Document RpZa4rdZpZEgXn60b4BvGdvEB

- If) MCC **70 Monsanto 'noonoxi C. j. y, Payne, (SS-18), Texas City, Texas__________________ February 8, 1984 cc *- ^romblee ** ftefiHNCt SHAC MINUTES - 2/8/84 TO : ATTENDEES: E. P. Bailey S. W. Moncla J. D. Richards J. A. Sta1, Jr. J. T. Payne ^R. T. Hammann These are the minutes of the February 8, 1984, SHAC committee. Fourth Quarter Inspection Awards Awards will be presented from 2:00 til 3:00 p.m. on Friday, February 10, 1984. c 2:00 p.m. Department 33 2:15 p.m. Fire Department 2:30 p.m. Insulator Shop 2:45 p.m. 3rd Floor Research 1 Conference Room SHAC will meet at the pool cars at 1:50 p.m., Friday. Signs showing the winners of the safety awards are displayed at the plant gates. SAFETY AWARDS Approval has been received for the individual safety award program (jackets). A bulletin board announcement will be developed to announce this to the plant. JANUARY/FEBRUARY SAFETY SYNDROME 1. The need for an expanded staff meeting to discuss safety will be discussed by the PMSB next week. 2. A feature article on units with the best safety records will be put into the plant news (Joe Stal; by the end of February). SC 001001 r STOP Emphasis STOP observations should be statistically analyzed in 1984. This should be considered by the PMS8. Unit Laboratory Inspection The following units have not completed their unit lab audits: 1. Methanol 2. Acetic Acid 3. Department 53 Hourly Safety Committee SHAC has been asked to survey the leaking PA blind incident and the plant 0^, flammable checking procedures (S. Moncla, before 2/28). SHAC has been asked to survey the problem of people not leaving a key in the ignition of vehicles (P. Bailey, before 2/28). Goals A goals document was developed. Annual Inspection It was felt that the best time for an annual inspection was the week of September 17, 1984 (or the preceding or following week). New Business Incident investigation TC 84-1 is attached. The ownership of ex-battery limits piping (recommendation 1) will be referred to SAC for policy. Corrugated fiberglass has been installed in the plant that is flammable and does not meet Monsanto's standards. A memo will be sent to key personnel. J. T. Payne JTPrsr Attachments SC 001002 LAM002200 \ r COMPANY CONFIDENTIAL I JHA/GOALS sc 001003 LAM002201 r r* ii Monsanto COMPANY CONFIDENTIAL _ _ _ ________ | JnA/GOALS 001004 sc LAM002202 G. L. Tromblee J. G. Trafton J. S. Haygood G. T. Ryan R. L. Hammond B. C. Lancaster G. W. Bostick D. W. Metten W. G. Juhl INCIDENT INVESTIGATION No. TC 84-1 DISTRIBUTION R. T. Hammann E. P. Bailey D. D. Kos H. Bessire R. W. Fransham W. Nonnenmacher R. E. Supak G. R. Vogtmann D. R. Wise sc 001005 LAM002203 r Repose No. TC 84-1 CONTRACT PIPEFITTER EXPOSED TO STYRENE SPILL IN PIPERACK NEAR STYRENE TRUCK LOADING STATION I. INCIDENT An Opel pipefitter was sprayed with styrene monomer when materials handling tried to load a truck through the line that was being worked on. The line had not been isolated and prepared for maintenance. II. CAUSE & CONTRIBUTING FACTORS Primary cause of this incident was trying to load styrene through a line which was being worked on. A major contributing factor was failure of the Styrene Manufacturing Foreman to ascertain the nature of the work to be done, which led to decontamination and isolation of the wrong line. III. RECOMMENDATIONS 1. The plant should reexamine the question of ownership of and oper ational responsibility for ex-battery limits pipelines and systems, with particular attention to material handling systems. Responsibility: SHAC Complete by: Initial report to PMSB by 3/84. 2. Review this incident with all operators and craftsmen, including Capital Projects, stressing the importance of thorough communication on work to be done, and the obligation of the responsible person to inspect the job site. Responsibility: Manufacturing Supt.s Capital Projects Supv. Complete by: 2/29/84 3. Safety shower/eyebath repairs should be worked to completion or alternate facilities provided. Responsibility: Maintenance & Mfg supt.s Timing: immediate 4. Re-emphasise the need to provide proper access to scaffolds and work platforms. Responsibility: Maintenance Supt.s Capital Projects Supv. Complete by: 2/29/84 IV. DETAILS a) Chronological Description of Incident On Wednesday, January 11th an Opel Foreman asked the Styrene Manufacturing Foreman to get a styrene loading line ready for SC 001006 LAM002204 Incident Report TC 84-1 Page 2 Capital Projects to make a tie-in for the Truck Entry project on the following day. On Thursday morning Styrene operations indicated the line was ready and three Opel pipefitters prepared to make the tie-in, which con sisted of removing a flanged "L" shaped spool from the 4 inch truck loading line and replacing it with a "T" section. They loosened flange bolts at about 