The U.S. Chemical Safety and Hazard Investigation Board (CSB) plans to issue two special Safety Bulletins arising out of board accident investigations.
One bulletin will focus on safety assessing and controlling hazards associated with changes in chemical processes, commonly known as "Management of Change."
Management of Change is a central feature of OSHA''s Process Safety Management standard.
CSB found that ineffective Management of Change likely contributed to three serious accidents:
- a fire at the Puget Sound Refining Co. in Anacortes, Wash.;
- a fire and explosion during specialized operations at a petroleum well in Bienville Parish, La.; and
- a runaway reaction and fire at a Condea Vista chemical plant in Baltimore, Md.
All three incidents occurred during the fall of 1998, the first year of CSB''s operations.
CSB Safety Bulletins are information publications on significant topics in chemical safety, usually stemming from Board investigations or hazard studies.
The intended audience includes plant managers, engineers and operators, safety professionals, and trade and labor groups.
"A Safety Bulletin is a new product for the agency, one which gets right to the heart of our mission to prevent chemical accidents," said Bill Hoyle, CSB director of investigations and safety programs. "By distilling the messages from multiple events, we hope to draw heightened attention to the common, preventable causes of chemical accidents. In some cases, Safety Bulletins will reach a wider audience than individual accident reports."
A second bulletin will draw attention to the hazards associated with hydroxylamine, a potentially explosive substance used in semiconductor manufacturing and other applications.
On Feb. 19, 1999, a hydroxylamine explosion destroyed the Concept Science plant in Allenton, Pa., killing five.
The blast left the United States without any domestic sources of hydroxylamine.
"We arrived at this decision after a lengthy review process, including an independent assessment by an outside safety engineering firm," commented, Board Member Andrea Taylor. "In the first year or so of the Board''s existence, more cases were initiated than could readily be completed, given the available resources. Issuing the bulletins will draw these four cases to a meaningful conclusion."
CSB contracted earlier this year with a Maryland engineering firm to review case files for all five investigations.
The consultants evaluated the resources needed to complete each investigation, the obstacles to producing scientific reports and the accident prevention value of the finished products.
All the cases studied were initiated under former Board Chairman Paul Hill, who resigned on Jan. 12 of this year.
"Until this year," noted Taylor. "the Board functioned with a skeleton investigations staff. We know have refocused our resources in a fairly dramatic way, putting the majority of our budget into investigations and recruiting a number of seasoned accident investigators and safety professionals. Over the next several years, we will build the capacity to conduct three to five major accident investigations per year. Well-trained teams will be dispatched to each accident site, and once deployed we will wrap each case up as expeditiously as possible."
Taylor said she expects CSB to publish the two safety bulletins by the early spring of 2001.
An outreach effort to publicize the bulletins will be undertaken, said Taylor.
A fifth case, involving a December 1998 explosion at Michigan-based Independence Fireworks, will also be closed.
CSB observations on this case will be shared with other agencies and organizations.
"The Safety Bulletins will be a valuable product from the early cases. We think these bulletins can play a constructive role in preventing future lapses in good practices that can lead to accidents," said Taylor. "Effective Management of Change procedures are an important component of good safety programs, as recognized by OSHA and many other organizations. Obviously not everyone is getting the message, however, that''s where the bulletins can help."
by Virginia Sutcliffe