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B.F.GOODR1CH CHEMICAL COMPANY Inter-Organization Correspondence To Location C- L. Woods Calvert Date From January 18, 1974 Johnnie Bloodworth Subject Incident of Experience Value - Vinyl Chloride Release /V ^ ^ ^ ** /O ^ k ( **V Review Board The Plant Manager held a review meeting of the subject incident at 10:30 a.m. on Tuesday, January 15. Mr. Woods opened the meeting stating that the incident was being reviewed because of the high frequency of similar equipment preparations done in the plant and the potential of a similar incident in many of these operations. The following people attended the meeting: C.L.Woods, F.R.Carvell, J-K.Koster, D.R.Hise, R.W.Edwards, D.B.Schrock,N-S.Grove, J.R.Render, G.E.Evens, K.C.Hardesty, G.B.Buchanan, R.A.Spurlock and J.W.Bloodworth. Narrative On Monday, January 14, ' were assigned the task of skilleting off a section of three inch VC1 trunsfRr i-inp -in preparation for replacement of a section of the line. The transfer line runs from North Cracking to a header'at the VCi TanlT Farm' Valves were turned by the tank farm operators to isolate the section of line. (See Diagram) The line was bled down by ,,cracking', a valve (#2) and opening a bleed valve (#1). , checked the line and since very little vinyl vapors were coming from the bleed valve, he signed the work order for to install the skillets. The skillets at the header in the vinyl tank farm were installed with no problems and the fitters proceeded to the valve on the line south of South Cracking (#1). The bolts were loosened and the fitters thought excessive vinyl vapors were coming out. The operation was stopped while went to get : opinion of the situation. put the road block chain up and stayed with the leak. soon returned. The leak had practically sealed itself because the gasket- flange integrity was still fairly good. In order to show Phillips the size of the leak. ` proceeded to cautiously spread the flange with a. screwdriver. When he did so, a section of the gasket blew out enabling vinyl vapors and liquid vinyl to rapidly escape^ The vapors wore carried toward the South Cracking furnaces. The fire alarm was turned in and a water hose from Hose House number 7 was reeled out and turned on the leak. The sprinkler system in the cracking plant was also turned on to further protect the area. Fortunately, the initial voluminous surge of vinyl was very brief and at once began to subside. The skillet was installed after a fifteen minute bleed down. A nitrv p&n purge was placed on the line to remove any remaining vinyl vapors. Analysis REDACTED Liquid vinyl was still in the section of line to be replaced. It appears NGC 15829 2. the most likely cause was that valve #2 was not open enough to allow tte vinyl to escape. This line carries off-spec vinyl which often, contains some water. The partially open #2 valve may have become frozen up and prevented complete bleed down. A bleed valve (#3) was found near the temporary repair. It was partially obscured by ice and gravel. It may have been possible to free this valve for use in bleeding down the low point of the line. Re commenda tions Three courses of action available to prevent escape of dangerous con centrations of flammable materials were covered at the Plant Manager's Meeting. They are as follows: (l) Allow plenty of time for the line to depressure. If the line continues to give off vapors, something is wrong and should be corrected before fully opening the line. Use a controlled nitrogen purge to move lingering vapors from the line. Purge the vapors into a flare system where possible. This will permit flammable vapors to be burned or vented in safe areas. JWB:bs cc: HWaltemate-JGressler EWHarrington-PDTe rry DRGray WEBrodine BAHealy GPow RAKelley RWEdwards-WCO'Brien JKKoster FRCarvell PESanderson GEEvens NSGrove DRHise DBSchrock HWCompton MCJohnson DKPruitt JJSchonaerts GFLefebvre RVRommeIma n EEAtkins JRRender NGC 15830 c SCHEMATIC OF LIME , VALUES , AM& S/^MLtTS NGC 15831 'SAW 'm--; % :&i to ( Jofut Gxe**lex ' ROM F.C. Vltley 1=lttO h'QlHt 0* AKRiW 0/5450 v'f-fT tM PL.OG. Cleveland rif* > '* AK**OH 1 PfAl' ft mm . HO, Safety Long Beach 1 Bil 11 .2-20-74 )9?Y 7; MeoA Mia.6 AcxiMiznt - Vinyl Reteaae -ox PAoceaA Meg. /> introduction >?/* */o pu.c <3ct>Gr a# ftfctft tJtT/S cx/k.osyye nixnJ&Z^ At 0920 AM on 2-12-74, the polymexzation building expexcenced a VCL go* dt&chaxge through a Aul-tlo Ultex cannl*tex. The, ptout my evacuatedgyufTixe wateA^m* applied (xom 5 f,lAe monltoA*. l7a. County Fixe Vepaxtment aexpanded to Atop , - ~ >j txalUc Into the okxunt. j'ex&onnel xe&oonded with gaodca bxeathina apparatus v ^ A <<nC and the. leghwa^^tojo^e^^n^^^^^^^^^^^^^^TThemeAgey^ylalted appAoxlmately 10 minuet* and personnel Aesponded as peA pAoceduxes. Coopexation Aom-the County Fixe Department and nelghbox plant* wa* exc.eZZ.ent. INCIDENT The event* suxxouyidlng the illtex cannlstex dlschaxge began at 0915, u)hen change opexatoA, closed the valve on the suction to Ho. 1 xecovexy system. This, opexatlon shut down halt the aqcovqau caaacltu o& the noAth side poly* by allowing aZZ the AecoveAy gate* to go through the Ho. 2 AecoveAy system. At I ed and pad aAea. The plant evacuation alarm wot, sounded Immediately. Afitex detexmlng the pxoblem, Bob BAulnAma, FoAeman, ChaAge opexatoA, went to the top OfJ the poly building to close the VCL gas filow to the f^iltex. At.the same time Vie watex was applied on the {lltex and pad aAea by the too BFG ixe monitor* and tfiA.ee monitor* fiAom Amexican Chemical. The alZ.-cZ.eaA was Aoanrfed 10 minuet* afitex the mexgency began. It m* estimated that lontiti nf vc.t was vented. A* a Aesult ot the cannlstex separatingt the Zldt tightening nut, and handle was propelled.upward and damaged a VCLsuppEyllne, hlnck VCL recovexy Xlnet and h Inch conduit line. The conduit tea* bxoHen but the wixtna too* Intact. The VCL suppIu line sustained a vexu smalt crack. CAUSE The jiltex cannistexs when In good condition axe designed to handle lull potu pressure. It wa* determined the xea*on thl* cannlstex blew apart wa* the secyjuna stud and halt had, become badly woAn to the point that thexe wa* m. enough thxead contact to *ecuxe the tiltex at higher pressure. A Review Boaxd Recommendationa: Attending' A.S. Clement* E.L. Beeler R.8. Oxen* haw W. L. Blount F.C. VIZley R.K. MlZlex R. HaAt Plant Marngex Paoduetto n Manages Department Manage; Personnel Manager Safety Englneex Technical Engineer ChaAge OpexatoA FoAeman REDACTED NC 13832 smi DDK 'O'J II puv I dncruQ {wo-vjjy) fajm *V ^ Md '0 firtnu *yg /waj. dirypov^ '3*0 /5rv0 *a*a *a*d - uo?Guvvwh *<ra - vorrdn *rr ^^nwrarjTDTO :dt> wv:aaj 9907 15/j T^aA^-vd 07 9qwxi7 0>| ai# md 10379/19 ^a^da ^773T/-'097p avnTd-nv 777379111 ,'d-ym?2'nd vfiry 07 paTTrafqw 70W dvo rvdqrxy} "dvn? 39 07 vdyjr} 07 7371039-071) *9W&fj? fiwncrjdTt wmop ^0771199 waifm 'uoTTWDaT/d 17*7x3 uv ry *q (93d^7 *vaipro umftr Ydvnvrwd vsy&rtj mttv rofmnp aroipr] d35flj 6MrwAcrwv wai/m iwop 10379/19 /jy3aowv Dy& 777149 07 70JY " iWipaocrvcf ?&imjd `/jwanbaT^ 333-143 ftjutfuow v vo pdjwdnrr 39 77?w 9V3777? 393qi *W79mn70 -*3777? 