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Unit III Case Study Read the Chemical Safety Board’s case study, The Explosion at Concept Sciences: Hazards of Hydroxylamine, regarding the February, 1999 hydroxylamine explosion at the Concept Sciences facility in Pennsylvania. Click here to access that case study. Then write a report that includes the following: · summary of the incident, · discussion of causal factors, · discussion of how inadequate process safety information contributed to the incident, and · recommendations for improvements to the process safety management program at the facility. Your response should be a minimum of two pages in length, double-spaced. All sources used, including the textbook, must be referenced; paraphrased and quoted material must have accompanying citations, and cited per APA guidelines. Information about accessing the Blackboard Grading Rubric for this assignment is provided below.
QUESTION 1
- Identify a chemical that exhibits at least three of the health hazards discussed in the course textbook. Explain how you made the determination.
Your essay response must be a minimum of 75 words in length.
QUESTION 2
- Identify a chemical that exhibits at least three of the physical hazards discussed in the course textbook. Explain how you made the determination.
Your essay response must be a minimum of 75 words in length.
QUESTION 3
- Explain the concept of Time-Weighted Average (TWA) and how it is used to control workplace exposures to toxic chemicals.
Your essay response must be a minimum of 75 words in length.
QUESTION 4
- In petrochemical processing plants, what would be the most effective method of reducing fire hazards? Support your discussion with examples.
Your essay response must be a minimum of 75 words in length.
QUESTION 5
- The textbook lists six conditions on page 57 that can affect the severity of the injury caused by a toxin. Discuss which of these conditions you feel is the most significant. Explain your choice.
Your essay response must be a minimum of 200 words in length.
QUESTION 6
- Provide an example of a chemical that can enter the body through all four routes of exposure. Describe one or more workplace scenarios that demonstrate how each of the exposures could happen.
Your essay response must be a minimum of 200 words in length.
1
THE EXPLOSION AT CONCEPT SCIENCES:
HAZARDS OF HYDROXYLAMINE
Tom Volk, The Morning Call
INSIDE . . .
Background
2
Incident
7
Analysis
10
Facility Siting 1
5
Conclusion 1
8
References 1
9
CONCEPT SCIENCES, INC.
Hanover Township, Pennsylvania
February 19, 1999
Introduction
This Case Study
describes a catastrophic
hydroxylamine (HA)
explosion that occurred
on February 19, 1999, at
the Concept Sciences,
Inc. (CSI), facility in
Hanover Township,
Lehigh County,
Pennsylvania. Four CSI
employees and one
employee of an adjacent
business were killed; 1
4
people were injured.
KEY ISSUES:
�
Hazards of Processing Hydroxylamine
� Process Hazards Evaluation
� Chemical Facility Siting
No. 1999-13-C-PA
March 2002
Case Study
U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD
2
1.0
Background
At 8:14 pm on February 19, 1999, a
process vessel containing several
hundred pounds of hydroxylamine
(HA) exploded at the Concept
Sciences, Inc. (CSI), production
facility near Allentown, Pennsyl-
vania. Employees were distilling an
aqueous solution of HA and
potassium sulfate, the first
commercial batch to be processed at
CSI’s new facility. After the
distillation process was shut down,
the HA in the process tank and
associated piping explosively
decomposed, most likely due to high
concentration and temperature.
Four CSI employees and a manager
of an adjacent business were killed.
Two CSI employees survived the
blast with moderate-to-serious
injuries. Four people in nearby
buildings were injured. Six
firefighters and two security guards
suffered minor injuries during
emergency response efforts.
The production facility was
extensively damaged (Figure 1). The
explosion also caused significant
damage to other buildings in the
Lehigh Valley Industrial Park and
shattered windows in several nearby
homes.
Tom Volk, The Morning Call
Figure 1
Damage to Concept Sciences, Inc., HA production facility
CSB Case Studies
summarize incident
investigation data and
present conclusions based
on CSB analyses. They do
not discuss root and
contributing causes or make
safety recommendations–
unlike the more
comprehensive CSB
Investigation Reports.
U.S. Chemical Safety and
Hazard Investigation
Board
Office of Investigations and
Safety Programs
2175 K Street NW
Suite 400
Washington, DC 20037
202-261-7600
http://www.chemsafety.gov
3
1.1
Incident Review
Process
CSB examined physical evidence at
the site and reviewed relevant
documents, such as a report
prepared by Hazards Research
Corporation (HRC, 1999) for the
Occupational Safety and Health
Administration (OSHA). CSB also
contracted with the U.S. Department
of the Navy, Naval Sea Systems
Command, Indian Head Naval
Surface Warfare Center, for
assistance in evaluating HA
chemistry and processing. The
center conducts research on
energetic materials (explosives,
propellants, etc.), including HA and
its derivatives.
1.2
Hydroxylamine
Properties and
Applications
HA is an oxygenated derivative of
ammonia, represented by the chemi-
cal formula NH2OH. Table 1 lists its
characteristic properties. HA is
usually handled as an aqueous
solution or as salts. The concen-
trated free base1 is susceptible to
explosive
decomposition.
