing whether the problem of reactive hazards was being adequately managed by existing government, professional societies, trade associations, etc. or if there was a need for an additional group to focus on this issue.

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This group of professionals, employees of a variety of private firms, government agencies and labor unions decided that the need to do an additional ‘something’ about the risks posed by reactive hazards existed. They felt that managing reactive hazards was a significant problem inadequately addressed by existing institutions and that this was particularly true in regard to smaller firms with limited financial and/or technical resources. Under the cover of an interim ‘charter’ granted to the organizers of this exploratory session by AIChE, they formed themselves into the Reactivity Management Roundtable (RMR) with the objective of developing a reactive management system work-product aimed at this class of firms with limited financial and/or technical resources. In this regard it is interesting to compare the RMR evaluation of customer need with the following statement by HarsNet39:

“The main objectives of HarsNet are a consequence of the urgent need to introduce hazard assessment techniques for reactive chemicals into the normal working procedures of small and medium enterprises”.

The RMR group has now been in existence for about four months. Its efforts have received support from the CSB, EPA and OSHA staff though the bulk of its members are industry. As noted above, OSHA Secretary Henshaw has signaled the importance that OSHA attaches to the RMR’s efforts by listing their support of the RMR as a tangible step towards addressing the issues raised in the Board’s recommendations to OPSHA. The RMR has held multiple teleconferences aimed at firming up its strategic objectives, arriving at a better definition of its ‘work’ product’s customers and settling on its relationships with sister AIChE-CCPS groups. Presently, the RMR is scheduled to meet again sometime this springing order to review the planning work done to date, decide on how to proceed with accomplishing the planned work and finalizing the charter under which it will work within the AIChE. The effort put forward by individual professionals on this effort is evidence of how seriously working professionals view the problem of reactive hazards. In the author’s opinion, and also that of several key organizers of the RMR, it is also further evidence of the contribution of the CSB report on reactive hazards to the reduction of industry risks associated with such hazards.

VI. Observations

a. Current status of the Chemical Safety Board

Based on the broad technical approval accorded CSB accident reports and stakeholders inputs, one can conclude that the CSB is now held in high regard. However it continues and will continue to face three challenges:

1. Incompatibility between its mandated responsibilities and its budgets 2. Converting investigations into prevention 3. Obtaining metrics to measure the impact of CSB activities

1.) Budget Issues

Section 112(r) paragraph (6) (E) mandates that; “In no event shall the Board forego an investigation where an accidental release causes a fatality or serious injury among the general public, or had the potential to cause substantial property damage or a number of deaths or injuries among the general public.” There are literally hundreds of releases that have “the potential to cause substantial property damage or a number of deaths or injuries among the general public”.

Given this provision, there are literally hundreds of incidents that, according to law the CSB must investigate and numerous hazards that the Board should investigate because they are far from fully characterized. In fact, CSB budgets have been set at about $8 million/year, an amount of money that does not even come close to allowing the Board to meet such investigatory requirements. This amount is only sufficient to execute about 6 to 8 full investigations and/or hazard studies, together with perhaps another 4 to 6 smaller incident bulletins.

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2.) Converting investigations into prevention

The challenge of converting its accident investigations activities into recognized prevention results is the Board’s greatest challenge. CSB investigations create no value per se unless they are converted into prevention, since the CSB, like the National Transportation Safety Board (NTSB) has no enforcement powers. The CSB has two major routes for converting its investigative activities into accident prevention:

o Responses to recommendations made in its investigative reports o Attracting practitioner attention to ‘unimportant’ system deviations that can destroy barriers to a Low

Probability – High Consequence accident. o Use of its Reports as a training tool

- Responses to CSB recommendations: One of the major instruments that the CSB possesses for converting its investigations into prevention is the formal public corrective recommendations made to organizations (trade associations, unions, companies, professional societies, etc.) whose activities are related to causation of the accident or realization of the hazard investigated. The CSB requests written responses to these recommendations and OSHA and EPA are legally required to respond to such recommendations, in writing within 180 days. Other organizations are not legally required to respond, but by and large they do to avoid adverse publicity from not doing so. Even if the parties to whom recommendations are issued do not choose to follow a specific CSB recommendation, the publicity attached to issuance of the recommendation causes these parties to at least examine their behavior and practices in the light of the scrutiny that their reply to CSB recommendations might receive.

