Document QJNmm1jkrnGDQYowarvaJzRa4

Goodrich INTER-ORGANIZATION ro , FIELD POINT OR DEPT. * BLDG. NO. T FROM . C. Recko Manufacturing Manager - Plaouemtne FIOD POINT OR bar. & BLDG. NO. --1__E/Uganfi. Bujo3------------------- Shift Foreman subject PLAQUEMINE - MANUFACTURING DEPARTMENT ;; TpXIC CHEMICAL RELEASE REPETITIVE ACCIDENT TYPE 10-A DATE THIS LETTER 2-13-84, ;Summary: On 0805 batch 2B572-0verpressured and vented vinyl -;i chloride through the double rupture disc assembly. 3^40O^sp&UfTdsiseof i [ the atmosphere. There was no exposure ; I fo personnel and no damage to equipment. Board of Review: i. i; R. M. Sandfry i| K. C. Recko C. D. Langlois D. E. Bu jol J. W, Noto REDACTED Plant Manager Manufacturing Manager Safety Engineer Environmental Shift Foreman Shift Foreman Reactor Area O.T. Board Operator O.T. Operator Specialist Manufacturing Superintendent Board Operator O.T. Reactor Area O.T. Operator Specialist Junior Operator Technician ; Narrative: A. ;; Ojn January 20, 1984 Reactor 2B reached reaction pressure at 0800 hours. Jl ;Tjie pressure continued to rise past the reaction pressure set point | (il5 psi). Board Operator, immediately instructed the .. 8: rife-actor area operators to take emergency action. All cooling water control valves were checked and found in the open position. The | continuous recovery line was checked and did have a flow. The nitric Y'| okide system was pressure checked and lined up while the reactor ; | icpntrol valves were being checked. The reactor pressure had now reached 132 psi. Boardman, ordered the operators to inject the nitric oxide. The first cylinder could not be injected ;; immediately due to a gasket which had become dislodged from the N.O. ; cylinder outlet noz2l^. The gasket plugged the N.O. injection line. The fiiTst cylinder was injected 2 minutes later at a reaction pressure of 180 psig. The second N.O. cylinder was injected when the pressure continued to rise. The pressure reached 225 psig at which time the . dual rupture disc assembly relieved. BFG-4956-E 11/80 LlTHO IN U-S.A. NOC 16192 Repetitive Incident 1U-A 2- - l-2-b4 !'. Facts Surrounding the incident: ; 1. The batch in 2B had an excessive heat-up time. The slow heat up ij was due to ice pluggage at the steam mixer. J :'l2. i i! ;j ; ij3, I hi. |:i In the course of troubleshooting the heat-up problem the condenser control valve was closed. This was a violation of operating * procedure. The gasket blocking the N.O. bottle could not be found during leak check since the system is pressured up to the N.O. cylinder nozzle; The N.O. injection procedure was followed. All checks were done according to procedure. 'j5. Communication between operators at shift change was not complete. |] There was miscommunication concerning the blocking in of the j i! condenser control valve. ! t ; ' jjtonclusions & Findings: |-7hree problems occurring simultaneously resulted in the overpressured ibatch and release of vinyl chloride to the'atmosphere. ;i : , ,1. Operating procedure was not followed. Due to the extreme cold ;j an ice plug formed at the steam mixer to 2B. In the troubleshooting \\\ process the condenser coiitrol valve was blocked in, this violated P; operating procedure. j |. ]2. Communication at shift relief was poor. There was a miscomraunicatioT i! of information. i. it ! ;3. The overpressured batch may have been prevented if the first bottle of N.O. could have been injected immediaitely. Management Systems Investigation 3 1. All pertinent procedures had been updated within the last two U years. All employees had previously received these procedures. ii , Appropriate disciplinary faction has been taken with the |j involved in the incident. ;I ' ; Corrective Action: : ! -; j 3-. This incident will be reviewed at all safety meetings. individuals : r i 2. |, All N.O. cylinders in the plant were checked. The N.O. system pressure check procedure will be reviewed and revised. NGC 16193 Repetitive Incident 1Q-A 1-20-84 -3- 3. All operators will review;procedures - in their respective areas. All operator's were instructed that understanding and following procedures is a job requirement. fiB/col i ii; ! |pc: d. Larson ; i| b. Langlois !j D. DiRienzo ! : i T. Neff 1 A " K. Recko i :j R. Sandfry Area Superintendent I i Supervision |! Bulletin Boards ii Safety Committee ;1 Eugene Bujol ! lS ' 1! 16] 94 rXV 00492701 s ** BFG IMSYVS----------MESSAGE SWITCHING ** DEST: CLEVP ORIGs PLQ02 DATES 01/27/S4 Pi 7 TIMES 138 54s 58 ATfeC'- CLEVELAND KRUEGER/g T LEFEDVRE - CLEVELAND WTtiMTTr ,,1^1^0NE7'''U'"Tr"TT0BEY,"::::--ClIEVEL'A'Nn' R D HARDESTY/ S ALIEN - ALTC AVON LAKE R M. KREAGER/ G THOMPSON - ATLTC AVON ALKE mmw GRIFFIN/ R'" U'.' R L MARTIN/ EL BEELER - LOUISVILLE R A ACCARINO/ W E HORTON - ALGC AVON LAKE !C^"ALTpMAr VIA CLEVELAND SAFETY ^' ' ''v'* WKMr'W^vmX^^-mMM WtFtrt dail' T M JONES/ J D CARONA-CONVENT E. L PAYNE/ W C FULTZ - DEER PARK J NAr.Y/ r c TFF - NAIAGRA FALLZ OMI^TO "CANADA 5 BPUUILLARD/ I Y inliilii- - IAPUK.I-, H-XA- FLAN'r~~ REPETITIVE INCIDENT TYPE 8 CHEMICAL FIRE f*A1 Al FtVJXJMAIEt Y 15u<> UN i-2fs-s4 A SMfV SK-5- DFGA=S1Ng rUMPRL^-SMH NhAK THF LUM^KLS FJHr nrn*WRFD DURING THE COMPRt^SnR STARTUi flUT 3GNTTIN0 AN APPAFFNT rAtK1ML* LFAr. At T INJURIES TO EMPLOYEES OR EQUIPMENT DAMAGE DUE TO THIS FLASH FIRE. -HIM I RFPQRT-TO FOli OW DAN L ANGt.li] -* i jSgfcS^.Tx-. jf;l r ; -4,- M NGC 16195 ' 1'