1 Ammonia and substituted amines are basic
and react reversibly with common acids to
form salts. Treatment of the salts with a
strong base (e.g., potassium hydroxide)
releases the free or unprotonated amine,
known as the “free base.”
Table 1
Characteristic Properties
of Solid or Pure Hydroxylamine
Colorless or white, thermally
unstable, hygroscopic, needle-like
crystals
Decomposes at room temperature
or in hot water
Very soluble in liquid ammonia,
water, and methanol; soluble in
acids
Molecular weight: 33.03
Melting point: 34°C (a)
Boiling point: 110°C
Explosion point: 265°C
Density: 1.227
Vapor pressure:
10 mmHg@47.2°C (b)
Fire hazard when exposed to heat,
flame, and oxidizers
May ignite spontaneously in air if a
large surface area is exposed
Explodes in air when heated above
70°C
Ignites on contact with copper (II)
sulfate, metals, and oxidants (e.g.,
chlorine)
SOURCE: Lewis, 1996.
(a) °C = degrees Celsius.
(b) mmHg = millimeters of mercury.
4
Only salts of HA were available until
the 1980s, when Nissin Chemical
Company, Ltd., of Japan,
commercialized aqueous free-base
HA by adding a proprietary
stabilizer to prevent decomposition.
HA is commercially available in
solutions up to 50 wt-percent.2
Over the past decade, the semi-
conductor manufacturing industry
has used HA solutions in cleaning
formulations to strip process
residues from integrated circuit
devices. HA and its derivatives are
also used in the manufacture of
nylon, inks, paints, pharmaceuticals,
agrochemicals, and photographic
developers.
The current market for
concentrated HA solutions is
expanding. If not for the explosion,
CSI would have been the first
company in the United States to
manufacture this product in
commercial quantities. Nissin
Chemical Company was the sole
global supplier of HA up to that
time. In early 1999, BASF
Aktiengesellschaft started up a new
HA production facility in Germany.
Fourteen months following the CSI
incident, a catastrophic explosion at
the Nissin plant in Japan further
decreased the availability of HA,
creating market shortages.
1.3
CSI Operations
CSI began development of its own
HA production process through
laboratory-scale experimentation in
1997. Development continued with
the construction of a 10-gallon pilot
plant, which was operational in early
1998. In July 1998, CSI leased
approximately 20,000 square feet in
a multiple-tenant building and began
to set up the production facility.
Ashland Chemical Company, a
division of Ashland Inc., was CSI’s
primary customer for purified HA
solutions. Ashland used the HA
solutions in residue cleaners for the
semiconductor industry.
Ashland planned to purchase
2 million pounds of 50 wt-percent
HA from CSI. In exchange for
discounted pricing of future
deliveries of HA solutions, Ashland
provided CSI with financial support
($350,000) to purchase production
equipment. By February 1999, CSI
had approximately 20 full-time
employees, 10 of whom were assigned
to the new production facility.
On the day of the incident, CSI was
producing its first batch of 50 wt-
percent HA solution at the new
facility. CSI’s production process
involved the four basic steps
outlined in Figure 2–reaction,
filtration, distillation, and ion
exchange purification.
2 Weight percent (wt-percent) is the weight of
HA in a solution divided by the total weight
of the solution.
If not for
the explosion,
CSI would have
been the first
company in the
United States
to manufacture
this product in
commercial
quantities.
On the day of
the incident, CSI
was producing its
first batch of
50 wt-percent HA
solution at the
new facility.
�
�
5
1. Reaction of HA sulfate and potassium
hydroxide to produce a 30 wt-percent HA
and potassium sulfate aqueous slurry:
HAS + 2 KOH2��� HA + K2SO4 + 2 H2O
where:
HAS = (NH2OH)2*H2SO4
HA = (NH2OH).
2. Filtration of the slurry to remove
precipitated potassium sulfate solids.
3. Vacuum distillation of HA from the 30 wt-
percent solution to separate it from the
dissolved potassium sulfate and produce
a 50 wt-percent HA distillate.
4. Purification of the distillate through ion
exchange cylinders.
Figure 2
Block flow diagram of the CSI HA production process
6
3
CSI referred to the larger distillation vessel
as the charge tank, though it is commonly
called a still pot. The two smaller receiving
tanks are commonly referred to as distillate
tanks. CSI referred to the vessel receiving
the initial cut of distilled HA solution as the
forerun tank and the vessel receiving the
final cut as the final product tank.
As diagrammed in Figure 3, CSI’s
distillation process included a 2,500-
gallon charge tank (25 feet long and
4 feet in diameter); a vacuum
distillation system, which consisted of
a glass column (heating column) and
remote water heater, a glass
condenser (condenser column) and
remote chiller, and a vacuum pump;
and two product receivers (a forerun
tank and a final product tank, both
1,500-gallon tanks, 15 feet long and 4
feet in diameter).3
The distillation is performed in two
phases. The first phase of the
process begins as a pump circulates
the 30 wt-percent HA from the
charge tank to the heating column, a
vertical tube-in-shell glass heat
exchanger. The HA enters the top of
the column and is heated by 1
20
degrees Fahrenheit (°F) distilled
water as it cascades through the
tubes back to the charge tank.