- Attracting practitioner attention: Attention is a very scare commodity. It is generally accepted that most accidental chemical releases and injuries from the realization of a hazard occur in spite of the fact that the knowledge needed to prevent it is known to practitioners or is reasonably available to them if they choose to look for it. Unfortunately, many practitioners’ attention tends to be focused on the many immediate crises they face daily rather than on the seemingly postponeable factors that increase the likelihood of Low Probability - High Consequence (LP-HC) accidents. For this reason Process Safety Management Systems are needed to ensure that process safety matters requiring action are not dependent on any single individual’s attention focus. Most practitioners recognize the need for effective, functioning management systems. Unfortunately building and even more so, maintaining effective safety management systems also require this same scare attention. The tragic events often portrayed in CSB investigative reports can, and often do serve to cause practitioners and their managers to pay this needed attention to their safety management systems. The scarcity of management and practitioner attention also leads the author to believe that aiming at capturing their attention to about 12 to 20 CSB investigation reports per year may be a cost-effective prevention effort, but that obtaining good value from significantly more reports would be very difficult. Use of CSB accident reports as training tools: It is generally recognized that CSB accident reports are excellent training tools. During the author’s term at the Board, he received numerous notes from colleagues in chemical companies and universities on its use in this manner. PACE, the Paper, Allied-Industrial, Chemical and Energy Workers International Union which represents over 300,000 workers in the US and Canada is also reported to have used the CSB report on the TOSCO accident as a training tool. The President of the International Chemical Workers Union Council wrote the to the CSB in November of 2003 and among other things said, “ I would like to let you know that the CSB reports of industrial chemical accidents have been of significant help to both our members and management at such facilities. These investigations have been used in our training activities at the ICWU Center for Worker Health and Safety Education to help build an informed workforce to prevent tragedies”

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3.) Metrics on the impact of CSB activities

Evaluating the impact of different types of CSB activities on the incidence of accidents within its purview is vital if the CSB wants to improve its effectiveness. Obtaining the data needed to evaluate the CSB impact on prevention is difficult but doable. At present, even rudimentary data on this subject based on either incidence metrics, surveys or interviews are not available. This is evident in all of the Board’s reports and I will not elaborate more on the subject of obtaining such metrics since the author’s thoughts have been published40 .b. Impact of the CSB Report on “Improving Reactive Hazard Management” Regardless of whether or not substantially all of the CSB Reactive Reports recommendations are adopted in a timely manner, the author believes the Report has already had and will continue to have an important positive impact on decreasing the likelihood of process accidents due to the realization of reactive hazards. As noted above, attention is a vital pre-requisite for preventing process accidents which are low probability events whose possible occurrence is crowded out of the consciousness of very busy employees and managers by the daily crises and weekly and monthly deadlines. Stakeholder attention to reactive hazards will continue to be higher than normal even after the initial spurt of attention that followed issuance of CSB Reactive Report. One can expect news stories and discussion each time events enabled at least in part by the CSB report, such as the following, occur:

• Issuance of reactive management guidelines by the RMR group of AIChE • Enforcement of the reactive hazard portions of its TCPA standard by the NJDEP, • CSB reports on the status of responses to reactive recommendation, • Actions by the ‘OSHA alliance’ on nonregulatory alternatives for improving reactive safety

For example Burrell’s clipping service reported that over 500 newspaper web sites in the U.S. and abroad picked up the AP story on the Board’s recent news release on its conclusions regarding the OSHA response to Board’s reactive recommendations. The author believes that regulation alone is not the best way to control most hazards. Cooperative action by well intentioned firms is vital. At the same time experience has also taught that OSHA and EPA need to develop a cost/effective regulatory approach that will in essence define minimum acceptable practice for firms that are marginally viable or technically limited. There are a number of papers that have outlined a basis for such approaches. Some were put forth in CSB/OSHA/EPA Roundtable discussed in this paper, the author and one of his associates have published a specific proposal41 couched in the language of the PSM and other proposals can be found in the references cited in this paper. While some of the government Agency people present at the CSB/OSHA/EPA Roundtable had hoped for participant agreement on one or more of these approaches, other observers noted that there never has been a specific major regulatory approach on which Labor, industry and Public interest groups agreed. Nevertheless, the existence of specific proposals on how industry and government can better control accidents due to reactive hazards and a heightened awareness of problem created by the Board’s Reactive Report will speed up the necessary negotiations by labor and industry, OSHA and EPA. Unfortunately, this negotiation will probably not start seriously until there is another major accident in the United States caused by an unregulated reactive hazard.

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Appendix I

“Objectives, Findings, Conclusions and Recommendations of the CSB report: ”Improving Reactive Hazard Management”

To facilitate reader understanding of this papers discussion of the CSB report “Hazard Investigation: Improving Reactive Hazard Management”, the Report’s Objectives, Findings, Conclusions and Recommendations have been extracted from the CSB report (No. 2001-01-H,Issue Date December 2002) and are reproduced below:

1. Objectives: • Determine the impacts of reactive chemical incidents. • Examine how industry, OSHA, and EPA currently address reactive chemical hazards. • Determine the differences, if any, between small, medium, and large companies with regard to

reactive chemical policies, practices, in-house reactivity research, testing, and process engineering. • Analyze the appropriateness of, and consider alternatives to, industry and OSHA use of the NFPA

instability rating system for process safety management. • Develop recommendations for reducing the number and severity of reactive chemical incidents.