7JD pa-vrDda'v pwr p3733d9M*i 10379oi/d 3147^0 39W3 31/7 07 9 73wwo9vad Sing-wado 771? wvo^mi *j p.TUOT-TMDTgrTJpirajttaoTraji pvog m3;va3h y ________________________________________________________Z 7>fr>A vavy 99a3ovj in' 3 93373y 7/jioy} - 7M3p733y 99>fl waft B*Fo GooJncL dtemacal Company InterOrganigttkm Correspondence To P. A. Wagner Location Ijouisville Date From April 8, 1974 Louisville ,,K,__4. Repetitive Accident Type No. 10, "Fill Building or Area with * Explosive Mixture" At approximately 11:14 a.m. on April 1, 1974, a half-inch, carbon steel, screwed nipple blew off the relief votive line on no. *5 blow down tank in-Building ill." The blow down tank contained one charge of 103EP from no. 20 poly, which had just been drained, and the pressure on the tank was 110 psig. There was no valve in the relief line* to shut off and stop the leak; so all windows on the second floor were opened, and the building was evacuated. At 11:33 a.m. an Explosimeter test showed the building to be safe, and the all clear signal was "sounded- StJoo to. H* -------- ' useo os/*. Investigation of this accident revealed that the nipple involved was a one-half inch carbon steel nipple screwed into a cast iron 3" x2n reducer which had been drilled and tapped. The nipple was badly cor roded in _the .threaded sections and, failed.under pressure. Further investigation revealed that nin,$ put^ of the twelve blow down tanks had the same arrangement in the relief line and that all were badly corroded in the threaded section of the nipple. It was also found that the twoinch black iron lines above the 3' x 2" reducers were badly corroded in the threaded section under the screwed flanges. Corrective action taken includes: Ox All carbon steel one-half inch nipples have been replaced with stainless steel. . \ Fabrication has begun on all stainless steel relief lines to replace the cast iron reducers and the black iron pipe on all blow down tanks. This work will continue daily until complete. OJLS e*. --------------- cXjyoO R. S. Kinnamon A J. .A r 4'll-* APR 101SW NGC 15834 B.F.GOODRICH CHEMICAL COMPANY r Avon Lake General Chemical Plant 10: 10CAT10N: R. N. Rylands Avon Lake General Chemical Plant FROM: P. W. Shore BATE: April 8, 1974 SUBJECT: Near Miss - Repetitive Type Accident Type #10 Spill Or Venting Of Monomers ' Introduction: On Tuesday, April 1, 1974 at approximately 1915 hours, a latex premix vessel vented into the atmosphere from B/463. Principal monomers released were vinyl chloride and ethyl acrylate. The wind direction was from the east. Many odor complaints were received froin the community west of the plant. A Board of Inquiry met to review the incident, and the following facts were established: Incident: A Geon 352 premix emulsion had been made up In premix vessel #3 on the 8-4 shift on April 1 in preparation for the next clean poly on the following 4-12 shift. The Geon Latex Operator, and the Foreman, Fred Beiswenger were both in the Latex Building at the time of the incident working on cleaning a transfer line. At 1920 hours, , Hycar Operator, received a phone mli *n the Control Room from within the Plant, and was informed that "something" was venting out of the Latex Building. Immediately Beiswenger, the Relief Operator, started investigating and found that the venting was coming from premix #3. Beiswenger shut off the agitator in hopes of stopping the stirring action, but was unsuccessful in holding the emulsion in the premix. Suspecting an overcharge of monomers, Beiswenger checked 1 p^emix valves and found them to be closed. In the meantime, Beiswenger told to turn on all exhaust fans and open all doors, to air out the building since the air intakes were pulling acrylate odors into the building. An building personnel Were instructed to don their Welsh respirators. The liquid vented material landed just to the west of the Latex Building. After the venting had completed at approximately 1945 hours, Beiswenger looked into the premix site glass and observed water pouring into the uremlx apparently from the agitator water seal. He then out the water seal unit on bypass, and the leaking into the premix stopped. The remaining 50 gallons of premix emulsion was pumped into our hold-up Pit and caustic treated for odor control. During this time, the plant guard, called Beiswenger and reported that he had received an odor complaint from neighbor. Beiswenger told what had happened and that the odor should dissipate within the hour. bedacteb APR 9 13ft NGC 15835 Near Miss - Repetitive Type Accident -2- April 6, 1974 Facts 1. Investigation showed that the agitator water seal failed resulting in a hvdrnriii condition causing venting of the rupture 41,80* No violent rupture occurred since it was a hydroful condition. This explains why the emulsion vented only between B/U63 and the west roadway, and why no noi6e from the rupture occurred. 2* The low pressure alarm on the seal water unit should have sounded when the leak occurred, but it failed to activate. 3. No employee in the plant was hurt or sustained any adverse effects from this venting. 4. A total of six neighbor complaints were received. An alleged labor walkout occurred at the local Ford plant due to the odor. The local radio station, WEOL, asked for a statement, and it was given by C. Carter of the Cleveland Office and R. Cross, Industrial Relations Manager of ALGCP. Conclusion: This incident most likely would have been prevented if the low pressure seal alarm on the water seal unit had sounded, or if relief valves with an alarm system were present on the premix vessels. Recommendations: The water 6eal unit pressure alarm system has been repaired. /} A program will be instituted to check seal water alarms and will be included in our weekly safely check. The EA that we have been preparing to install automatic relieving valves including a hold-up tank has been revised to include the premix vessels in the Latex Building. 4. This incident will be reviewed with all department personnel. RfS/jdn cc: H.Waltemate^i----" J,Greasier J.L.Nelson-R.D.Scott E.W. Harrington-P.D * Terry D.R.Gray G.lbv R.N.Rylands R.L.Cross W.T.Gunning R.W.McKay-D.E.Rider P. W. Shore C.Lane C.R.Carter W.C.Holbrook L. A.Bennett W.E.Brodine B.A.Healy R.A.Kelley General Foremen Department Managers NOC 15836 B.F.GOODRICH CHEMICAL COMPANY Avon Lake General Chemical Plant TC: LOCATION: W. T. Gunning ALGC Plant FROM: J. R. Shellenberger DATE: April 26, 1974 SUBJECT: Repetitive Accident Type #10 - VC1 Escape Into The Building Summary: On April 22, 1974 at 0900 hours, approximately 100 pounds of vinyl chloride vapors and some PVC slurry escaped into the third floor of Geon West Building 46l. An open valve in the blowdown line to Poly 115 permitted VC1 vapors from an adjacent polv (which was being dropped to the blowdown tank) to ^backup" into Poly 11*5 and to escape through the open manhead. The uninsuirable material loss was $10.00. There were no injuries. A Board of Review was held immediately after the incident with the following in attendance: ____ . - Poly Cleaner - BD Operator Charge Operator Larry Kemer - Foreman Ron Kaminski Lynn Wallis Ron Mather Bill Gunning John Shellenberger Events Involved: 1. Poly 115 was being cleaned on the 12-8 shift. The poly was partially plugged with a heel of resin. 2. A Helper was working with the 12-8 Blowdown Operator in trying to unplug the poly to the blowdown tank. The job was not completed on the 12-8 shift, and there was no conunnnination from 12-8 shift to the 8-4 shift on the work that had transpired^" At 0900 hours, the charge in Poly ll6 was dropped to the blowdown tank. It "backed up" through an open valve in the blowdown lines on Poly 115, since both polys share a common blowdown tank. Slurry and VC1 vapors came through the open manhead of Poly 115. 