Vapor from the column is condensed
using a chilled water condenser
(condenser column). The distillate,
initially consisting primarily of water
with some HA, is directed into the
forerun tank.
When the concentration of HA
reaches 10 wt-percent in the forerun
tank, the distillate is diverted to the
final product tank, where it is
collected until the concentration of
the liquid phase in the charge tank
is 80 to 90 wt-percent HA.4 At this
point, the first phase of distillation
is complete.
The charge tank and column are
cleaned using a 30 wt-percent HA
solution, and the charge tank is
taken out of service.
In the second phase of distillation,
the 45 wt-percent HA solution
collected in the final product tank is
further concentrated by redistilla-
tion. It is fed back to the top of the
heating column and flows through
the tubes, where it is heated by
140°F water.
The distillate is directed back to the
final product tank. Water is
removed from the HA solution until
the material in the final product
tank reaches 50 wt-percent HA, at
which point the distillation is
complete.
4
The material in the charge tank is a slurry.
The solids, which are predominately
potassium sulfate, are removed from the
liquid to determine the HA concentration of
the liquid solution.
7
2.0
Description of Incident
2.1
The Incident
CSI began its first distillation to
produce 50 wt-percent HA in the
new facility on Monday afternoon,
February 15, 1999. The charge tank
contained approximately 9,000
pounds of 30 wt-percent HA. About
30 hours of distillation was required
to complete the batch under normal
conditions.
By Tuesday evening, the concen-
tration of liquid solution in the
charge tank was approximately
48 wt-percent, and the product was
being collected in the forerun tank.
CSB was unable to determine exactly
when the product was diverted from
the forerun tank to the final product
tank.
The process was shut down Tuesday
evening for maintenance when it was
determined that water had leaked
Figure 3
Simplified process flow diagram of the CSI HA vacuum distillation process
8
CSI personnel visually monitored
the distillation system for the forma-
tion of crystals. At approximately
7:45 pm Friday, the still was shut
down and cleaned with 30 percent
HA to wash away crystals that may
have formed.5 The second phase of
distillation was never started.
A manufacturing and engineering
supervisor was called at his home
and arrived at the facility shortly
after 8:00 pm. The explosion
occurred at 8:14 pm. The events
during the minutes prior to the
explosion could not be conclusively
determined.
5
The normal procedure was to add 30 wt-
percent HA solution to the charge tank to
dilute the material contained in it. This
material was then circulated through the
heating column and heated to 120°F. The
vapors generated (i.e., water with a low
concentration of HA) were thought to clean
the condenser column.
2.2
Overview of Potential
Initiating Scenarios
Although a detailed review of poten-
tial initiating scenarios is not within
the scope of this case study, HA
crystals and solutions are known to
explosively decompose at high
concentrations (85 wt-percent;
Koseki and Iwata, 2001). Heating
and the presence of contaminants
can accelerate decomposition.
During the distillation process at
CSI, the material from the charge
tank was fed to the heating column.
The mixture returned to the charge
tank had a higher concentration of
into the charge tank through broken
tubes in the heater column. The
necessary repairs were made by
Thursday afternoon, and the distil-
lation process was restarted. At
11:15 pm, the concentration of
liquid solution in the charge tank
was 56 wt-percent, and the concen-
tration of the material collected was
15 wt-percent. The distillation
continued until approximately 11:30
pm that evening.
On Friday, February 19, a 1.5-inch
feed line to the heater column was
replaced with a 2-inch line, which
delayed startup until later in the
morning. The concentration of
liquid solution in the charge tank at
that time was about 57 wt-percent
HA. It steadily increased through-
out the day. Between 7:00 and 7:
15
pm, the concentration of liquid
solution in the charge tank was
recorded as 86 wt-percent HA.
From laboratory distillations, CSI
management knew that crystals
formed with HA concentrations
greater than 80 wt-percent. As
noted in Table 1, crystals of HA are
unstable and potentially explosive.
Management was also aware of the
hazards associated with concentrat-
ing HA. As described in CSI’s
material safety data sheet (MSDS):
Danger of fire and explosion
exists as water is removed or
evaporated and HA concen-
tration approaches levels in
excess of about 70% (CSI,
1997).
Between 7:00
and 7:15 pm, the
concentration of
liquid solution in
the charge tank
was recorded as
86 wt-percent HA.
�
HA crystals and
solutions are known
to explosively
decompose at high
concentrations . . .
Heating and the
presence of
contaminants can
accelerate
decomposition.
�
9
HA because much of the water had
evaporated.
Any of several sequences of events
could have caused this incident–
addition of excessive heat to the
distillation system, physical impacts
from partial or total collapse of the
glass equipment, or inadvertent
introduction of impurities. Friction
may have heated the mixture as it
passed through the pump that
supplied the heating column. With
the HA at a high concentration, this
source of heat could have caused an
explosion within the charge tank or
the feed line to the tank.