2. Findings 1. The limited data analyzed by CSB include 167 serious incidents in the United States involving

uncontrolled chemical reactivity from January 1980 to June 2001. Forty-eight of these incidents resulted in a total of 108 fatalities. The data include an average of six injury-related incidents per year, resulting in an average of five fatalities annually.

2. Nearly 50 of the 167 incidents affected the public.42 3. Over 50 percent of the 167 incidents involved chemicals not covered by existing OSHA or EPA

process safety regulations.43 4. Approximately 60 percent of the 167 incidents involved chemicals that either are not rated by NFPA or

have “no special hazard” (NFPA “0”).44 Only 10 percent of the 167 incidents involved chemicals with NFPA published ratings of “3” or “4.”

5. For the purpose of the OSHA PSM Standard, NFPA instability ratings have the following limitations with respect to identifying reactive hazards:

• They were originally designed for initial emergency response purposes, not for application to chemical process safety.

• They address inherent instability only, not reactivity with other chemical substances (with the exception of water) or chemical behavior under non-ambient conditions.

• NFPA Standard 4945–on which the OSHA PSM-listed highly reactive chemicals are based–covers only 325 chemical substances, a very small percentage of the chemicals used in industry.46

• The OSHA PSM Standard lists 137 highly hazardous chemicals–only 38 of which are considered highly reactive based on NFPA instability ratings of “3” or “4.”

• The NFPA ratings were established by a system that relies, in part, on subjective criteria and judgment.

6. As a result of the joint OSHA-EPA chemical accident investigation of the Napp Technologies incident in April 1995, a recommendation was made by EPA and OSHA to consider adding more reactive chemicals to their respective lists of chemicals covered by process safety regulations. To date, neither OSHA nor EPA process safety regulations have been modified to better cover reactive hazards.

7. Reactive hazards are diverse. The reactive incident data analyzed by CSB included: • Over 40 different chemical classes (i.e., acids, bases, monomers, oxidizers, etc.), with no single

dominating class. • Several types of hazardous chemical reactivity, with 36 percent attributed to chemical

incompatibility, 35 percent to runaway reactions, and 10 percent to impact-sensitive or thermally sensitive materials.

• A diverse range of chemical process equipment–including reaction vessels, storage tanks, separation equipment, and transfer equipment. Storage and process equipment (excluding chemical reaction vessels) account for over 65 percent of the equipment involved; chemical reaction vessels account for only 25 percent.

8. Reactive incidents can result in a variety of consequences, including fire and explosions (42 percent of incidents) as well as toxic gas emissions (37 percent).

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9. No one comprehensive data source contains the data needed to adequately understand root causes and lessons learned from reactive incidents or other process safety incidents.

10. Incident data collected by OSHA and EPA provide no functional capability to track reactive incidents so as to analyze incident trends and develop preventive actions at a national level.

11. Causes and lessons learned are reported in only 20 percent of the 167 incidents. (Industry associations, government agencies, and academia typically do not collect this information.) However, more than 60 percent of the incidents for which some causal information was available involved inadequate practices for identifying hazards or conducting process hazard evaluations; nearly 50 percent involved inadequate procedures for storage, handling, or processing of chemicals.47

12. Over 90 percent of the incidents analyzed by CSB involved reactive hazards that are documented in publicly available literature accessible to the chemical processing and handling industry.48

13. Although several computerized tools49 and literature resources are available to identify reactive hazards, surveyed companies do not generally use them. In some cases, these tools provide an efficient means of identifying reactive hazards without the need for chemical testing.

14. Surveyed companies share chemical data of a general nature for most chemicals (e.g., material safety data sheets [MSDS]) and good handling practices for some. However, detailed reactive chemical test data, such as thermal stability data–which can be valuable in identifying reactive hazards–are not typically shared.

15. Approximately 70 percent of the 167 incidents occurred in the chemical manufacturing industry. Thirty percent involved a variety of other industrial sectors that store, handle, or use chemicals in bulk quantities.

16. Only limited guidance on the management of reactive hazards throughout the life cycle of a chemical manufacturing process50 is currently available to industry through professional societies, standards organizations, government agencies, or trade associations. There are significant gaps in the following:

• Unique aspects of reactive hazards that should be examined during process hazard analysis (PHA), such as the need for reactive chemical test data, and methods to identify and evaluate worst case scenarios involving uncontrolled reactivity.

• Integration of reactive hazard information into process safety information, operating procedures, training, and communication practices.