5* The gas alarm was sounded and the building evacuated^___Xfrg system removed.the .vapors from...the third floor very quickly- subsequent monitoring cycle (12 pjnute cycle). the Bendix probe registered 25 ppm. REDACTED NGC 15837 J Repetitive Accident Type frlO VOj. Kscape into 'lhe Building 2- - April 26, 1974 Reconvr.endations: 1. The incident could have been prevented had the incoming shift thoroughly checked out the blowdown system before using J.t.__It should be common practice to_ .double check all systems prior to use. We will re-emphasize this to all foremen and Blowdown Operators through letters and safey meetings. 2. Though not directly related, the Scott-Pak system presently in use is awkward with the units stored in a box. We win mpunt these on a wall so that during an emergency it is necessary to only back up to the unit and slip it on. This will be done in both B/451 and B/461. John B. Shellenberger JRd/jdn cc: H.Waltemate J.Gressler J. L.lNelson-R .D. Scott E. W.Harrington-P.D.Terry D.R.Gray G.Pow K. H.Rylands R.L.Cross R.C.Kaminski C.L&ne C.R.Carter tf,C.Holbrook L. A.Bennett B.A.Healy W.E.Brodine General Foremen Department Managers R.A.Kelley ( Disabling Injuries - Blowdown Hose Rupture _ .. Ac <?.'$// * Incident: ' r kb rys,c**-/t &~f A Oi/ji,/-1' v* On 4-26-74 at 11:50 AM two employees at the Long Beach Plant received lost time in-juries when struck bv a blowdown hose which separate^ under pressure while being used to recover a Polymerizer through the bottom valve. ? Charge Operator was struck on the right ankle by the Kam-Loc fitting. Recovery Operator,. was struck on the right ankle and leg by the same hose and Kam-Loc fitting. Another employee, received a bruise to his head when in the confusion of the noise and excitement he ran into some overhead piping. lost 2 davs from work with a bruisg on the right ankle,. lost 6 davs from work with a severe, bruise on the right ankle and leqf. An Inquiry Board met 4-29-74 with the following people in attendance. A.W. Clements Plant Manager E.L. Beeler Production Manager c R.B. Crenshaw W.L. Blount General Foreman Resin Industrial Relations Mgr. R.J. Bruinsma Shift Foreman Charge Operator F.C. Dilley Safety Engineer Recovery Operator, had experienced problems recovering Poly #19 as the normal recovery lines were plugged. It was decided by the Foreman to recover this Poly through the bottom valve and into an empty Poly under vacuum. Two blowdown hoses were needed. A shorl^ piece of hose was secured from the Dryer Building to complete the line. The section of hose from the Dryer Building was not the proper hose to use for this type of service. As the valve was cracked opeff and material appeared to be transferring into the empty Poly the Kam-Loc fitting separated from the section of hose which was obtained from the Dryer Building. As the blowdown hose relieved pressure it whipped back and forth striking the two operators on the right ankles. Both operators were taken to the hospital for X-ray. Corrective Action: 1. The incident was reveiwed with all Poly Building personnel. 2. Hoses have been purchased for this service. These hoses will be used only for this operation and will be pressure checked after each application. MCV. n/l# UlTHO. U.6A. REDACTED NGC 15839 MAY 22 1974 \ ( Disabling Injuries - Blowdown Hose Rupture - page 2 F.C. Dilley Safety Engineer ECD:rm Enclosures (3) cc J.W. Gresslerc^-- H. Waltemate *y J.L. Nelson - R.D. Scott E.W. Harrington ~ P.D. Terry D.R. Gray W.E. Brodine G. Pow B.A. Healy R.A. Kelley (Akron) r tv- <>e cP/y* A f y^ J' A tr H. 32Z \ 15840 \ T* 1 ^m FllkO RIINT OR AKROR BlMtHTMINT A LDH, MO. >* ,*s " w. m y..* . WTI TWR UTTM J j j " w. A. Reed Wli riccD mint oh akron dcpaktmkkt a km. ho* DATE TMI* LCTTKft M. F. Knapp MMtCT June 19* 197U INCIDENT OP EXPERIENCE VALUED-FILL BUHDrNO CHI AREA WITH EXPIDSIVE MIXTURE TgePET\Tv6 Ag^OEUT Ho. |q At Hi00 on Monday June 17, 197U there was a 30 second VCM_Telease_J.n the pHin hunting when a prepolv charge which had been cooled and was awaiting pretransfer was inadvertently dropped to am open autoclave. Approximately lh70 lbs of Material was released* The Facts Leading up to this incident: NGC 15841 At 08:31 on June 17* the prepoly was started in anticipation of charging it to Reactor 8U* At 08s57 after cleaning was completed Reactor was started* Charging of both vessels proceeded normally* In the meantime* Reactor 81 was put into the clean step at 0?s3U* Cleaning was completed approximately 30 minutes later* At about 10:15 entered the Mass Resin building and noticed a severe leak around the manhead Of RE 81i* He instructed the technician I not to continue with the charge to Reactor oli* but instead to recover Reactor 6U (because of the leaking manhead) and to put the prepoly charge to Reactor 81 which was now waiting in the clean step* Since this operation has been done before* it was assumed that it would be handled routinely* At 10:17 the prepoly was put to Hold* However* this does not allow the prepoly to cool down automatically at the end of reaction* At 10:2it> Reactor 8U was put to Hold* At 10:27 oticed the prepoly in Hold and had it brought out so that it would get cooled down since there was now no reactors ready to receive the prepoly because Reactor 8U was in Hold and Reactor 61 was still in clean* At this time* ` explained to console technician the need to use the Pretransfer button to get the prepoly to drop to Reactor 81, However, in retrospect* a better choice would have been to use Re-entry 8 which is specifically for this purpose and would have performed all operations automatically* At approximately 10:58 after preparing Reactor 81 for charging Mass resin lead technician turned the entry switch on Reactor 61 to computer position* The manhead was still off because the first step in the charging sequence is the additior of a solid catalyst through the manway. were all standing on top of Reactor 81 waiting for the first addition light to come on so that they could add the solid catalyst and close up the manway* At 10:59 - put Reactor 81 to Hold and then pushed the pretransfer button* (When asked later stated that he thought the pretransfer button would proceed with the normal charge sequence of vacuums* etc*) At 11:00 the nrepolv then started dropping to Reactor Si which was still open since the building people had not yet seen the first addition light. VCM gas and resin was released through the open manway* Thirty seconds later, Reactor 81 went to Hold and the valves closed since the reactor agitator was not running as it should have been When the VCM release was observed* n called and told him to close the 8102 valve* However, Reactor 81 went to Hold and did this before the console technician was able to* The building people then evacuated to the Mass resin nolvroerlsation office. However, the ga alarm was not sounded* (When questioned lat^r stated that he did not sound the gas alarm because he observed that the source of the release had already been stopped*) RCV. |l ' nrHO. IM U.I, A. REDACTED W* A* Reed Page 2 June 19, 197U Air masks were then donned in order to resume closing up the manway of Reactor 61. At 11:07 entered the console room and proceeded to put Reactor 61 on the vacuum jets. After learning that the manway of Reactor 81 was not yet secured. Reactor 8l was put back in Hold at 11:08* At 11:09 Reactor 81* was put on recovery* After making sure Reactor 81 was ready to charge, it was put to Re-entry 8 at 11:16* The charge was then completed to Reactor 81, Recommendations to Prevent 'Recurrence: (ji