2.3
Effects of Explosion
Four CSI employees and a manager
of an adjacent business were killed.
Two CSI employees were buried in
the building rubble until rescued by
emergency responders; their injuries
were moderate to serious. In addi-
tion to six firefighters and two
security guards, who received minor
injuries, four people in a nearby
building were also injured.
The explosion damaged 10 buildings
within the Lehigh Valley Industrial
Park and several local residences. A
toy vending machine business
adjacent to and in the same building
as CSI and a package delivery
service facility across the street
received significant structural
damage. A nearby daycare center
had minor structural damage. Most
of the residential damage was limited
to broken windows. Estimated
property damage in February 1999
was $3.5 to $4 million.
Debris from the blast fell around the
immediate area surrounding the CSI
facility, and a cloud of chemical
residue dispersed downwind of the
site. Liquid potassium hydroxide
solution drained from two onsite
storage tanks onto an adjacent
parking lot.
Hazards Research Corporation, an
OSHA contractor, noted that sections
of the distillation equipment frame
were thrown more than 1,000 feet
(HRC, 1999). No identifiable
sections of the charge tank were
recovered, but the end manway of
the tank was found about 200 feet
east of its original location. Fire
damage was primarily limited to
CSI’s raw materials storage area.
A crater approximately 6 feet wide,
26 feet long, and 16 inches deep was
found in the concrete floor directly
below where the charge tank had
been located (Figure 4). Based on
observed crater dimensions, Hazards
Research Corporation estimated an
explosive force equivalent to 800
pounds of trinitrotoluene (TNT;
HRC, 1999).
Because of the lack of batch records,
it was not possible to determine the
exact amount of HA in the charge
tank at the time of the explosion.
The explosive energy of HA is
essentially equivalent to TNT on a
weight basis. Hazards Research
Corporation estimated that the HA in
the tank was equivalent to 667
pounds of TNT (HRC, 1999).
�
�
Any of several
sequences of
events could have
caused this
incident–addition
of excessive heat
to the distillation
system, physical
impacts from
partial or total
collapse of the
glass equipment,
or inadvertent
introduction of
impurities.
The explosive
energy of HA is
essentially
equivalent to TNT
on a weight basis.
10
3.0
Management of Chemical Process Safety
and documentation” and “process
safety reviews for capital projects”
significantly contributed to the CSI
incident.
3.1
Process Knowledge and
Documentation
System Components
A process safety management system
for chemical manufacturing is only
as good as the foundation upon
which it is built–the actual research,
development, design, construction,
and operational data. Basic process
safety information includes the
following:
� Chemical, physical, and reactivity
properties of materials.
� Health and toxicity data for
reactants and products.
� Thermal and chemical stability
data for reactants and products.
� Process chemistry and technology
information.
� Range of equipment design
temperature and pressure vs
process conditions.
� Equipment and materials of
construction specifications.
� Material and energy balances of
chemical process.
� Safety systems (e.g., interlocks,
pressure relief systems, detection
or suppression systems).
The CSI incident demonstrates the
need for effective process safety
management and engineering
throughout the development, design,
construction, and startup of a
hazardous chemical production
process.
In Guidelines for Technical
Management of Chemical Process
Safety, the American Institute of
Chemical Engineers (AIChE) Center
for Chemical Process Safety (CCPS,
1989) describes the 12 core elements
of a good process safety management
system. Among these elements,
deficiencies in “process knowledge
Figure 4
Building damage and charge tank crater (foreground)
11
� Operating procedures and
training information.
� Design codes and regulatory
standards.
To achieve accident prevention
goals, all of this information should
be compiled, analyzed, and updated
before initiating design and
construction. This information
should be made readily available to
employees.
Inadequacies of Information
Management
At CSI, the development, under-
standing, and application of process
safety information during process
design was inadequate for managing
the explosive decomposition hazard
of HA.
During pilot-plant operation,
management became aware of the
fire and explosion hazards of HA
concentrations in excess of 70-wt
percent, as documented in the MSDS
(see Section 2.1). This knowledge
was not adequately translated into
the process design, operating
procedures, mitigative measures, or
precautionary instructions for
process operators.
CSI’s HA production process, as
designed, concentrated HA in a
liquid solution to a level in excess of
85 wt-percent. This concentration is
significantly higher than the MSDS-
referenced 70 percent concentration
at which an explosive hazard exists.
Only sketches and basic process flow
diagrams were developed; there
were no standard engineering
drawings. Operating procedures
provided only rudimentary
information. Engineering drawings
and detailed operating procedures
should have been a key component of
operations and maintenance
training.
3.2
Process Safety Reviews
for Capital Projects
System Components
In the chemical process industry,
numerous safety reviews commonly
occur during the implementation of
capital projects, such as development
and construction of a new plant.
Among these reviews are hazard
reviews (discussed below), siting
reviews, and process design reviews.