• Review of the impact on reactive hazards due to proposed changes in chemical processes. • Concise guidance targeted at companies engaged primarily in the bulk storage, handling,

and use of chemicals to prevent inadvertent mixing of incompatible substances. 17. Several voluntary industry initiatives, such as ACC’s Responsible Care and NACD’s Responsible

Distribution Process (RDP), provide guidance on process safety management for chemical manufacturers and distributors. However, no voluntary industry initiatives list specific codes or requirements for reactive hazard management.

18. The EPA RMP regulation and the European Community’s Seveso II directive both exempt covered processes from some regulatory provisions, if the facility documents the absence of catastrophic damage from process accidents under reasonable worst case conditions. The State of New Jersey is also considering similar action in its proposed revisions of the Toxic Catastrophe Prevention Act (TCPA) regulations.

3. Conclusions 1. Reactive incidents are a significant chemical safety problem. 2. The OSHA PSM Standard has significant gaps in coverage of reactive hazards because it is based on a

limited list of individual chemicals with inherently reactive properties. 3. NFPA instability ratings are insufficient as the sole basis for determining coverage of reactive hazards

in the OSHA PSM Standard. 4.

5.

6.

7.

8.

The EPA Accidental Release Prevention Requirements (40 CFR 68) have significant gaps in coverage of reactive hazards. Using lists of chemicals is an inadequate approach for regulatory coverage of reactive hazards. Improving reactive hazard management requires that both regulators and industry address the hazards from combinations of chemicals and process-specific conditions rather than focus exclusively on the inherent properties of individual chemicals. Reactive incidents are not unique to the chemical manufacturing industry. They also occur in many other industries where chemicals are stored, handled, or used. Existing sources of incident data are not adequate to identify the number, severity, and causes of reactive incidents or to analyze incident frequency trends. There is no publicly available database for sharing lessons learned from reactive incidents.

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9.

10.

11. 12. 13.

14.

Neither the OSHA PSM Standard nor the EPA RMP regulation explicitly requires specific hazards, such as reactive hazards, to be examined when performing a process hazard analysis. Given that reactive incidents are often caused by inadequate recognition and evaluation of reactive hazards, improving reactive hazard management involves defining and requiring relevant factors (e.g., rate and quantity of heat and gas generated) to be examined within a process hazard analysis. The OSHA PSM Standard and the EPA RMP regulation do not explicitly require the use of multiple sources when compiling process safety information. Publicly available resources51 are not always used by industry to assist in identifying reactive hazards. There is no publicly available database to share reactive chemical test information. Current good practice guidelines on how to effectively manage reactive hazards throughout the life cycle52 of a chemical manufacturing process are neither complete nor sufficiently explicit. Given the impact and diversity of reactive hazards, optimum progress in the prevention of reactive incidents requires both enhanced regulatory and nonregulatory programs.

4. Recommendations:

Occupational Safety and Health Administration (OSHA) 1. Amend the Process Safety Management (PSM) Standard, 29 CFR 1910.119, to achieve more

comprehensive control of reactive hazards that could have catastrophic consequences. • Broaden the application to cover reactive hazards resulting from process-specific conditions and

combinations of chemicals. Additionally, broaden coverage of hazards from self-reactive chemicals. In expanding PSM coverage, use objective criteria. Consider criteria such as the North American Industry Classification System (NAICS), a reactive hazard classification system (e.g., based on heat of reaction or toxic gas evolution), incident history, or catastrophic potential.

• In the compilation of process safety information, require that multiple sources of information be sufficiently consulted to understand and control potential reactive hazards. Useful sources include:

Literature surveys (e.g., Bretherick’s Handbook of Reactive Chemical Hazards, Sax’s Dangerous Properties of Industrial Materials). Information developed from computerized tools (e.g., ASTM’s CHETAH, NOAA’s The Chemical Reactivity Worksheet). Chemical reactivity test data produced by employers or obtained from other sources (e.g., differential scanning calorimetry, thermogravimetric analysis, accelerating rate calorimetry). Relevant incident reports from the plant, the corporation, industry, and government. Chemical Abstracts Service.

• Augment the process hazard analysis (PHA) element to explicitly require an evaluation of reactive hazards. In revising this element, evaluate the need to consider relevant factors, such as:

Rate and quantity of heat or gas generated. Maximum operating temperature to avoid decomposition. Thermal stability of reactants, reaction mixtures, byproducts, waste streams, and products. Effect of variables such as charging rates, catalyst addition, and possible contaminants. Understanding the consequences of runaway reactions or toxic gas evolution.

2. Implement a program to define and record information on reactive incidents that OSHA investigates or requires to be investigated under OSHA regulations. Structure the collected information so that it can be used to measure progress in the prevention of reactive incidents that give rise to catastrophic releases.