Re-define the use of all console action buttons, such as pretransfer and shortstop to clarify the situations in which they are to be used, --Kloepfer, Clarification of the conditions under which Mass resin autoclave Re-entry 8 is to beused: Re-entry 8 is ttto schedule a second autoclave if a problem develops with the first one scheduled," In such a case do not put the prepoly to reaction Hold* Placing the first autoclave to Hold will prevent transfer there* If the second is not ready to receive the charge by end of reaction, the prepoly will automatically cool and wait for normal preparation per MRe-entry 8" logic, (5), Re-program Mass resin pretransfer logic to check that the autoclave manway and dump port contacts read closed,--Killer Ufi Emphasise the need for good communications between the building people and the cotSsole technician. *> The gas alarm must be used In cases such as this to warn anyone of this potentially dangerous situation* At the time the extent of the spill was not complete! dear* ^ MFKAjs cci A. R. Webber T* B* Johnson"" J* W, Goetsch W, T. Kloepfer M. A* Killer T, S. Nasife C, I. Mullen A* Garlic Console Technicians M, F, Knapp NGC 15842 n?i TO: R. S. Mather LOCATION: Geon West B.F.GOODRICH CHEMICAL COMPANY Avon Lake General Chemical Plant FROM: J. R. Shellenberger DATE: July 23, 1974 SUBJECT: Vinyl Chloride Escape in Building #461 - Repetitive Accident Type #10 INTRODUCTION: On July 21, 1974, at 0224 hours, a vinyl chloride gas escape occurred in Building 461, Geon Vest. A manhead gasket on Polv #103 (1100 gallon) ruptured permitting the gas escape. The buildine was evacuated for 20 minutes until the Bendix instriMaent^refldij^fl^refaar^d to nornjSI No injuries resulted tram the Incident. Loss ot raateriaJ. amounted to approximately 100 pounds of vinyl chloride. /) FACTS: The poly had just reached reaction temperature (135 F) when the rupture occurred. Only the third floor of the building was affected. After donning Scott Air-Pecs. building personnel reentered the area*vhere they attempted to tighten down on the ^ manhead lid. When tiieir attempts to reduce the leakwere unsuccessful, the charge in the Polv was drooped to a blowdown tank. The polv was then placed on recovery. ^j .3 .0 The gasket which ruptured was new and had not previously been used. We have found that, even though tightened down thoroughly, the new lead gaskets occasionally tend to soften as the polv heats. Generally only mild leaks occur which can be corrected by tightening. The reason for this abnormal gasket problem and the resulting rupture is not known. There have been no problems with other gaskets from the same lot. The extent of the vinyl chloride concentration is not known, however the two probes for the Bendix instrument pegged at 100 ppm. ACTION TO BE TAKEN: We are now in the process of phasing out all lead gaskets. They are being replaced with an 0 ring type gasket which will be retained in a channeled metal ring. In the two poly buildings B/451 - B/461, the new gaskets have been installed on 50 of the 80 polys. The retaining rings for the remaining polys have been provided and we are awaiting delivery of 0 rings. The project is expected to be completed in July or early August. To date the 0 ring type gaskets installed have definitely reduced manhead gasket leaks. We have not experienced any ruptured gaskets similar to that described in this incident. JRS/bu cc J.W.Gressler G. Pow H.Waltemate B.A.Healy J.L.Nelson-R.D.Scott R.A.Kelley E.W.Harrington-E.D.Terry R.N.Rylands D.R.Gray Department Managers W.E.Brodine General Foremen John R. Shellenberger General Foreman, Geon West r NGC 15843 BF GoojvieL ClieBiBisffil Company InterOgaaigatfan Correspondence To W. K. Peraber Location Louisville Date From August 14, 1974 Louisville ac nriK,<uit Repetitive Accident Type No. 10, "Fill Building or Area gupjcct with Explosive Mixture11 i^~?Y *1T ^// On Saturday, August 10, 1974, at 1:10 p.m., in Building 111, a gasket failed on a sight glass in a pipeline between no. 45 poly and the re- covery knock-out bottle immediately above the poly. A charge of 300X7 was in no. 45 poly when the leak occurred. A mixture of VC1 and latex struck the operator. , in the back as he was attending -to no. 4^ poly. i immediately alerted ' the other oper ator, to evacuate the area and sounded the building evacuation alarm. _____ and area-supervisor Goodrich, using Scott Alr-Paks. re entered the area and_dropped the charge, into the north and south blow down tanks on the second floor. This was not achieved until it was found that the charge could not be recovered by the usual overhead sys tem, due to plugging. The all clear was sounded at 1:55 Corrective Action CD Cut-off valve installed between knock-out bottle and sight glass. Pressure gauge installed on knock-out bottle. 3.New gasket installed on sight glass. Unplugged vent line from knock-out bottle to outside recovery tank. Checked for plug in overhead recovery line from no. 45 poly to overhead recovery system in Building 111 second and third floors. M. D. Schrader ru Distributions. J. W. Gressler H. Waltemate J. L. Nelson - R. D. Scott E. W. Harrington - P. D. Terry D. R. Gray W. E. Brodine G. Pow B. A. Healy R. A. Kelley P. H, Lawrence Department Managers General Foremen Supervisors REDACTED */ NGC B f7* Go<a^a4cli CSienmiesal Company IoterOrganisatloQ Correspondence To W. K. Pember Location Louisville Bate From August 15, 1974 Louisville Subject Repetitive Accident Type No. 6, "Splashing Chemical Exposure" / 9 7 */ ^S On Sunday, August 11, 1974, at approximately 12:45 p.m., the flexible stainless steel hose In the vent line of no. 6 reactor in Building*"*!" rupturea, ai-Lowing fee reactor contents to he vented into the building. A charge of 605x560 was made and soaked for one hour. The charge had been properly vented and water added according to procedure^ Approxi mately lb minutes after the water had been added. chemical operator, heard a pop and saw chlorine and resin being emitted from no. 6 reactor through the flexible stainless steel vent hose. The area was immediately evacuated. Area supervisor Paul Sumpter and Blevens donned Scott Air-Paks. re-entered the building, and closed the manual valve. The all clear^was sounded at 12:57 p.m. Both Sumpter and 1 were treated at the plant Dispensary for Inhalation of chlorine fumes and then returned to work. No. 6 reactor operates at six pounds pressure with a double carbon rupture disc with a 24-pound rating. The rupture disc is protected by a high pressure alarm instrument designed to actuate a mechanical valve at eight pounds of pressure. Investigation of the accident revealed that the emergency alarm failed to funcuiop..thus causing the rupture disc l;o~falT7 Upon failure of the rupture disc, a plug in the vent pipe, left .from a former blown charge, caused the, ^flexible hose to rupture^ An inspection of the high pressure alarm has not yet revealed why it failed to actuate. Corrective Action (T) A procedural change now requires that the flexible steel hose be changed after each lost charge. (2\ The possibility of installing a solid vent pipe is to be investi gated . a> The entire high pressure alarm system has been checked and is in operating order. M. D. Schrader \ 16tf*4 NOC 15845 B*F Goocbieli CWmieflil Campany InterOrganigition Correspondence To W. K. Pember Location Louisville Date Prom August 19, 197^ Louisville Repetitive Accident Type No. 10, "Pill Building or Area Snb3ect wwiitthh EExxpplloossiivvie Mixture" -TT **tZ. At approximately 5:55 p.m. on August l4, 197^-* OVA operator______ discovered a VC1 leak at the east first stage VC1 recovery pump located in the west area of building 3^1. first floor. While the pump was being isolated. the leak became worse, activating.the Bendix alarm. The fire alarm was sounded at 6:00 p.m., and the building was evacuated. Foreman C. D. Macy and Operator....................... , equipped with Scott AirPaks. re-entered the building, isoxatea the pump, washed down the ice build-up with hot water, and allowed the pump to vent. The all clear was sounded at 6:37 p.m. The total VC1 loss is estimated at 50 pounds. Cause Bleed offs on VC1 charge pumps are piped into the suction side of the first stage recovery pumps. Upon start-up^ both latex charge pumps were vapor locked. In an attempt to free the vapor-locked pumps, the latex charge operator was bleeding VC1 vapor into the recovery pump. The recovery pump was overpressured, resulting in damage to the seal and causing the leak. Corrective Action The bleed off lines on the VC1 charge pumps will be piped into the dis charge side of the second stage recovery pumps, eliminating the possibilHy~o? overpressurin^ the first stage pumps. M. D. Schrader ru Distribution. J. W. Gressler H. Waltemate J. L. Nelson - R. D. Scott E. W. Harrington - P. D. Terry D. R. Gray W. E. Brodine G. Pow J. M. Hyslop R. A. Kelley P. H. Lawrence Depa r tment Mana ge rs General Foremen Supervisors NGC 15846 REDACTED AUG 20 (974 B.F.GOODRICH CHEMICAL COMPANY Avon Lake General Chemical Plant To; W. T. Gunning Location: Safety Department Date: August 20, 1974 From: R. C. Kaminski Subj ect: Summary: HEAR MISS - PINCHED FINGER FROM POLY CHAIN FALL HOOK Pfn/CH --T WV u. /y/M r "c At approximately 2000 hours on August 15, 1974, poly #146 was opened using a chain fall to prepare it for cleaning. Poly #148 directly across from it was being high pressure lance-cleaned. Due to congestion and ambient VC1 considerations, a helper, tried to close the manhead bat neglected to remove the chain fall. The lid went 3/4 of the way down and pinched his finger which straddled the chain and hook. He suffered laceration and fracture of the right fourth finger. He was treated at Ht. Josephus hospital and returned to work. Facts: A Board of Review was held at 1530 on August 16, 1974, to discuss the incident. The following persons attended the meeting: J.R.Shellenberger, W. T. Gunning, R. C. Kaminski, E. Evans-Foreman, Helpers I were preparing poly #146 for cleaning. Poly #146 man- head binds slightly at the closure "ears". The overhead chain fall was attached to the handle and opened. The Aqua Blast contract employee was high pressure lancing poly #148 directly across from poly #146. Due to the congestion, decided to wait until poly #148 was finished and proceeded to close poly #146. He neglected to remove the chain fall and placed his fourth finger between the chain and hook. He started closing the manhead until the chain snapped taut at the 1/4 open position pinching his finger. Recommendations 1. E. Evans, Foreman, has had other manheads checked for sticking and these have been corrected. 2. Geon East is investigating a worm gear drive to open and close manheads. An experimental 38-1 drive for the manhead hinge has been ordered. Should this prove satisfactory a similar unit will be ordered for Geon West. This Incident will be publicized and reviewed with operating personnel, The importance of removing the chain hoist before closing manhead will be emphasized^. RCK/ecw cc: J.W.Gressley H.Waltemate J.L.Nelson-R.D.Scott E. W. Harring ton-P.D.Terry D.R.Gray W.E.Brodine G.Pow B.A.Healy (f R.A.Kelley R.N.Rylands Department Managers General Foremen NOC 15847 redacted r 5$o l7* Gooelraela Clieimeol C yID--R--rUrg,,BI,,Q, _iS4a?Q,O,--n UO--i.R-^--O--n-- Q-- -Ci_u--Ce To P. A. Wagner Location Louisville Date From August 20, 1974 Louisville RuKwt Repetitive Accident Type No. 10, "Fill Building or Area with Explosive Mixture" /77y 7{.jcu'a^^u At approximately 10:30 AM, Saturday, August 17, 1974, two mechanics working on no. 2 slurry pump in Build ing 111,, noted the blow down lines going into no. 3 blend tank were vibrating considerably^ They immediately reported this unusual occur ence to Doug 'McWhorter, area shift foreman, who was entering the area at the time. McWhorter, detecting vinyl chloride vapors, immediately summoned Building 111 recovery operator, to the area. While (wearing his respirator) closed off bhe bottom valve of no. 4 blow down tank, into which two charges were being dropped, McWhorter turned in the fire alarm, put on a Scott Air-Pak, and cleared the area. The alarm was registered at 10:44 AM. A fire water spray was then directed into the blend tank pit area to ' wash away the vinyl vapors. When the water spray was begun, the vinyl - chloride vapors could easily be seen in the pit area itself. The all clear was sounded at 10:56 AM, when the pit area reached 100 ppm vinyl chloride. An investigation into the incident revealed the following series of events. At 5:^5 AM, August 17, polys 14 and 15* containing 103EP charges, were blown down into no, 4 blow down tank for recovery prior to transferring to the blend tank. According to the operator, (who was working his last shift before starting vacation), the recovery phase was completed at 6:30 AM, and the charges.were drained to no. 3 blend tank. The blow down tank was then logged as being empty and under 15n Hg. vacuum at 7:00 AM. The final shift read ing listed the"status of no. 4~blow down tank as "vacuum", meaning- ready for next charges. The recovery operator on the incoming shift, day relief operator went about his normal operations until approximately 10:30 AM. At this time, polys 13 and 16 (103EP) began to peak, requiring an early blow down. _______reported noting the vacuum on no. 4 blow down tank: however, he did not look into the presumably empty tank.. } then proceeded to blow down polys 13 and lS into no. 4 blow down tank. It is now evident that the bottom valve on no. 4 blow down tank was open rather than the presumed closed^ The two "fresh" charges then began to pass - through no. 4 blow down tank directly to 3 blend tank. redacted NC 15848 AUG 22 1974 2 The amount of vinyl chloride actually released into the building is difficult to estimate. Two Geon 103EP charges, at time of blow down, have approximately 775 pounds of unreacted vinyl chloride apiece, or a total of 1,550 pounds. That would have been the largest possible loss; however, as soon as the two polys were opened to 4 blow down tank, the vinyl chloride recovery valve was opened on the blow down tank. Other vinyl chloride which reached no. 3 blend tank was lost out the blend tank ventilation system. After no. 4 blow down tank was closed off, approximately one full charge was still in the tank. Based upon this information, it is estimated that the vinyl chloride released into the building was approximately 150 pounds. Recommendations to prevent recurrence: All Building 111 recovery operators, including day relief and vacation relief operators, will be required to take the following steps during their shifts: The outgoing shifts will check all tanks, lines, and valves and report accurately the condition of each. 6> The incoming shifts will also make it a habit to check all tanks, lines, ana valves^Tor which they are responsible to learn the condition of each. In an effort to prevent the "forgetting" to complete the final steps of an operation, efforts