Document jyY7pZjM5a9OkLbVNnOk5K12N

*. A J?73 7. r TO; W. T. Gunning LOCATION: ALGCP B.F .GOODRICH CHEMICAL COMPANY Avon Lake General Chemical Plant FROM: J. R. Shellenberger DATE: January 3, 1974 SUBJECT: Near Miss - Separation of Speed Line Flanges on Wash. Down Line Bldg. 461 INCIDENT: At approximately 0400 hours on December 28, 1973, a speed line flange on the wash down lines for polys 149-156 separated while under steam pressure. The wash down line from poly 152 had been plugged and was in the process of being cleared by the use of high pressure (I85 psig) steam. When the flange separated the 3M wash down line moved approximately Is" into a 110 volt light fixture and the light fell to the floor. There were no injuries and there was no damage other than to the deflected wash down line and the light fixture. The uninsured loss that occurred was $400. A Board of Review comprised of the following people was held on January 2 at 1600 hrs: - Blow Down Operator Donald Guggenbiller - Geon Shift Foreman Gene Krupp - Safety Inspector Ronald Mather - Product Manager Polyvinyl Resins John Shellenberger - General Foreman DETAILS: The charge in poly 152 could not be blown down by the normal method since the blow down valve appeared to be plugged. The blow down valve is in the line between the reactor and the blowdown tank. The blowdown operator, _ indicated that since he could not drop the charge to the blowdown tank, he would drop it directly from the poly to the blend tank via the wash down lines. (The charge was already- recovered in the poly1), As he prepared to do this he discovered that, wash down lf1eg.,wxg algo Plugged,___He then tried. _to clear the wash down lines with D.M. water (3 00 psig) but was unsuccessful. He then started using steam to blow out these lines. The steam was turned on and off intermittently, after a period estimated to be 5-15 minutes, the operator heard a loud bang which was found to be the result o? the~line separating at the flemge and hitting tihe light^YixtnreT NGC 15790 FACTS FOUND AFTER THE INCIDENT: 1. A piece of hard resin 3" in diameter and about 8T* long was found on the floor. This was the line obstruction. 2. The blowdown valve on poly 152 was plugged solid and explained the inability to drop the charge to the blowdown tank. a> Flange on the wash down lines were not backvrelded. These lines had been generally in low pressure (lQOpsig with D.M. water) service and was one area that was not felt to be critical a year ago when the problems with rolled flanges were revealed. It was not felt that lines vented to the atmosphere as these were through the tanks would become a pressure system, however, when theselines are plugged this is not the case. REDACTED Avon Lake General Chemical Plant Page 2 Near Miss - Separation of Speed Line Flanges on Wash Down Line Bldg 461 BECC3MMENDATIQNS t All flanges on the wash down lines were immediately backwelded to prevent additional separations. The practice of using steam to clear the plugged wash down lines will be discontinued immediately. G A GPO has been written to revise the wash down lines with an adequate slope to facilitate better drainage. 4. The incident is being publicized within the department. JRS/bu, ccs H.Waltemate J. dressier 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 Department Managers General Foremen J. R. Shellenberger me 15791 TO: W T, Gunning ( LOCATION: ALGCP - Safety 7-/ > ', . /. /9 73 4* <? FROM: *R. M. Yurovich DATE: April 4, 1973 ** 3 SUBJECT: Near Misa Repetitive Accident Type #9 - Machinery In Operation - Pinch Boint Accidents - No Lost Time ACCIDENT DESCRIPTION: On April 1, 1973 at approximately 0800 hours, Millroom East First Class Mill Operator sustained abrasions to the back of his right hand and right index finger while attempting to clear lammed transparent compound from ih2 cuber slitter rolls and the strip guide on discharge side of slitter rolls leading to feed rolls. The; jammed condition of the cuber had occurred on the previous shift and at that time the product flow and size reduction operation diverted to #1 cuber. ipon arriving at his work, station learned of #2 cuber condition through shift change commun ications and set his first priority to unjamming the cuber to make it operational as the standby unit for immediate use if and when necessary. After observing the extent and condition of the cuber, " fed several small strips of compound into the cuber in an attempt to force and dislodge the jammed material through the introduction of the small strips. Several attempts by this method only succeeded in