U.S. Environmental Protection Agency (EPA) 1. Revise the Accidental Release Prevention Requirements, 40 CFR 68 (RMP), to explicitly cover

catastrophic reactive hazards that have the potential to seriously impact the public, including those resulting from self-reactive chemicals and combinations of chemicals and process-specific conditions. Take into account the recommendations of this report to OSHA on reactive hazard coverage. Seek congressional authority if necessary to amend the regulation.

2. Modify the accident reporting requirements in RMP*Info to define and record reactive incidents. Consider adding the term “reactive incident” to the four existing “release events” in EPA’s current 5-year accident reporting requirements (Gas Release, Liquid Spill/Evaporation, Fire, and Explosion). Structure this information collection to allow EPA and its stakeholders to identify and focus resources on industry sectors that experienced the incidents; chemicals and processes involved; and impact on the public, the workforce, and the environment.

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National Institute of Standards and Technology (NIST)

Develop and implement a publicly available database for reactive hazard test information. Structure the system to encourage submission of data by individual companies and academic and government institutions that perform chemical testing.

Center for Chemical Process Safety (CCPS) 1. Publish comprehensive guidance on model reactive hazard management systems. At a minimum,

ensure that these guidelines cover: • For companies engaged in chemical manufacturing: reactive hazard management, including hazard

identification, hazard evaluation, management of change, inherently safer design, and adequate procedures and training.

• For companies engaged primarily in the bulk storage, handling, and use of chemicals: identification and prevention of reactive hazards, including the inadvertent mixing of incompatible substances.

2. Communicate the findings and recommendations of this report to your membership. American Chemistry Council (ACC) 1. Expand the Responsible Care Process Safety Code to emphasize the need for managing reactive

hazards. Ensure that: • Member companies are required to have programs to manage reactive hazards that address, at a

minimum, hazard identification, hazard evaluation, management of change, inherently safer design, and adequate procedures and training.

• There is a program to communicate to your membership the availability of existing tools, guidance, and initiatives to aid in identifying and evaluating reactive hazards.

2. Develop and implement a program for reporting reactive incidents that includes the sharing of relevant safety knowledge and lessons learned with your membership, the public, and government to improve

3. Work with NIST in developing and implementing a publicly available database for reactive hazard test information. Promote submissions of data by your membership.

4. Communicate the findings and recommendations of this report to your membership. Synthetic Organic Chemical Manufacturers Association (SOCMA) 1. Expand the Responsible Care Process Safety Code to emphasize the need for managing reactive

hazards. Ensure that: • Member companies are required to have programs to manage reactive hazards that address, at a

minimum, hazard identification, hazard evaluation, management of change, inherently safer design, and adequate procedures and training.

• There is a program to communicate to your membership the availability of existing tools, guidance, and initiatives to aid in identifying and evaluating reactive hazards.

2. Develop and implement a program for reporting reactive incidents that includes the sharing of relevant safety knowledge and lessons learned with your membership, the public, and government to improve safety system performance and prevent future incidents.

3. Work with NIST in developing and implementing a publicly available database for reactive hazard test information. Promote submissions of data by your membership.

4. Communicate the findings and recommendations of this report to your membership. National Association of Chemical Distributors (NACD) 1. Expand the existing Responsible Distribution Process to include reactive hazard management as an area

of emphasis. At a minimum, ensure that the revisions address storage and handling, including the hazards of inadvertent mixing of incompatible chemicals.

2. Communicate the findings and recommendations of this report to your membership. International Association of Firefighters, Paper, Allied-Industrial, Chemical & Energy Workers International Union (PACE)’, The United Steelworkers of America,,Union of Needletrades, Industrial, and Textile Employees (UNITE), United Food and Commercial Workers International Union, American Society of Safety Engineers (ASSE), American Industrial Hygiene Association (AIHA) 1. Communicate the findings and recommendations of this report to your membership. “

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REFERENCES 1To be presented at 3rd NRIFD Symposium March 10-12, 2004, Tokyo] 2 Paul R. Kleindorfer, James C. Belke, Michael R. Elliott, Kiwan Lee, Robert A. Lowe, and Harold I. Feldman, “Accident Epidemiology and the U.S. Chemical Industry:

Accident History and Worst-Case Data from RMP*Info, Risk Analysis, Vol. 23, No. 5, 865-881, 2003 .http://opim.wharton.upenn.edu/risk/wp/wplist02.html

3 Reactive hazard : The author uses the following definition of Reactive Hazard: A substance or a mixture of substances with the potential for a chemical transformation that

generates energy or substances capable of causing harm to people, ecosystems or property. The CSB used a closely related definition: Reactive properties and physical

conditions of a single chemical or mixture that have the potential to generate heat, energy, and gaseous byproducts that have the potential to do harm. (Definition used in

CSB Report, ”Improving Reactive Hazard management,http://www.csb.gov )