will be made by recovery operators to space their transfers throughout the shift as much as possible rather than trying to do numerous transfers at once. The third item above is the result of studying the transfer sheet for the 12-8 shift on^August "17. On that shift, a total of five charges were transferred between 2:00 AM and 2 :3Q AM; four charges "between 4:30 AM and ~4745 AM; and eip;ht charges between -6^30.' AM and 7:00 AM. If is felt that if fewer transfers were made between 6:3Q..AM and 7:00 AM. the bottom valve on 4 blow down tank might not have .befirL..la.f.t open R. J. Grahek ru Distribution: J. W. Gressler H. ^alternate J. L. Nelson - R. D. Scott E. W. Harrington - P. D. Terry D. R. Gray W. E. Brodine G. Pow J. M. Hyslop R. A. Kelley P. H. Lawrence Department Managers General Foremen Supervisors NGC 15849 ;-- To: W. T. Gunning From: P. W. Shore B.F.GOODRICH CHEMICAL COMPANY Avon Lake General Chemical Plant ALGC Plant - Safety Department ALGC Plant - Latex Department npi 7-yr^ Subject: NEAR MISS -- INCIDENT OF EXPERIENCE VALUE -- ALGC - VENTING OP GEON 460x6 POLYMERIZES.. Repetitive Type 10. Fill Building With Explosive Vapors SUMMARY; At 0020 hours on September 10, 1974, Polv #5 In the Avon LaWg I-a^ex Plaqt developed pressure with such sudden force that it not oply blew the four inch relief disc^ but blew the "0** ring out of the manhead gasket. the gasket under the agitator unit and the agitator seal system which is normally run at 150 nsig. No one was injured. The building was evacuated for 15 minutes until the Bendix returned to 25 ppm. The flushing of the area into the storm sewers subsequently caused a whitening of the domestic sewage at the Avon Lake City City Sewage Treatment Plant. No further difficulty was encountered. The charge loss was 15,000 lbs. BOARD OF REVIEW: An inquiry was conducted at 0900 on 9/10/74 attended by R. N. Rylands, R. W. McKay, M. D. Rider, R. E. Mick, B. L. Barden, P. W. Shore, Foreman--H. Luke, and Charge Operator-- FACTS AND NARRATIVE: 1. Geon 460x6 is a vinyl chloride-vinyl acetate copolymer. It was charged on the morning of 9/9/74. Proportioning from the premix to Poly #5 (a 4000 gal, vessel) was started at 1130 hours and completed at 2300 hours. All this time and up untiriffitb hours on v/iu/74 everything appeared normal with the exception of the faster than normal addition of the proportioned ingredients. At 0010 hours the charge operator observed the sudden rise of ^.Pgr.a.ture and, pressure^ He attempted to .manually vent out the one inch vent to the~dor scrubbing system and refrigerated water was turned on. This failed to hold the charge and in a period of a few minutes the gaskets blew as well as the relief disc. Exact sequence is not known since all happened so fast. The building was immediately evacuated. 2. The premix and poly make-up appear to have been normal with proper amounts of raw materials and water being charged. 3. Geon 460x6 has had a history of poor reaction control. Ten percent of all (80 charges) charges made since we began making it in 1972 have either vented or gone hard in the poly. In addition, at least ten others have been borderline charges* REDACTED NGC 15850 W.'T.G 2 - 9/12/74 4. A dP cell was Installed In August after the magnetic flow meter failed and caused ' 460x6 charge to fuse in this same poly. Since the dP cell had been installed nine successful charges were made. Controlling by the dP cell had held the proportioning rate below 3.0 GPM. No knowledge is available to the operator as to how fast the pro portioning is going since there is no totalizing or weighing equipment available. 5. The reaction temperature is 113F., a relatively low one in comparison to other latexes. It is an accepted fact that vinyl acetate reactivity is sluggish under these conditions. The faBt addition df premix apparently created a frfath vofiffle of unreactants in the nolv at the end of the proportioning period when it started to warm up it really took off bevond control even though refrigerated water was turned into the jacket when it started to heat up. CONCLUSION: Cause of venting was saturation Hue to metering at ton hioh a rate cmminP the_ nhagfg fro be low conversion at the completion of metering. RECOMMENDATION AND ACTION TAKEN: Discontinue production of this product until acceptable changes are made in the equipment and/or process to assure us of a safe manufacturing process. 2. Tell Operators we will not run it again until we can do it safely. This has been done. 3. Continue investigation as to why the proportioning on this charge went so much faster *han the previous one using the dP .cell. 4. Work with M. D. Rider to resolve polluting the local sewage treatment plant when area flushing becomes necessary as in this case. Meet with Dave Weaver of ALTC and R.Y.Garrett of Divisional Manufacturing Services to outline a program to provide immediate and long range plans to handle //I above (1st meeting held on 9/11/74 and a second one will be on 9/17/74). A separate report will follow. Repair the vessel and check it structurally for soundness. PWS/ecw cc: J.W.Gressler H.Waltemate J.L.Nelson-R.D.Scott E. W.Harrington-P.D.Terry D.R.Gray W.E.Brodine G.Pow B.A.Healy P. W. Shore Latex General Foreman R.A.KeUey - *<. Rylands Department Managers G ?.nera! Foremen Latex Foremen R.Nick B.Barden File NGC 15851 Inter- organization Correspondence A. R. Webber FIELD POINT OR AKRON DEPARTMENT BLDG. NO. FROM E. C. Martinelli nELD PMT on AKROM 0APARTMENT V* BU3Q. NO. CUBJECT Incident of Experience Value-VCL Monomer Release \EEGoodrich da re roun lcttcr DATE THl* LETTER October 9,1974 Repetitive Accident fllO-^Filling Building or Area with Explosive Mixture'1 /97/ 7-yfA^/O On Saturday, September 28, 1974, at 10:00 a.m. a VCL monomer release occurred in Poly Building 513. Approximately 3.000 lbs, of vinyl chloride was discharged onto the first floor area, from the meter station through the meter calibration tank. The incident was reviewed by the following people: J`. W. Goetsch-Pearl/Paste Resin Manager E. C. MartineHi-Senior Production Engineer C -Lead Technician -Technician Trainee Facts On the 12-8 shift Saturday, September 28, several, pearl charges had abnormal pressure rises. To determine the cause, one of the many things done was to calibrate the charge meters. technician, set up the meter station for calibration by opening the manual valve to the calibration tank and pulling the air hoses from the computer operated valves for vinyl charging. He also closed a manual vaTve on the recovered vinyl charge line_. The meter calibrations were checked and found to be accurate. started the calibration tank draining to the sewer. He called on the radio to have someone on the second fLoor set the meter station up for charging. c responded to the call. He connected the air hoses and opened the manual valve on the recovered VCL charge Line. He did not close the manual valve from the meter station tp LbLj^llbxaiLiQn tanJT Theldr'aTn valve on thfe calibration tank was also left op~eiu 'DTiver then'notified the Computer Console Technician the meter station was ready for charging. A charge was started an_ saw the gas spill after 3,000 lbs, of vinyl chloride had been charged through the_meter _scation< The gas alarm and fog system were immediately activated and the building evacuated,, The Console Technician on hearing the oas alarm immedi. ate L y a topped charging by putting the raeLer station to hoid. ^OACTJEJ) NGC 15852 Repetitive Accident #10 -2- Cprrective