1015 hours. Considerable styrene ran out and was still dripping from the flange as lunch time approached. The fitters washed down the area and went to lunch. When the three returned from lunch the flange had stopped dripping. They removed the "L" spool and cleaned the flanges in preparation for installing the new "T" section. The fixed pipe end had drooped several inches when the spool was removed and one of the men was in the process of & tieing the end of the pipe up with wire. He was standing directly in front of the open flange, which was about three feet above the scaffold floor, and bending down toward the flange. At the same time Material Handling was preparing to load a truck with styrene from T18-2 (see piping Flow sketch,.Figure 1). They had loaded a tank car at about 0945 hours that morning and had left the line lined up from the pump to both the tank car and tank truck loading racks (valves 4 and 7 open). One pumper gauger stood by at the truck loading station while the other went to start the loading pump which is located about 100 yards to the East. When the pump was started, styrene gushed from the open flange where the Opel fitters were working striking the Opel fitter on the left hip and drenching him. The injured and the other two fitters moved about 20 ft south along the pipe rack to a caged ladder and decended to the ground. (The spill alarm was turned in by a Materials Handling chief pumper-gauger who was working nearby, and sounded at 1310 hours.) The injured man went to a safety shower at the ACY loading station, about 90 ft to the West, got under the shower, stripped to his shorts, and washed for 10 to 15 minutes. The eyebath did not have enough flow to work properly so he washed his eyes as well as he could by turning his face up into the shower flow. Two Plant nurses showed up at the scene and took the injured to the dispensary. The shower in the dispensary was not working properly so the injured was taken to the main gate locker room where he showered again and put on clean coveralls. He then returned to the dispensary where he was examined by Dr. O'Bryant. Blood and urine samples were taken. (Urine samples were also taken from the other two Opel pipefitters.) Ointment was used to treat the injured's eyes. He went home at the end of his regular shift and returned to work on his normal shift next dav. 1 SC 001007 UJVJ002205 Incident Report TC 84-1 Page 3 The pumper-gauger who started the loading pump returned to the truck loading area and saw the styrene spilling from the pipe rack. It took him and the other materials handling personnel a minute or two to realize that the spill was coming from the loading pump, after which he returned to the pump and shut it off. The pump was on for an estimated 5 minutes and a total spill of 1900 gallons occurred (determined from tank level). b) Findings 1. The "injured" was sprayed with styrene from his face to his feet and his clothing saturated. The only injury was irritation to the eyes, for which first aid treatment was provided. 2. Styrene is not considered to be a serious industrial hazard. Toxicity is low. Vapor concentrations above 400 ppm cause moderate irritation to the eyes and respiratory tract. Liquid styrene will cause severe eye irritation, but no permanent damage, and can cause skin irritation and, with prolonged con tact, blistering 3. The wrong line was decontaminated and isolated. The Styrene Manufacturing foreman was familiar with the styrene loading area. He did not go into the field to inspect the work site, and instructed an operator to prepare the 16T18-1 recirculation line for maintenance, which was done. 4. The Opel Foreman and the Opel pipefitters did not check the line out, before breaking into it, to verify it had been isolated and locked out. 5. When starting the styrene loading pump the pumper-gaugers at the pump and truck loading rack are not in visual or voice contact. 6. An uninvolved Opel pipefitter working in the area "guestimated" that as much as 2 to 3 barrels of liquid drained from the truck loading line after the flange was cracked open. 7. Styrene manufacturing personnel are generally not familiar with the styrene loading system and do not know how the lines are interconnected and what valving exists. 8. EB/Styrene has a written procedure that outlines ownership and operational responsibility for ex-battery limits process and utility headers. 9,, The three Opel fitters were wearing hard hats and safety glasses on this job. Styrene internal practice would have called for wearing full protective gear when breaking the first flange of a closed piping system. In this incident Manufacturing pro vided no direction on protective equipment. (Note that the incident did not occur until about 3 hours after the first flange was broken.) SC 001008 LAM002206 r Incident Report TC 84-1 Page 4 No Styrene manufacturing personnel were in the area while the job was in progress. 