4 http://www.harsnet.de

5 Estimating Chemical Accident Costs in the United States: A new Analytical Approach, Collins, L., D’Angelo, C, Mattheissen, C., and Perron, M., in Process Industry

Accidents, Center for Chemical Process Safety, New York City, pp, 467 – 471, 2000

6 For additional information on the history and function of the CSB, see presentation on,” THE ROLE OF THE CHEMICAL SAFETY BOARD IN PREVENTING

CHEMICAL ACCIDENTS , Hazards XVI, 11/06/0i, Manchester, UK Gerald V. Poje, Ph.D., and Isadore Rosenthal, Ph.D,

7 Among these incidents were:: Phillips Petroleum in Pasadena, TX, Arco Refinery in Channelview, TX, Marathon Oil in Texas City, TX, Shell Petroleum in Norco, LA.

8 Clean Air Act, 42 USC 7412

9 Ibid reference 5

10 See CSB website at http://www.csb.gov/ for copies of reports below:

October 29, 2003 Catalyst Systems Inc. Reactive Chemical Explosion, Gnadenhutten, OH

October 15, 2003 First Chemical Corp. Reactive Chemical Explosion, Pascagoula, MS

September 30, 2003 Kaltech Industries Waste Mixing Explosion, New York, NY

September 17, 2003 Environmental Enterprises Hydrogen Sulfide Release, Cincinnati, OH

September 17, 2003

June 25, 2003

May 1, 2003 DPC Enterprises Chlorine Release, Festus, MO

March 6, 2003 Third Coast Industries Petroleum Products Facility Fire, Friendswood, TX

November 20, 2002 Georgia-Pacific Corp. Hydrogen Sulfide Poisoning, Pennington, AL

September 17, 2002

August 28, 2002 Motiva Enterprises Sulfuric Acid Tank Explosion, Delaware City, DE

May 20, 2002 BP Amoco Thermal Decomposition Incident, Augusta, GA

February 1, 2002

December 6, 2001 Bethlehem Steel Corporation Gas Condensate Fire, Chesterton, IN

March 21, 2001 Tosco Avon Refinery Petroleum Naphtha Fire, Martinez, CA

September 21, 2000 Sonat Exploration Co. Catastrophic Vessel Overpressurization, Pitkin, LA

August 16, 2000 Morton International Inc. Runaway Chemical Reaction, Paterson, NJ

June 23, 1999

February 23, 1999 Union Carbide Corp. Nitrogen Asphyxiation Incident, Hahnville, LA

September 23, 1998 Sierra Chemical Co. Reclaimed Munitions Explosion, Mustang, NV

BLSR Operating Ltd. Vapor Cloud Fire, Rosharon, TX

Hazards of Nitrogen Asphyxiation

Improving Reactive Hazard Management

Concept Sciences Hydroxylamine Explosion, Allentown, PA

Herrig Brothers Farm Propane Tank Explosion, Albert City, IA

11 The CSB Safety Bulletin, “Hazards of Nitrogen Asphyxiation” is another example of CSB dealing broadly with a hazard. This bulletin dealt with the nature and

prevention of practices leading to employee asphyxiation from the use of nitrogen during inerting operations.

12 http://www.csb.gov/reports/2000/morton/morton_01.htm

13 “Recommendation 2. to OSHA and EPA Participate in a hazard investigation of reactive chemical process safety conducted by the CSB”, (see report 1998-06-I-NJon the

Morton Chemical incident,, p. 60).

14 The Morton incident resulted from an exothermic runaway reaction involving ortho-nitrochlorbenzene, 2 ethyl-hexyl amine, and automate yellow #96

15 The major U. S.A. regulation covering the impact of poor process safety on employees is the, OSHA Process Safety Management (PSM) Standard (29 CFR 1910.119)

promulgated in 1992.

16 . The NAPP incident involved the water-reactive materials: aluminum powder and sodium hydrosulfite.

17

http://www.csb.gov/

http://www.csb.gov/completed_investigations/info.cfm?ID=40



































http://www.csb.gov/reports/2000/morton/morton_01.htm


18

17 Six labor unions (Union of Needletrades, Industrial, and Textile Employees (UNITE); United Steelworkers of America (USWA); Oil, Chemical, and Atomic Workers

(OCAW); American Federation of Labor-Congress of Industrial Organizations (AFL-CIO); International Association of Fire Fighters (IAFF); and International Chemical

Workers Union (ICWU)) petitioned OSHA for emergency revision of the PSM Standard, stating that it failed to cover reactive chemicals. In a follow-up letter, the labor

unions asked OSHA to consider the following issues in any revision of the standard:

• Addition of NFPA category “1” and “2” reactives to the list of highly hazardous chemicals.

• Hazard evaluation, including the conditions for use of highly hazardous chemicals.