Action 1. The incident will be reviewed in all departmental meetings. A check list for the technician has been prepared and put into use before and after meter calibration. A contact switch will be installed on the manual valve between the meter station and calibration tank. The switch will read back to the computer and be checked by the computer logie before charging. cc; J. W. Gressler H. Waltemate J. L. Nelson-R. D. Scott E. W. Harrington-F. D. Terry D. R. Gray U. E. firodine G. Pow J. M. Hyslop R. A. Kelley (Akron) Area Managers T. B. Johnson dm N0C 1*J3 B. 1?. GOODRICH CHEMICAL COMPANY Avon Lake General Chemical Plant TO: W. T. Gunning ALGC Plant - Safety Department FROM: J. R. Shellenberger ALGC Plant - Geon West October 15, 1974 SUBJECT: Near Miss - Fill Building with Explosive Mixture - Repetitive Accident #10 SUMMARY: ^7^0 At 0410 hours on October 9, 1974, the bottom valve on poly #143, which was in the middle of the reaction cycle, was opened by mistake and allowed a portion of the contents to spill onto the second floor. The building was evacuated for 20 minutes until the Bendix readings returned to normal. There were no injuries and only a minor loss of material. FACTS: A Board of Review was held at 0800 following the incident with the following present: D. Guggenbiller - Foreman - Poly Cleaner - Poly Cleaner R. Kaminski R. Mather L. Wallis J. Shellenberger 1. was' training with in cleaning poly #144. W. Day had only 10 davs plant experience and only 3 days poly cleaning experience. 2. Poly #144 had been washed down and was ready for HRC cleaning. 3. An adjacent poly #143 was in the middle of its reaction cycle. 4. V went to the second floor to set up the valving to HRC poly #144. went downstairs via the South stairway versus his normal path of the North stairs. In going to a spot rather than a specific polv number he became unknowingly confused on his location. By mistake he removed the inspection plate and opened the valve on polv #l43. Slow stem action oi fee Yarwav automatic vaiVc fllriirtVlzAfl tftg~'Pr'0fl> uct loss and exposure of employees to vinyl chloride. 5. Leak was discovered by the blowdown operator and the foreman who donned Scott Air ftaks anti closed the valve. 6. Foreman did not allow anyone to reenter building until all readings were under 25ppm. RECOMMENDATIONS: O Even though polys are clearly numbered presently, the numbers are visible from only one path of approach. We will paint the poly numbers in several other places close to the bottom valve and with a bright color. 2. This situation and the cause has since been discussed in 10 minute safety meetings on all shifts. REDACTED NGC 15854 Avon Lake General Chemical Plant Near Miss - Fill Building with Explosive Mixture - Repetitive Accident #10 Page 2 RECOMMENDATIONS: We will start implementing the J.I.T. manual as soon as possible. We will start 3 with new employees and expand to other operating jobs as quickly as practical. JRS/bu cc: J. W. Grassier H. Waltemate J. L. Nelson - R. D. Scott E. W. Harrington - P. D. Terry D. R. Gray W. E. Brodine G. Pow 6. A. Mealy R. A. Kelley R. N. Rylands Department Managers General Foremen Geon Foremen (12) L. Wallis John R. Shellenberger Geon West General Foreman NGC 15835 organization (parrespandfeii-pfe no.n point or no, > i-hitmiwi a sius. no. J. W. Gressler Cleveland PROM FlLO*OINT Oft MdON nRPAftTMENT et.Dfi. 1 T. B. Johnson Pedricktown October 16, 1974 Incident of Experience Value-Repetitive Accident #10-Fill Building or Area with Explosive Mixture /77y 7 e ^7 I-', f, l.f&A ' ` -f & 2-jL At 4:00 a.m. October 12, 1974, approximately 200 pounds of VCL monomer were released on the second floor in Poly Building 513. A leaking 3-way valve on Poly fe Vfo,. charge line caused the release through a broken flange when a blind was removed. No^personal injury or equipment damage resulted. A review was heLd with the following personnel in attendance: -Area Lead Technician -Technician J. W. Goetsch-Area Manager, Pearl/Paste T. B. Johnson-Safety Engineer Sequence of Events Poly #5 had been cleaned and was assigned to prepare the vessel for charging, broke the flange and removed a blind from the VCL charge line. VCL immediately began spraying out. The' chain f alT support^was ~ slacked off"and piping dropped in place. Attempts to tighten the flange bolts were futile. The gasket was defective and adjacent piping iced up. noted the problem and requested the Console Technician put polys to r ou O hold. " arrived and the poly manhead was closed in an attempt to remedy the situation through the recovery system. This was to no avail because the Yarway valve had been removed from the vessel short circuiting the recovery capability. Poly #4 was then closed and its VCL charge line opened in an attempt to bleed header pressure into the vessel. This was unsuccessful also. The Console Technician was then requested to flush the main VCL header with hot D.M. water to Poly #4. Afterward the main header 3-way valve was switched toPoly #5 and its VCL charge line fLushe.d also. An aLl-cLear was sounded at 4:35 a.m. Corrective Action NGC 15856 Poly entry check sheet revised to include opening a bleed to check for pressure before installation or removal of blinds on charge lines. 2, This incident will be covered in all Plant safety meetings. REDACTED cc: ; j. W. Grassier H . V.'cil ram etc J, L. Me 1 . on -R . D. Scott E. W. il c..-c ir.gton-P. H- Tevry D. R. Cray W. E. i'-rcdim C. Low J . M. 1! v s 1 op R . A. Kelley (Akron) A. R. Webber Area Managers > \ .O l POLY ENTRY .CHECK SHEET Revised: 10/16/'/** SHIFT____________ TIKE POLY :iO.DATE fref^ratio;: eok entry Agitator locked out and tagged. Evacuation hose in poly. (In at least 20 minutes before entry.) -- Computer switch in "Enter" position. Main factory air supply to valve drives disconnected and tagged. Water injection manual block valve closed; bleed open (pearl only) _ Lines blanked: a. Charge line .Open bleed before blanking to check pressure (pearl only)_ 7. 8. 9. 10* .11 .12 .13 .14 .15 * .16 **17. b. Recovery line c. Shortstop line (i>carl only) d. blowdown line _ Oil Seal a. Double block and bleed on nitrogen supply. b. Valves In oil lines open. Close double block valves anu open bleed valve on nitrogen supply line to emergency seal water tank. .'NOTIFY CONSOLE TUChj Close double block valves and open bleea valve on steam supply line to poly sparge system. Ebly cleaning ladder in poly. Fresh eir mask MOST iiE WORK Poly cleaning tools in poly. Men entering has harness on connected to chain hoist. Alarm cart positioned and working properly. Gloves, liners, rubber boots eno head cover MUST HE WORN. lifter one hour, exit the poly and have the accumulated water drained. This must be done once per hour, (pearl only.) Air line respirator and regulator checked. SIGNATURE OF AREA TECH SIGNATURE OF CLE/i&NG TECH 3. COMPLETION OF CLEANING TIME Agitator, baffles and thermowell clean Recovery header clean. Manual vent clean. Rupture disc clean. Pressure transmitter clean. Charge line clear. (pearl only) Water injection line clean, (pearl only) Tools and ladder removed from poly. n. Fresh air mask removed from poly, blanks removed from: a. Charge line. Open bleed before blanking to check pressure(peerl only.) b. Recovery line, c. Shortstop line. (pearl only? d. Eloirdotm line. Oil Seal: *12. a. Oil seal pressure b. Valves in oil lines open, Open double block valves and close bleed valve on nitrogen supply line _______ ______ 13. to emergency se*l water tank. NOTIFY CONSOLE TECh'j Open double block valves and close bleed valve on steam supply line to poly sparge system. .. __________ 14. L5. 