Hazard Reviews
A hazard review is a systematic
method for identifying process and
occupational hazards. Many types of
hazard reviews may be performed at
various stages in a project life cycle.
An adequate reactive chemical
hazard evaluation and process
hazard analysis (PHA) would have
helped CSI quantify, evaluate, and
mitigate the hazards of HA
production. Such analyses might
have caused management to question
whether its planned process
presented substantial risks to
employees and to the community.
�
CSI’s HA
production process
. . . concentrated
HA in a liquid
solution to a level
in excess of
85 wt-percent . . .
significantly
higher than the
MSDS-referenced
70 percent
concentration at
which an explosive
hazard exists.
An adequate
reactive chemical
hazard evaluation
and process
hazard analysis
would have helped
CSI quantify,
evaluate, and
mitigate the
hazards of HA
production.
�
12
Inadequacies of Reactive
Hazard Review
Typically, the first step in a reactive
hazard evaluation is a literature
search. HA has long been
recognized as an unstable chemical
and explosive when concentrated at
high
temperatures.
Bretherick’s
Handbook (1999) describes a 1948
incident in which an extremely
violent explosion occurred toward
the end of vacuum distillation.
Additional incidents involving HA or
its salts are also documented. As
demonstrated in the Hazards
Research Corporation report, a
literature review would have readily
identified that HA is subject to rapid
exothermic decomposition and
exhibits an explosive force equiva-
lent to TNT (HRC, 1999).
HA could have been tested within
CSI’s process parameters to estab-
lish the magnitude of potential
reactive chemical hazards.6 Basic
reaction hazard testing and evalua-
tion procedures are readily avail-
able. For example, the following
documents contain review assess-
ment and evaluation strategies,
including commonly available
screening methods:
� Chemical Reaction Hazards
(Barton and Rogers, 1997).
� Guidelines for Chemical
Reactivity Evaluation and
Application to Process Design
(CCPS, 1995a).
� Guidelines for Safe Storage and
Handling of Reactive Materials
(CCPS, 1995b).
The Health and Safety Executive
(HSE) of the United Kingdom has
published additional guidance since
the CSI incident (Designing and
Operating Safe Chemical Reaction
Processes [HSE, 2000]).
As demonstrated during laboratory
distillations, CSI’s process chemistry
created the potential for HA crystal
formation and exothermic decompo-
sition. During preproduction
development, the potential of HA
concentrations exceeding 70 wt-
percent to explosively decompose
should have been investigated to
determine the magnitude of the
hazard.
Prior to or during development of
the process design, CSI should have
systematically evaluated the reactive
hazards of its process and identified
control measures. Potential reactive
hazards include concentration
peaks, temperature variations,
possible interactions with impurities
or contaminants, and stabilizer
requirements.
Inadequacies of Process
Hazard Analysis
CSI purchased equipment before it
had conducted a formal engineering
design review for the specific
manufacturing process. CSI’s design
6
Although CSI conducted numerous
laboratory tests to assess the stability of HA–
particularly with respect to stabilizers–it is
not evident that it completed a detailed
reactive analysis of specific process
conditions and deviations, such as the
presence of HA crystals or the addition of
heat.
� HA has long been
recognized as an
unstable chemical
and explosive
when concentrated
at high
temperatures.
13
and safety review was inadequate
given the hazards of highly
concentrated HA. A critical
evaluation of process materials,
conditions, equipment, and
development experience would have
indicated that credible scenarios
presented the potential of a
catastrophic HA explosion.
Process development records show
that CSI was aware that its process
created potentially hazardous
conditions in the charge tank (i.e.,
HA concentration exceeding 80 wt-
percent mixed with solid potassium
sulfate). An effective PHA during
process design would have provided
CSI with scenarios resulting in
explosions similar to the one that
occurred. CSI could have then
developed appropriate control
measures or modified the process
chemistry to avoid high concentra-
tions of HA.
CSI performed a “What If ” PHA,
which was reported in a one-page
document. However, it did not
adequately address the prevention
or consequences of events that could
trigger an explosion of high
concentrations of HA, such as the
following:
� High concentrations of potassium
sulfate in the charge tank.
� Potential formation of solid HA
crystals in the condenser and
charge tank.
� Potassium sulfate blockage of
reboiler tubes.
� Adequacy of flow and temperature
indicators.
� Failure of process equipment and
controls.
� Inappropriate facility siting (i.e.,
proximity to the public).
The PHA recognized the potential
danger of the process and identified
safeguards, such as remote control
operation, blowout walls, and
shielding for protecting employees if
foreseeable hazards were realized.
However, CSI did not implement any
of these safeguards.
3.3
Subsequent Incidents
Involving
Hydroxylamine
Subsequent to the CSI incident,
Koseki and Iwata (2001) evaluated
the ability of HA to detonate at high
concentrations while under
containment. The June 10, 2000,
Nissin Chemical Company HA
incident, in Gunma, Japan, caused
four fatalities, injured 58 people,
destroyed the HA distillation tower,
and significantly damaged the plant.
