Document 2R0yypR2eDYjRZZxxo6OeN1bR
REDACTED
I N T R Q F F l C MEMORANDUM
Date: From:
Dept:
Tel No:
16-May-1994 09:33am EDT KASWELLG KASWELLG@PED26QMRGATE@CLE
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Subject: NARRATIVE REPORT DISTRIBUTION Subject:
INCIDENT OF EXPERIENCE
VCM RELEASE
THE GEON COMPANY ' PEDRICKTQWN, NJ PLANT
VALUE
SUMMARY AND CAUSE:
ON FEBRUARY 21,1994, A LEAK OCCURRED ON THE EQUIPMENT RECOVERY HEADER FROM THE RECOVERED MONOMER SAMPLE STATIONRESULTING IN THE RELEASE OF APPROXIMATELY 6.4 POUNDS OF VINYL CHLORIDE (VCM) OVER THE 4 MINUTES THAT THE LINE WAS UNDER PRESSURE. WATER HAD ACCUMULATED IN THE LINE AND THEN FROZE, CAUSING THE LINE TO RUPTURE. THE LEAK OCCURRED AFTER SEVERAL DAYS OF WARM WEATHER. ONE EMPLOYEE WAS EXPOSED TO THE VCM. HE WAS GIVEN APPROPRIATE MEDICAL ! SURVEILLANCE THE FOLLOWING DAY. THERE WERE NO OTHER INJURIES, AND THERE WAS NO EQUIPMENT DAMAGE.
3QARD OF REVIEW:
A BOARD OF REVIEW WAS HELD ON ON FEBRUARY 2i, 1994, WITH THE FOLLOWING IN
ATTENDANCE:
CONSOLE TECHNICIAN
DAVE DORAN
CONSOLE TECHNICIAN
NORM AVARS
LEAD TECHNICIAN
JIM DIRIENZO
SR PROCESS ENGINEER
SILL WAGNER
SUSPENSION RESIN MANAGER
MAY JOHNSON
SR ENVIRONMENTAL ENGINEER
DENNIS O ? KEEFE
MANAGER, SAFETY AND HEALTH
BILL FULTZ
plant manager
CORRECTIVE ACTION:
NGC 13674
CiN i -jM.'itK ;
j ) i|j(_ Miiiii! Cnli i
M,-r .Nl i- ` i >* 'r..... Y. c i- r<.QB ulLrtS UN fMt
RU.l:-. ERv CYST . SS `if A 3 R |.,JAS BEING P'.^LSL- INTO Ti-:-. S.STEn A iEN THE
QUlr-MS>N i -RECOVERY SYSTEM WAS IN SERVICE . TREY CHECKll- I HE SYSTEM FOR ANY
OBVIOUS PROBLEMS, AND FOUND NONE. THE DAY SHIFT ALSO CHECKED THE SYSTEM AND
POUND NO OBVIOUS PROBLEMS. NORM AYARS AMD
... CHANGED THE
RUPTURE DISC- ON TK-iE, BUT THAT HAD NO EFFECT. THE EQUIPMENT RECOVERY ..
HEADER CAN BE SEPARATED INTO TWO PIECES, THE POLY SIDE AND THE BUILDING
SIDE. THIS SHIFT (AVARS, AND DAVE DORAN) HAD PRESSURE ON THE
HEADER EARLIER IN THE MORNING ON THE 21ST AND HAD DETERMINED THAT THE LEAK., .
WAS ON THE BUILDING SIDE OF THE HEADER, AT ABOUT 1035 HRS, DORAN PUT A BLOWDOWN
TANK ON EQUIPMENT RECOVERY, AND AYARS AND '
' WERE PREPARED TO GO LOOK FOR
ANY FUGITIVE EMISSIONS WITH HNU METERS.
. u.
ALMOST IMMEDIATELY, THE 25% LEL ALARM IN THE RECOVERED MONO^M..
WMT
OFF. DORAN CLOSED THE VALVES ON THE BLOWDOWN TANK TO START TO 'pOCL THE
EQUIPMENT RECOVERY HEADER DOWN TO A VACUUM. THE 50% LEL (IN THE RECOVERED .
