Investigation Report Recommends Agencies Join CSB In Study of Reactive Chemicals Safety and Issue Guidelines

(WASHINGTON, D.C. - August 24, 2000) Members of the U.S. Chemical Safety and Hazard Investigation Board (CSB) have voted to adopt a final investigation report on the April 1998 explosion at Morton Specialty Chemical's (now Rohm & Haas) Paterson, New Jersey facility, saying the April 1998 incident likely could have been prevented.

The report says the incident might not have occurred had the company's safety program for reactive chemicals followed recommended industry safety practices. The blast injured nine workers and released chemicals into the neighboring community.

The Board immediately made the full text of the report available for viewing and downloading on the CSB web site.

The Board also adopted a number of recommendations, including two to both the U.S. Environmental Protection Agency (EPA) and the Occupational Safety and Health Administration (OSHA). The first recommendation requests that EPA and OSHA issue joint guidelines for the management of reactive chemical process hazards. The Board noted that existing federal safety standards do not provide sufficient guidance for reactive chemical process safety, in such areas as reporting and investigating deviations from normal operations, the use of chemical screening techniques and proper design for pressure relief, emergency cooling and safety interlock systems.

The other recommendation involving OSHA and EPA urges the two agencies to join the CSB, and other chemical safety organizations, including industry, in a CSB "hazard investigation" of reactive chemical process safety.

Unlike an investigation of a particular incident such as the one at Morton, the CSB hazard investigation will examine a series of related incidents to identify common incident causes so that the Board may make recommendations for preventing them in the future. This hazard investigation will result in further recommendations for preventing incidents similar to the 1998 explosion at Morton. The Board said that the CSB will seek input from interested parties regarding the design and conduct of the hazard investigation.

Board Member Dr. Andrea Kidd Taylor said the Morton investigation report is important both to the Paterson community in which the incident occurred, but also to all facilities, worldwide, that are engaged in reactive chemical processes. The Morton report contributes to the growing body of knowledge about reactive chemical hazards.

"This report also represents a good foundation upon which the Board and its partners hope to build further conclusions on reactive chemical safety by examining a number of similar incidents," Taylor said.

RUNAWAY CHEMICAL REACTION The Paterson plant manufactures a series of dye products. The explosion and fire occurred during the production of Yellow 96 Dye, which was used to tint petroleum fuel products. A 2,000-gallon kettle being used to produce the dye experienced an uncontrolled rapid temperature and pressure rise (runaway chemical reaction) which resulted in the explosion, injuries and release of material into the community. Yellow 96 Dye was produced by the mixing and reaction of two chemicals, ortho-nitrochlorobenzene (o-NCB) and 2-ethylhexylamine (2-EHA).

The Board concluded that the safety programs that were used by Morton for managing reactive chemical hazards did not uncover the potential for a catastrophic runaway chemical reaction in the production of Yellow 96 Dye. The Board also found that important safety information and recommendations about the hazards of the Yellow 96 Dye process discovered by Morton's United Kingdom research facility were not made known to development and production people at the Paterson facility. This resulted in design flaws and omissions in the kettle and operating instructions used to produce the dye.

For example, CSB investigators found that the kettle did not have the cooling capacity to safely control the temperature of the reaction if reasonably foreseeable upsets occurred. The kettle also was not equipped with safety equipment, such as a quench system or a reactor dump system, to stop the process in the event of a runaway reaction. In addition, a high-pressure relief device was far too small to safely vent the excess pressure in the event that an uncontrollable runaway reaction took place.

Investigators further determined that company training and operating procedures did not prepare operators to safely operate the process to produce the dye or to recognize hazardous situations that would require evacuation of the facility. Some of those injured had stayed near the kettle even while pressure was building uncontrollably and the vessel was rumbling and showing other signs of an impending explosion.

RECOMMENDATIONS MADE TO THE COMPANY The Board made the following recommendations to Morton Specialty Chemical:

- Establish a program to ensure that reactive chemical process safety information and operating experience is shared with all relevant units of the company.

- Revalidate Process Hazard Analyses for all reactive chemical processes in light of the findings of the CSB report and upgrade, as needed, equipment, operating procedures and training.

- Evaluate pressure relief requirements for all reaction vessels using appropriate technology, such as the Design Institute for Emergency Relief Systems (DIERS) method and test apparatus, and upgrade equipment as needed.

- Evaluate the need for and install as necessary, devices, such as alarms, added safety instrumentation, and quench or reactor dump systems, to safely manage reactive chemical process hazards.

- Revise operating procedures and training for reactive chemical processes as needed, to include descriptions of the possible consequences of deviations from normal operational limits and steps that should be taken to correct these deviations, including emergency response actions.

- Implement a program to ensure that deviations from normal operational limits for reactive chemical processes that could have resulted in significant incidents are documented, investigated and necessary safety improvements are implement. Revise the Yellow 96 Material Safety Data Sheet (MSDS) to show the proper boiling point and NFPA reactivity rating. Evaluate the need for and change, as necessary, the MSDSs for other Morton dyes. Communicate the MSDS changes to current and past customers (who may retain inventories of these products).

At a July 18 public meeting held in Paterson, New Jersey to present the CSB's preliminary findings and recommendations, Morton company officials indicated that the company agreed "in principle with the recommendations the staff [had] outlined. In fact, most of the recommendations have already been implemented at the facility". In addition to the recommendations to the company, EPA and OSHA, the Board also recommended that a number of organizations distribute the findings of the Morton investigation report to their membership. The organizations include the American Chemistry Council; Center for Chemical Process Safety; Paper, Allied-Industrial, Chemical & Energy Workers International Union; and the Synthetic Organic Chemical Manufacturer's Association.