• Adequacy of the NFPA ratings process.

• Synchronization of the OSHA PSM and the EPA RMP lists; and expansion of worker/union involvement.

18 Section 112(r) also required EPA to develop regulations to prevent the accidental release of substances. However, EPA efforts were directed primarily at accidental

releases which could have serious effects on the public or the environment. It was only in 1996, about four years after the PSM was in place, that EPA promulgated its

Accidental Release Prevention Requirements: Risk Management Programs (RMP); 40 CFR 68 in response to this congressional mandate. The RMP standard was aimed

primarily at protecting the public and the environment from the impact of accidental chemical releases. RMP established new requirements with regard to assessing the

potential consequences of accidental releases outside of a facility’s fence line, public notification, emergency response, and accident reporting. The EPA RMP standard

covered some facilities not covered by PSM, as well as many already covered by PSM and it incorporates requirements for managing process safety that are essentially the

same as those of the OSHA PSM Standard. The RMP ‘covers’ substances by listing them and it generally covers many of the same processes and substances covered by the

PSM except that RMP does not cover reactive hazards as such and it has different threshold amounts for many of its covered materials.. .

19 This incident resulted from an exothermic runaway reaction involving ortho-nitrochlorbenzene, 2 ethyl-hexyl amine, and automate yellow #96. See, U.S. Chemical

Safety Board, 2000. Investigation Report, Chemical Manufacturing Incident, Morton International, Inc., Paterson, New Jersey, April 8, 1998, No. 1998-06-I-NJ.

20 This incident involved the water-reactive materials: aluminum powder and sodium hydrosulfite. See, USEPA, 1997. EPA/OSHA Joint Chemical Accident Investigation

Report, Napp Technologies, Lodi, NJ. EPA 550-R-97-002.

21 A runaway reaction was initiated by the introduction of steam into a reactor containing sludge, aluminum, and aluminum chloride. See, U.S. Chemical Safety Board,

2001. Safety Bulletin, Management of Change, No. 2001-04-SB, August 2001.

22 Ammonium nitrate mixed with free nitric acid and became sensitized from a pH drop, titanium piping, and prolonged heating to about 400 F (from 200 psig steam),

resulting in a decomposition reaction which caused an explosion. See, USEPA, 1996. EPA Chemical Accident Investigation Report Terra Industries, Inc., Nitrogen Fertilizer

Facility, Port Neal, Iowa.

23 Terra Industries Inc. self assessment report, July 17 1995, Exhibit 3.

24 In this incident a runaway chemical reaction occurred when a batch reactor was mischarged with butadiene and catalyst during a reactor cleaning operation.

25 This incident involved concentrated hydroxlamine solution. See, U.S. Chemical Safety Board, 2002a. Case Study, The Explosion at Concept Sciences: Hazards of

Hydroxylamine, No. 1999-13-C-PA, March 2002.

26 The court reviewing OSHA citation of Concept Sciences under the PSM standard, sided with Concept Sciences position that OSHA had not established that their process

was covered under the PSM standard.

27 An 8,000 gallon reactor exploded due to overpressures generated by a runaway reaction during the production of phenol-formaldehyde resin. This incident involved

phenol, formaldehyde, catalyst and phenol-formaldehyde resin. See, USEPA, 1999. How to Prevent Runaway Reactions - Case Study: Phenol-Formaldehyde Reaction

Hazards. EPA 550-F99-004.

28 When placed against or close to a hot compressor discharge pipe, bulk sacks of Azinphos methyl (AZM) 50 decomposed generating flammable vapors that then ignited,

causing an explosion. See, USEPA, 1999. EPA/OSHA Joint Chemical Accident Investigation Report, BPS, Inc., West Helena, AK. EPA 550-R-99-003.

29 One of the major considerations in the OSHA listing of a substance as a “reactive hazard’ was an NFPA instability rating “3” or “4” in the 1975 version of NFPA 49,

Hazardous Chemicals Data. An NFPA instability rating of “4” means that materials in themselves are readily capable of detonation or explosive decomposition or explosive

reaction at normal temperatures and pressures. A rating of “3” means that materials in themselves are capable of detonation or explosive decomposition or explosive

reaction, but require a strong initiating source or must be heated under confinement before initiation.

30 In February 1996, the Chemical Manufacturers Association (now the American Chemistry Council - ACC) and the American Petroleum Institute (API) submitted a letter

to OSHA on issues raised in the draft ANPR. It indicated support of PSM as an effective standard, but reflected an opinion that expanding PSM in the ways proposed would

greatly increase compliance costs without substantial benefits and that a large amount of the additional cost would fall on small businesses.

31 The fifth objective which focuses on developing recommendations for reducing the number and severity of reactive incidents, will dealt with in separately since it results

from the type of analysis of conclusions that this section addresses.