MONOMER DIKE AREA) WENT OFF, SETTING OFF THE DELUGE SYSTEM AND SOUNDINGJTHE
FIRE ALARM. DIRIEN20 WENT TO INVESTIGATE, GOT AS FAR AS THE yTJLITY BUILDING,
SMELLED VCM, AND CAME INTO THE CONTROL ROOM TO SOUND THE GA AL^RM.
WITHIN 4 MINUTES, THE EQUIPMENT RECOVERY HEADER WAS UNDER A VACUUM, AND
DORAN SWITCHED OVER TO THE VACUUM JETS. AYARS VALVED OUT THE DELUGE, AND
HE, '
DIRIENZO, BOB BACON, AND GEORGE LEHMAN RESPONDED TO THE
RECOVERY STRUCTURE. AYARS AND '
WERE EQUIPPED WITH HNU METERS TO
HELP FIND THE LEAK. THEY WERE DOING A SYSTEMATIC SEARCH OF THE STRUCTURE
WHEN BACON NOTICED SOME VCM VAPORS COMING FROM THE INSULATION ON THE
EQUIPMENT RECOVERY PIPING FROM THE RECOVERED MONOMER SAMPLE STATION.
THE SAMPLE STATION WAS ALREADY ISOLATED FROM THE RECOVERED MONOMER PUMPS,
BUT AYARS ALSO CLOSED THE BLOCK VALVE ON THE EQUIPMENT RECOVERY HEADER PIPING,
FURTHER ISOLATING THE LEAK.
FACTS SURROUNDING THE INCIDENT:
1.) THE EQUIPMENT RECOVERY HEADER IS USED TO PREPARE EQUIPMENT FOR MAINTENANCE. IT'S NORMAL SERVICE IS ALTERNATING PRESSURE/VACUUM.
2.) AT THE TIME OF THE LEAK, THE PRESSURE IN THE HEADER WAS APPROXIMATELY 28 PSIG.
3.) THE SPLIT PIPE WAS A 1 INCH CARBON STEEL LINE. IT SPLIT 3~4 INCHES
ABOVE AN ELBOW. THE SPLIT WAS 2 INCHES LONG AND 1/2 IN. WIDE AT IT'S WIDEST POINT.
4.) THE HNU METER'READINGS TAKEN AT THE STRUCTURE WERE ALL LESS THAN 5 PPM.
5.) THE RECOVERED MONOMER SAMPLE STATION HASN'T BEEN USED IN AT LEAST TWO MONTH..
6.) THE ELECTRICAL HEAT TRACING ON THAT SECTION OF PIPING WAS NOT WORKING. 7.) THE LEL DETECTOR HEAD IN THE RECOVERED MONOMER DIKE AREA WAS
APPROXIMATELY 20 FEET FROM THE SOURCE OF THE LEAK. 8.) THERE WAS 4-6 INCHES OF WATER AND ICE IN THE DIKE, EFFECTIVELY REDUCING
THE VOLUME OF VCM NEEDED TO SET OFF THE LEL.
MANAGEMENT SYSTEMS INVESTIGATION:
'THE SAFETY SYSTEMS WORKED AS DESIGNED. THE LEL, DELUGE, AND FIRE ALARM - ALL FUNCTIONED NORMALLY.
2.) THE PERSONNEL RESPONDING TO THE KNOWN VCM LEAK DID NOT USE PROPER RESPIRATORY PROTECTION.
CONCLUSION:
NGC 13675
-THE EQUIPMENT RECOVERY HEADER PIPING AT THE RECOVERED MONOMER SAMPLE STATION FILLED WITH WATER, FROZE, AND EITHER BURST THE PIPE OR SUBSTANTIALLY WEAKENED IT. THE ICE PLUG REMAINED IN PLACE AND DIDN'T BEGIN rrO THAW UNTIL THE NIGHT OF FEBRUARY 20TH. THE COMBINATION OF WARMER TEMPERATURES AND THE PRESSURE ON THE HEADER AT 1035 HRS ON 2/21 WAS ENOUGH (iJOj.RUPTURE THE LINE OR BLOW OUT THE ICE PLUG, CAUSING THE VCM LEAK.
eJ>
II;jii) ACCIDENT REPORTS
1991 - CURRENT OSHA 200 LOGS
NGC 13676