To produce 50 wt-percent HA
solutions, Nissin used a process
similar to CSI’s.
Prior to the explosion at Nissin, the
HA process had been shut down for
5 hours to replace oil in a vacuum
pump. The explosion occurred
approximately 30 minutes after
startup, during distillation. The
process concentration of HA, prior
to the incident, was 85 wt-percent.
The results of Koseki’s steel tube test
indicated that 85 wt-percent HA was
easily detonated.
� A critical
evaluation of
process materials,
conditions,
equipment, and
development
experience would
have indicated that
credible scenarios
presented the
potential of a
catastrophic HA
explosion.
14
3.4
Regulatory Coverage of
Hydroxylamine
OSHA’s Process Safety Management
(PSM) standard (29 CFR 1910.119)
regulates facilities with any process
that contains 2,500 pounds or more
of HA.
On August 11, 1999, OSHA issued
CSI several willful and serious
citations, alleging multiple violations
of the PSM standard. CSI contested
the citations. On November 5, 2001,
a settlement was reached between
OSHA and CSI in which the
citations were kept, but with willful
violations reclassified.7
The OSHA citations included the
following PSM violations:
� Failure to compile written process
safety information to enable the
employer and employees to
identify and understand specific
hazards.
� Failure to develop and implement
written operating procedures
for safety systems and their
functions–startup, shutdown, and
normal operation–or for the
consequences of deviation from
operating limits.
� Failure to document that the
process equipment complied with
generally accepted good
engineering practices.
� Failure to conduct an adequate
and appropriate process hazard
analysis.
� Failure to conduct adequate
process training.
� Failure to perform a prestartup
safety review.
� Failure to establish and implement
procedures for the management
of change.
On November 9, 2000, a Federal
grand jury indicted the president of
CSI for alleged criminal violations of
the PSM standard. The U.S.
Attorney’s Office for the Eastern
District of Pennsylvania
subsequently prosecuted these
criminal charges pursuant to Section
17(e) of the Occupational Safety and
Health Act (29 U.S.C. § 666(e)). On
September 5, 2001, as a result of the
defendant’s Motion to Dismiss, a U.S.
District Court dismissed the
indictment, specifying that the PSM
regulation is ambiguous with respect
to whether CSI’s HA production
process is covered, and that informal
interpretations issued by OSHA are
prohibited from being used against
the defendant in a criminal case.
7Willful violations were changed to violations
under “Section 17” of the Occupational
Safety and Health Act of 1970.
15
4.0
Hazardous Chemical Facility Siting
4.1
Site Evaluation and
Selection
Facility siting evaluations typically
include process safety analyses and
reviews of government regulations,
industry guidelines, and local
emergency planning requirements.
CSI was located in a multiple-tenant
building within a suburban
industrial park. Fortunately, the
timing of the explosion–8:14 pm on a
Friday–limited the number of
fatalities and injuries.
One of the fatalities was an employee
of another company, whose work area
was separated from CSI by a concrete
block wall. Several workers at a
package delivery service facility–
located directly across the street–
were injured, and the building was
extensively damaged (see top left
corner of cover photograph). A
daycare center located within 900 feet
of the explosion and several nearby
residences received minor damage.
Facility siting should consider all
potential hazards (e.g., fire,
explosion, toxic material release) to
people, property, and the
environment. Siting evaluations
should be an integral part of process
design. If CSI had performed an
adequate PHA for the planned HA
manufacturing operation, it would
have recognized the danger to the
public. Management could have
selected an alternate site where no
one at neighboring facilities would
be exposed to such a substantial risk.
Ashland Chemical Company raised
the facility siting issue in its process
review. The original siting location
considered by CSI was similar to the
one finally chosen. It was described
by Ashland as:
. . . an office/commercial type
building . . . not a separate
building but connected in a
strip to other buildings.
Ashland concluded that the building
was “not a good location for a
chemical process.”
4.2
Industry Guidance
The explosives industry uses physi-
cal separation between explosive
hazards and occupied buildings as
an effective mitigation technique.
The American Table of Distances for
Storage of Explosive Materials,
published by the Institute of Makers
of Explosives (IME, 1991), provides
guidance on the safe separation of
explosive hazards from inhabited
buildings. Although this information
was developed for the manufacture
and storage of commercial explo-
sives, it demonstrates the importance
of chemical facilities also ensuring
the safe siting of potentially explo-
sive operations.
If CSI had
performed an
adequate [process
hazard analysis]
for the planned
HA manufacturing
operation, it would
have recognized
the danger to
the public.
�
16
Several industrial risk insurers
provide siting guidance for
petroleum and chemical facilities.
This guidance is developed primarily
for determining appropriate spacing
between process units within plants
to minimize property losses and is
not intended to provide for the
safety of building occupants.
Available industry guidance
includes:
� Factory Mutual Insurance
Company’s Property Loss
Prevention Data Sheet, Spacing
of Facilities in Outdoor Chemical
Plants (2000).