10. The scaffold constructed for this job, consisting of boards placed across horizontal I beams in the pipe rack, terminated 10 feet from the permanent cage ladder used for access. No means for bridging the gap was provided. The area is very congested and getting across this 10 foot gap would pose a significant hazard. 11. The injured tried to use a safety shower located at the foot of the cage ladder at the job site but it was out of service due to freeze damage. The Opel fitters knew some showers in the area were out of service but did not know which ones. 12. The LP&S review for the Truck Entry project was held about 1 1/2 years ago. Meanwhile, the project engineer for the project had left and been replaced. Styrene operations did not have a clear understanding of what the project was all about. c. Discussion 1. Ex-Batterv Limits ResDonsibilitv ( ' '- The plant does not have a clear policy or procedure delineating ownership and operational responsibility for ex-battery limits lines. Loading systems are a particular problem. They are generally remote from the operating unit. Manufacturing owns them, but has little to do with their operation, and is generally not very knowledgeable about physical details of the system i In some instances Materials Handling has essentially complete operational responsibility. This split responsibility increases the probability of incidents such as the one reported here. P-0117 (Fire, Entry and Special Permit Procedure) incidentally addresses the ownership/responsibility question in Section IV. Many of the statements in this procedure are fuzzy or contra dictory in the case where one group owns a system and another uses it. Also, since P-0117 deals with permitted work, does it apply, or would people consider it, when dealing with work not requiring a permit? P-0118 (Work Permit for Off-Battery Work, and Use of Heavy Equipment Near Electrical Lines) also refers to ownership and responsibility in a number of places. It does not say, however, that use of a work permit is required for off-battery work other than that near electrical lines. Most of the plant apparently does not use P-0118, except for work near electrical lines, and the people we talked to were generally unaware of V its non-electrical provisions. SC 001009 LAM002207 Incident Report TC 84-1 Page 5 The key to safe and proper maintenance is to specify clearlv one person who has responsibility for a system and to hold that individual accountable for understanding the job and taking the actions necessary to insure it can be done safely. 2. Communications The pipe line tie-in involved in this incident was one which clearly required the involvement of 3 groups: Manufacturing, Materials Handling, and Capital Projects. All the people necessary to insure a safe job were readily available, and the Opel Foreman took the first step by requesting the line be pre pared for maintenance. The Styrene Manufacturing Foreman, as the "owner" of the pipeline, should have assumed responsi bility for being sure he understood the work to be done, specified preparations to be made and safety equipment to be worn, and communicated with Materials Handling to be sure they knew what was being done. 3. Safety Showers Three malfunctioning showers were involved in this incident. The safety shower at the spill site was not working (no water) delaying the time required to get under a shower by 30 seconds to a minute. This could have been critical if a severely cor rosive or toxic exposure had been involved. The eye bath on the safety shower at the ACY rack did not have sufficient water pressure to function properly, and the shower in the dispensary did not work properly due to low water pressure. These prob lems were apparently due to potable water system damage that occurred during the heavy freeze between Christmas and New Years -- about 2 weeks before the incident. We are being too com placent about repairs and creating a situation that could lead to a major injury. V. APPENDIX Figure 1: Styrene Loading Area Piping Flow Diagram Figure 2: Sketch of injury area Figure 3: Cause and Effect Diagram VI. PERSONNEL Involved: William C. Birdwell, Opel pipefitter (injured) James C. Fuller, Opel pipefitter Rick D. Brown, Opel pipefitter Gary L. Hood, Opel Foreman John F. Couch, Styrene Mfg. Foreman Harlan Bessire, Mat'l. Handling Chief Pumper-Gauger 001010 LAM002208 Incident Report TC 84-1 Investigators: Harlan Bessire Robert Fransham Weldon Nonnenmacher Ray Supak Glenn Vogtman Doyle Wise Page 6 (jjccf/c /f? hairman LAM002209 Sc SM T/CAR U5A0IKC RACK Lo^diNi^ Tn^vJtC 2. sketcm of Spill area STY R tM E M*NUF/\c.TUR\NO, AREA _--___-<eo '' . ou T" ! 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