15. 17. 18. Water injection manual block valve open; bleed closed, Factory r.ir line to valve drives connected. Computer twitch in "Ola.m" position. All poly surfaces rinsed with b.i water. Evccua.tic. hose removed from poly. (pearl only) NGC . _ 15857 ________ 19. Equipment put st.*ny and area clean. ________ SIGNATURE OF TECil SIGNATURE Or CLEANING TECH nter. organization Correspondence , BFGoodrich. Herm ^alternate ncuo POINT OR AKRON DEPARTMENT O. BIOS. HO. D/5450 Cleveland DATE YOUR LETTER F. C. Dllley FIELO PONT OR AKRON bCTAI^MEHT B> BUB. NO. Long Beach Plant. Safety Dept DATE THIS LETTER 10-30-74 flUOJGCT Narrative Accident Report - Dryer Operator, Long Beach Plant &CQ/0? f/-r * // o On 10-16-74, 0210 hours. Dryer Operator In the Resin Department sustained a blow to the head when a Kam-loq fitting uncoupled gn,a resin transfer line and struck I on the rlgtit temple, was taken to St, Francis Hospital, x-rayed and his condition was diagnosed as a mild ^ $f[ concussion. Dr, Lorabarul kept in the hospital for observation for approximately 32 hours anu then released him to return to his regular job and shift. // ^ f" On 10-23-74 a boaru of inquiry was held with the following people in attendance: E. L. Beeler R, B, Crenshaw P. Jaspar W, L. Blount F. C. Dilley Production Manager General Foreman Resin Foreman trainee Industrial Relations Manager Safety Engineer Dryer Operator stated he was starting up the dryer and was in the process of manually transferring some material from batch conveyor unit D to resin storage bin 4. He further stated that as he pressed the switch to start the timer for the conveyor the Kam-loc fitting on the flex hose uncoupled and the metal eno struck him on the arm. This blow pushed him back against a wall (4` distance) causing his hard hat to fall off. at this time trieo to turn off the batch conveyor switch which is approximately two feet from the separated line ana was struck on the head by the whipping hose. This line operates at approximately 25 psi. The operator thought the line to Bin 4 was pluggeu at the time. The involved equipment' was inspected immediately after the incident and found to be in good condition. It was impossible to pull or shake the coupling loose when the locking levers were firmly in pla^e. Corrective Action l. jThis acciuent will be uiscussed with all dryer builuing personnel. The importance of always checking all connections of resin con veying equipment will be discussed. 2. An effort will be ma^e to devise a safety for these line connectors to prevent separations. 0 Until a useable safety is ueviseu the Kara-iocs will be safety wireu by wiring down the closure levers on the Kam-locs. vA REDACTED F. C. Dilley FCD/et cc: J. W. Gressier J. L. Nelson - R. D. Scott E. W. Harrington - P- D. Terry D. R.. Gray er9S*-o RRetVv 1 *. '>0 l| FHU IN KJS A. \ W. E. Brooir.e ri i it ii J. M. Hyslop G. Pow R . A. K e 1 1 ey ( Ahvon) -1' NGC 15858 , i Bo Fa G<n>sSi5!a Claemm BiterOrganixation Correspondence To P. A. Wagner Location Louisville Date From November 1, 197** Louisville _ Repetitive Accident Type Wo. 10, "Fill Building or Area subject______________________________________________________with Explosive Mixture" An inquiry was held on November 1, 197*+j at 8:00 AM concerning the cir cumstances which resulted in the gas escape that occurred in Building 1 on October 29, 197**. Present were: P. A. Wagner - PVC Product Manager S. T. Brown - Engineer A. S. Flynn - Safety Inspector . - PVC Charging Operator P. T. Claggett - HRC Operator Chemical Helper L. D. Pringle - PVC-2 General Foreman L. T. Hood, PVC-2 foreman on D-shift, who was working on B-shift at the time of the incident, was interviewed on October 29 and 31 and was nob present at the inquiry. Each individual working in the Building 1, third floor, area at the time of the escape was asked to give his account of the incident. From these accounts it was concluded that at approximately 2:35 PM on Octo ber 29, 1974, when started liquid VC1 to no. 9 nolv. approxi mately 120 gallons was misdirected into no. 8 poly, which was being prepared~for iffiC cleaning. The man head on"no. 3 was open-and the bot tom valve was open and connected to the HRC drain header. Some of the liquid VC1 flashed out the open poly on the third floor level, and the remainder of the liquid drained to the first floor dumpster, where it vaporized into the first and second floor levels. When saw the vapor emitting from no. 3 poly man head, he immediately closed the VC1 charging valve at the meter, proceeded to no. 8 poly, where he closed the partially open manifold valve, and left jhe building"~via~the catwalk to Building 15. The building was clear of VC1 and the all clear sounded at 3:11 PM. No. 3 poly had been charged on the 12-8 shift. The 12-3 operator was unable to recall specifically whether or not he closed the manifold valve; however, normal operation calls for closure of the manifold valve and the polymerizer block valve immediately after the recipe amount is metered into the reactor. The partially open position of the valve indicates some unkrTown" unusual occurrence may have partially opened" the valve whTle The ~charge~was^ running. When"'the charge was blown down and recovered on the o-l shift, the poly block valve was opened, properly, to recover any VC1 in the manifold. The HRC operator and helper did not notice that the charging valve was partially open and as a result recovered the VC1 in the entire charging header. At completion of recovery, the poly was opened, washed down, and set up for HRC cleaning. When VC1 was introduced into the VC1 charge header for no. 9 reactor, it instead flowed to the "open" no. 3. NGC 15859 redacted Corrective Action to Prevent Recurrence <P The incident will be the subject of all shift safety meetings the week of November 3* 1974. Charging operators will again be contacted regarding the importance of checking their equipment for normal valve position and operation at the beginning of each shift. 3J --^ HRC operators and charging operators will be instructed to check all manifold valves, water and vacuum on the Powell valve, manifold and VC1, bleed off* and continuous water injection on the charging manifold before recovery of the manifolds is begun. Additional Comments Once again the inadequacy of our present fire alarm was evident. Several people in Building 1 did not hear the alarm and did not evacuate rapdily enough to avoid VC1 exposure. A separate gas alarm is the only sure way to correct this problem. Its installation should be expedited. Several people from various other departments were observed in the building WITHOUT PROPER RESPIRATORY PROTECTION and had obviously entered the building without determining the degree of emergency present. cPZ s-Jc's r///s ts s? <l c. 3* People evacuated from Building 1 should be cleared completely out of the PVC-2 geographical limits. IT SHOULD BE EMPHASIZED THAT FOR EMERGENCIES OF THIS TYPE, PRODUC TION PERSONNEL HAVE THE RESPONSIBILITY FOR PROPER EVACUATION OF THE AREA AND DETERMINATION WHEN IT IS PROPER TO RESUME NORMAL OPERATIONS. y e*/ (ripo&.'rfi L. D. Pringle ru Distribution:^J. W. Gressler H. Waltemate J. L. Nelson - R. D. Scott E. W. Harrington - P. D. Terry D. R. Gray W. E. Brodine G. Pow J. M. Hyslop R. A. Kelley P. H. Lawrence Department Managers General Foremen Supervisors NGC 15860