� Industrial Risk Insurers’
IRInformation guideline, Oil and
Chemical Plant Layout and
Spacing (2000).
� CCPS’s Guidelines for Evaluating
Process Plant Buildings for
External Explosions and Fires
(1996).
� American Petroleum Institute’s
(API) Management of Hazards
Associated With Location of
Process Plant Buildings (1995).
The spacing distances provided in
these guidelines demonstrate the
value of using physical separation to
protect buildings located near
hazardous processes.
4.3
Local Planning and
Zoning Authorities
CSI considered two locations near
Allentown, Pennsylvania, for the HA
production facility. There are two
Hanover Townships in this area, one
in Northampton County and the
other in Lehigh County.
CSI first considered a site in
Hanover Township, Northampton
County, the site referenced in the
Ashland process review (Section 4.1).
This township’s zoning ordinance
included regulations for applying to
the planned industrial/business park
district, which did not permit the
siting of a manufacturing facility
“whose primary uses involve
chemical manufacturing or . . .
hazardous chemicals or materials”
without conditional approval. CSI
was notified on March 30, 1998, that
the zoning officer could not issue a
building permit or a certificate of
occupancy.
CSI then identified the site on Roble
Road in Hanover Township, Lehigh
County. Hanover Township granted
CSI a certificate of occupancy for
this site on September 16, 1998.
According to a township represen-
tative, the zoning ordinance did not
prohibit chemical manufacturing
facilities in Lehigh
Valley Industrial
Park in July 1998.
Hanover
Township issued a zoning permit to
Lehigh Realty Associates, owner of
the building, on September 18, 1998.
CSI provided the local township with
MSDSs for raw materials and
finished products, but did not alert it
to the process hazards associated
with HA production.
�
� CSI provided the
local township with
MSDSs for raw
materials and
finished products,
but did not alert it
to the process
hazards
associated with
HA production.
. . . the zoning
ordinance did not
prohibit chemical
manufacturing
facilities in Lehigh
Valley Industrial
Park in July 1998.
17
4.4
Local Emergency
Planning Committees
As a result of the Federal Emergency
Planning and Community Right-to-
Know Act of 1986 (EPCRA; 42
U.S.C. § 11011-11050), Local
Emergency Planning Committees
(LEPCs) were established across the
country, most commonly as county-
level organizations. Their
responsibilities included the review
or development of local emergency
plans for responding to hazardous
chemical releases, and the collection
and dissemination of chemical
information to the public.
In 1990, Pennsylvania implemented
EPCRA by promulgating Act 165,
known as the Hazardous Materials
Emergency Planning and Response
Act (35 Pa. Stat. Ann. § 6022.101-
6022.307). It established a system of
fees and grants to support LEPCs in
meeting the requirements of EPCRA.
Each of Pennsylvania’s 67 counties is
designated as a Local Emergency
Planning District, and each is
required to have a planning
committee.
Pennsylvania LEPC responsibilities
are essentially those established by
EPCRA, with additional specific
requirements under Act 165. One of
these requirements is promulgated in
Section 203(g)(5), which describes
one of the duties of an LEPC as
follows:
Meet, when appropriate, with
any Commonwealth agency or
local or regional agency, which
is empowered to exercise the
governmental functions of
planning and zoning, to
regulate land use and land use
development, or to authorize
the siting of a facility within
the county to discuss and
review with the Common-
wealth agency and local
agency all mitigation factors
necessary to protect the
health, safety and welfare of
the general public from a
potential release of hazardous
materials from a proposed
facility. Mitigation factors
include, but are not limited to,
environmental impacts,
shelter and evacuation
feasibility, emergency warning
and communications,
availability of response
equipment and future
population and economic
growth in the area of the
proposed facility.
Act 165 allowed the Lehigh County
LEPC to become engaged in the
facility siting process prior to the
issuance of an occupancy permit for
the industrial park location.
However, the LEPC was not notified
of the CSI
siting issue.
Prior to and
as of this writing, no planning or
zoning authority has notified the
Lehigh County LEPC of any new
chemical facility development within
the county.
� Act 165 allowed
the Lehigh County
LEPC to become
engaged in the
facility siting
process prior to
the issuance of an
occupancy permit
for the industrial
park location.
However, the
LEPC was not
notified of the CSI
siting issue.
18
The following factors contributed to
the cause and serious consequences
of the CSI incident:
� CSI’s process safety manage-
ment systems were insufficient to
properly address the hazards
inherent in its HA manufacturing
process and to determine whether
these hazards presented
substantial risks.
� Inadequate collection and analysis
of process safety information
contributed to CSI’s failure to
recognize specific explosion
hazards.
� Basic process safety and chemical
engineering practices–such as
process design reviews, hazard
analyses, corrective actions, and
reviews by appropriate technical
experts–were not adequately
implemented.
� The existing system of siting
approval by local authorities
allowed a highly hazardous
5.0
Conclusion
facility to be inappropriately
located in a light industrial park.