loosening the jammed material. (The feeding of small strips in this.manner is safe, operating procedure and practice. No `'back1* feeding was attempted). Observing the jammed material loose, raised the hineed plate between the discharge side of the slitter roll and the feed roll leading to the fly knife blades. This action exposes the bed area where the compound, cut by the slitter role, travels to the now exposed feed roll, leading into the covered fly knife action. The cuber at this time was operating, but no product was being sized reduced. grasped the loosened material at the base of the slitter roll discharge chute with his gloved hand (mill glove) and attempted to pull this material free. While pulling the material in this manner, he lost his grasp and with the subsequent momentum the back of his gloved hand struck the turning amosad fly knife feed roll. The feed roll immediately grasped the loose fitting mill glove, pulled his hand from the glove sustaining the abrasions. The mill glove was fed through the fly knife action by the feed roll gear. i shut the cuber down, reported the incident to the Shift Foreman, and received medical attention for his injury. The accident was initially investigated by Curt McClung, Shift Foreman, and the report of injury accident report completed. At 1330 hours on April 2, a complete review of the accident was held with the following in attendance. R.N.Rylands - Plant Mai ager R.M.Sandfry - Compound Manager W.T.Gunning - Sr. Safety Engineer R..F.Gascoigne - Safety Engineer R.M. Yurovich - Millroom East General Foreman CMcClung - Millroom East Foreman - Mill Operator REDACTED NGC 15792 ApR5 m 1 ** Near Miss Accident ( April A, 1973 Page 2 DISCUSSION: A guard had been installed to cover the feed roll and the area between it and the slitter roll cover. The slitter roll is frequently jammed with material. There is presently no effective method to remove the jammed material. CONCLUSIONS OP REVIEW: Apparently it has been the practice of the cuber operators to lift thy piiar^l between the rolls in order to pull the material from the slitter roll. In discussing the practice we find a misinterpretation of operating procedure. The exercise of complete awareness to the possible and eventual circumstance was not demonstrated. The present practice must immediately cease to eliminate any possible recurrence of this nature. The uninsured cost of this accident is estimated at 656.30. CORRECTIVE ACTION: ( An immediate review and corrective action taken with all shift operating and [ supervisory personnel. " The_ operating procedure will be rewritten to specifically prohibit exposing any moving equipment on the cuber until after the cuber is locked out. ^Jl A comprehensive engineering study to develop a possible safe practical method of clearing slitter roll of jammed material. Until this method can be developed and operational, the unlsimni no of enhera will be completed following the Lockout Safety Procedure. SA-2. Rv. 4. If this method is not successful, the clearing of the cuber will be accomplished with the aid of Maintenance personnel by removing the top slitter roll or whatever is necessary to clear the equipment in a safe manner. RMX/alra R. M. Yurovich General Foreman Millroom East cc: H. Waltemate R.N.Rylands D.L.Dowell J.L.Nelson-R.D.Scott R.M.Sandfry Department Manager E.W.Harrington-P.D.Terry General Foremen D.R.Gray W.E.Brodine G. Pow R.A.Kelley 4 * <s. A' -A NGC 15793 /- J V / Cf ~Ao _r e* e - /f. . 0 7 . i,, .. r- 4 J.W. Gressler T.B. Johnson - ..................... * Cleveland r^LD I-OINT cfl AiMtoN fUAfi a Et-nc. no. Pedricktown / sy'fT NEAR MISS - REPETITIVE ACCIDENT #6 CHEMICAL EXPOSURE DAT- i t>J ` 4--i 'li!C DAlfc *1(41$ LCITF < December 27, 1973 BACKGROUND: j On December 24, 1973 at approximately 6:00 p.m., I a Technician Trainee with 13 months experience, was found unconscious over the manway of #1 Pearl Polv. As a Contract Serviceman, entered Building 513 through the north door, he saw a hose spewing water and whipping about in the vicinity of #1 Pearl Poly. turned off the water and then saw slumped over the vessel manway, had one hand under his forehead resting on the rim of the manway, noticed _ was bleeding from the back of his head as he lowered Whipkey to the floor. then summoned . . the Area Lead Technician. < assessed c'g' .-^the situation and quickly sounded the gas alarm, since it was the nearest alarm 'device__.