32 The Report has 14 Conclusions. However two of them, 8 and 12 are identical.

33 NOAA’s The Chemical Reactivity Worksheet, ASTM’s CHETAH, and Bretherick Database of Reactive Chemical Hazards.

34 “Life cycle” refers to all phases of a chemical manufacturing process–from conceptualization, process research and development (R&D), engineering design,

construction, commissioning, commercial operation, and major modification to decommissioning.”

35 Letter from Merritt to Hensaw Press release, 02/05/04, http//:www.csb.gov

36 Part V Environmental Protection Agency 40 CFR Part 68 Accidental Release Prevention Requirements: Risk Management Program Requirements Under Clean Air Act

Section 112(r)(7); Amendments to the Submission Schedule and Data Requirements; Proposed Rule, July 31, 2003

37 http://www.state.nj.us/dep/enforcement/relprev/tcpa/tcparulefinal.pdf

38 In the summer and fall of 2002 the NJDEP proposed the following approach to the NJDEP revision workgroup, an informal group of individuals chosen by the NJDEP to

provide inputs on revisions under development for the Year 2003:

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• “’Reactive Hazard Substance’ or RHS means an ‘extraordinarily hazardous substance’ (EHS) that is a substance, or mixture of substances, which

individually or when combined, is capable of undergoing chemical transformations producing energy and causing an extraordinarily hazardous accident.”

RHSs are identified at N.J.A.C. 7:31-6.3(a), Table I, Part D, Group I.

• “’Reactive Hazard Substance Mixtures’ means a chemical substance or combination of EHSs that is intentionally mixed in a process vessel and is capable

of undergoing a chemical reaction producing toxic or flammable EHSs or energy. The negative value of the heat of reaction of an RHS mixture is greater

than or equal to 100 calories per gram of RHS mixture (when the intended combination is tested under adiabatic conditions in an acceptable calorimetry test

over a temperature range that is 300 C higher than the maximum projected or observed processing temperature). Reactive Hazard Substance Mixtures

include a reactant, product, or byproduct that is a chemical substance listed in Table I, Part D, Group I or a mixture of substances having one or more

functional groups specified in Table I, Part D, Group II.”

Part D, Group I is a fairly conventional list of highly reactive materials culled from lists such as NFPA 49, 325 and 432 and DOT lists 4.1, 4.2, and 4.3. Part D, Group II is a

list of some 43 functional groups. This NJ ‘functional group’ approach appears to have been constructed in order to establish a de facto class of reactive mixtures that will be

compatible with the enabling NJ law’s apparent injunction that the NJDEP regulate only ‘listed’ chemicals. The aspect of these NJ considerations that is more important and

relevant to our discussion is the planned use of ∆H Mixt as a criterion to define coverage (section 7.31-6.3 (b) of the draft proposal) and to classify any intentionally charged

Reactive Mixtures that can produce more than 100 calories per gram as a Reactive Hazard Substance Mixtures. “

39 http://www.harsnet.de

40 Setting Metrics for Process Safety, Rosenthal, Chem. Eng. Progress, pp. 58-62 (2002)

41 “Improving Coverage of Reactive Hazards Under the OSHA Process Safety management Standard”, Rosenthal, I. and Poje, G., Proceedings of the AIChE Process Plant

Safety Symposium, 2003, New Orleans, pp 1 –26.

42 “Public impact” is defined as known injury, offsite evacuation, or shelter-in-place.

43 OSHA PSM Standard (29 CFR 1910.119) and EPA Accidental Release Prevention Requirements: Risk Management Programs (RMP) Under the Clean Air Act, Section

112(r)(7) (40 CFR 68).

43 An NFPA instability rating of “0” means that materials in themselves are normally stable, even under “fire” conditions.

44 NFPA 49, Hazardous Chemicals Data (1975 Edition).

46 The Chemical Abstracts Service maintains data on over 200,000 chemicals that are listed under national and international regulations.

47 The summation of causal factor statistics exceeds 100 percent because each major incident can, and often has more than one cause.

48 See Section 6.1 for a list of selected literature

49 National Oceanic and Atmospheric Administration’s (NOAA) The Chemical Reactivity Worksheet, American Society for Testing and Materials’ (ASTM) CHETAH, and

Bretherick Database of Reactive Chemical Hazards.

50 A recently initiated CCPS project, Managing Reactive Chemical Hazards, may address this gap in industry guidance.

51 NOAA, The Chemical Reactivity Worksheet; ASTM’s CHETAH, and Bretherick Database of Reactive Chemical Hazards.

52 “Life cycle” refers to all phases of a chemical manufacturing process–from conceptualization, process research and development (R&D), engineering design,

construction, commissioning, commercial operation, and major modification to decommissioning

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