The hazards and complexity of CSI’s
HA production process required
careful and comprehensive
application of current engineering
codes, guidelines, and good
practices. Based on many years of
research and experience, these tools
are well established and represent
the fundamental principles of
chemical engineering design.
Manufacturers should take the
necessary actions to minimize
hazards and implement appropriate
safeguards while developing HA
production capabilites. Government
agencies, local officials, suppliers,
and customers share a responsibility
for reducing the likelihood and
serious consequences of incidents
similar to that which occurred at
CSI.
�
�
CSI’s process
safety
management
systems were
insufficient to
properly address
the hazards
inherent in its HA
manufacturing
process . . .
Government
agencies, local
officials, suppliers,
and customers
share a
responsibility for
reducing the
likelihood
and serious
consequences
of [similar]
incidents . . .
19
American Petroleum Institute (API),
1995. Management of Hazards
Associated With Location of
Process Plant Buildings,
Recommended Practice 752, May
1995.
Barton, John, and Richard Rogers,
1997. Chemical Reaction
Hazards, Rugby, U.K.: Institution
of Chemical Engineers (IChemE).
Bretherick, Leslie, P. G. Urben, and
Martin J. Pitt, 1999. Bretherick’s
Handbook of Reactive Chemical
Hazards, Sixth Edition, Vol. 1,
Butterworth-Heinemann.
Center for Chemical Process Safety
(CCPS), 1996. Guidelines for
Evaluating Process Plant
Buildings for External Explosions
and Fires, American Institute of
Chemical Engineers (AIChE).
CCPS, 1995a. Guidelines for
Chemical Reactivity Evaluation
and Application to Process Design,
AIChE.
CCPS, 1995b. Guidelines for Safe
Storage and Handling of Reactive
Materials, AIChE.
CCPS, 1989. Guidelines for
Technical Management of
Chemical Process Safety, AIChE.
Concept Sciences, Inc. (CSI), 1997.
50-HA Material Safety Data
Sheet, Revision 2, October 27,
1997.
Factory Mutual Insurance Company,
2000. Spacing of Facilities in
Outdoor Chemical Plants, FM
Global Property Loss Prevention
Data Sheets 7-44, 17-3, May 2000.
Hazards Research Corporation
(HRC), 1999. Concept Sciences,
Incorporated, Hydroxylamine
Explosion, February 19, 1999,
HRS Report 8034, prepared for
U.S. Department of Labor, OSHA,
July 2, 1999.
Health and Safety Executive (HSE),
2000. Designing and Operating
Safe Chemical Reaction Processes,
Norwich, U.K.: HSE Books.
Industrial Risk Insurers, 2000. Oil
and Chemical Plant Layout and
Spacing, IRInformation Guideline
IM.2.5.2, June 3, 1996.
Institute of Makers of Explosives
(IME), 1991. American Table of
Distances for Storage of Explosive
Materials, Safety Library
Publication No. 2, June 1991.
Koseki, Hiroshi, and Y. Iwata, 2001.
“Study on Risk Evaluation of
Hydroxylamine/Water Solution,”
Proceedings, Beyond Regulatory
Compliance, Making Safety
Second Nature, Mary Kay
O’Connor Process Safety Center,
Texas A&M University, October
2001.
Lewis, Richard J., 1996. Sax’s
Dangerous Properties of
Industrial Materials, Ninth
Edition, Van Nostrand Reinhold.
Surrick, Judge R. Barclay, 2001.
United States of America v. Irl
“Chip” Ward, CN-00-681, U.S.
District Court for the Eastern
District of Pennsylvania.
6.0
References
20
CSB Investigation Reports may be
purchased from:
National Technical Information Service
5285 Port Royal Road
Springfield, VA 22161
(800) 553-NTIS or (703) 487-4600
Email: info@ntis.fedworld.gov
For international orders, see:
http://www.ntis.gov/support/cooperat.htm.
Information on available publications may
be obtained by contacting:
U.S. Chemical Safety and Hazard
Investigation Board
2175 K Street NW, Suite 400
Washington, DC 20037
(202) 261-7600
CSB is an independent Federal agency whose mission is to ensure the safety of
workers and the public by preventing or minimizing the effects of chemical incidents.
CSB is a scientific investigative organization; it is not an enforcement or regulatory
body. Established by the Clean Air Act Amendments of 1990, CSB is responsible for
determining the root and contributing causes of accidents, issuing safety
recommendations, studying chemical safety issues, and evaluating the effectiveness of
other government agencies involved in chemical safety. No part of the conclusions,
findings, or recommendations of CSB relating to any chemical incident may be
admitted as evidence or used in any action or suit for damages arising out of any matter
mentioned in a CSB report (see 42 U.S.C. § 7412(r)(6)(G)). CSB makes public its
actions and decisions through investigation reports, summaries, and briefs; safety
bulletins; safety recommendations; case studies; special technical publications; and
statistical reviews. More information about CSB is found on the World Wide Web at
http://www.chemsafety.gov.
Salus Populi Est
Lex Suprema
People’s Safety
is the Highest Law