___________ regained consciousness as___ returned stating that he was okay and asking what had happened. told to remain on the floor and lie "i1 then placed , a Technician who had responded to the alarm, on an emergency stretcher and transported him to the Laboratory for first aid. Laboratory personnel applied a compress to Whipkey's head and drove him to the Salem County Hospital. received 12 stitches and head x-rays. He was re Leased after a 2-hour observation period and returned to the plant. ^ On December 27, 1973, a meeting was held with the following personnel to review this incident: - Area Lead Technician Jc - Serviceman John W. Goetsch Area Manager Bart Johnson - Safety Engineer Bill Riley - Personnel Manager Joe Smith - Plant Engineer l - Technician Trainee Results of this meeting are as follows: FACTS: 1. 2. G> (2^) 5. 6. 7. (5 9* The computer had released #1 Pearl Poly for unheading. The vessel was unheaded by An evacuation hose was placed in the manway prior to transfer. It was removed before washdown to facilitate effective use of the water hose. For the last 3-4 months the procedure has specified that a short evacuation hose will be placed in poly manways immediately after unheading. This hose will remain in the manway until the H.R.C. unit is installed. mounted a platform adjacent to the vessel and proceeded to wash down the interior through the open manway. Demineralized water at approximately 100# pressure was used. The 1" hose used for washdown was equipped with a steam hose clamp and Chicago fitting at the nozzle. The combustible content of the vessel after the accident was 15% L.E.L. without aeitation and 35% L.E.L. with agitat ir>T', hard hat was found inside the vessel. 4AK ^ t__ _ ' redacted NGC 15794 J.W. Gressler -2- December 27, 1973 10, only remembers washing down the interior of the vessel then regaining consciousness on the fLoor. SUPPOSITION: 1. 100# D.M. water applied inside the vessel pushed vinyl vapors up through the open manway. 2. breathed these vapors while peering into the manway as he washed down the interior. 3. V lost his grip on the hose. The nozzle then came out of the vessel. 4. The hose knocked his hard hat off and into the vessel. 5. The whipping effect of the hose caused the nozzle to hit and cut the back of his head. CORRECTIVE ACTION; The procedure of placing a short evacuation hose in the manway of a poly immediately after unheading and keeping it there through the washdown until the H.R.C. unit is installed will be followed. This accident and the above procedure is being related to personnel through: a. Immediate discussion between the Area Manager and Lead Technicians. b. Weekly building sessions. c. Shift meetings conducted by the Area Manager. Modifications being evaluated on the exhaust assembly are as follows: a. Installation of 90 elbow at end of hose. b. Use of more flexible hoses. c. Use of a clamp at manway to keep hose in place. TBJ/rdr cc: J.W. Gressler - H. WaLtemate J.L. Nelson - R.D. Scott W.E. Brodine - G. Pow E.W. Harrington - P.D. Terry D.R. Gray - B.A, Healy R.A. Kelly (Akron Bldg. 24-A) Area Managers File T.B. Johnson \ Ai \ NGC U795 /97J 7~Y/0 * X*-* . <J TO* L. V. Goode LOCATION* ALGCP B.F.GOODRICH CHEMICAL COMPANY Avon Lake General Chemical Plant FROM: W. T. Gunning DATE: March 6, 1973 SUBJECT* Vinyl Chloride Release at Tank Farm - Repetitive Accident Type #10 On Friday, March 2, 1973, an estimated 5000 gallons of vinyl chloride escaped into the tank farm area when an Ever-Tlte coupling in the unloading line from a railroad tank car uncoupled. The plant gas escape alarm and then the plant evacuation alarm were sounded, A Geon Polymerization Area Foreman and the Tank Farm Operator entered the area and closed the valves on the tank car to stop the flow of vinyl chloride. There were no injuries nor damage to equipment as a result of the VC1 escape. INCH38NT* At about 7 s35 A.M., Latex Operator telephoned the Latex Office to inquire about the noise he heard coming from the vicinity of the railroad tank car at the vimrl chloride unloading station. The Latex Foreman went outside the office building to investigate. The VC1 tank farm is located approximately 125 yards West of the Latex office building. The foreman stated he could see VC1 vapors surrounding fr.hft -railroad tank car dome and throughout, the area ad.iacent to the unloading station. The foreman immediately went to the Latex building where he sounded the gas escape alarm* He was soon met by Geon Polymerization Area Foreman, Louis Carballada, on the road way which parallels the VC1 tank farm railroad track and is located 75 yards East of the track. Carballada stated that he could readily smell the vinvl chloride and in viewing the extent of the area enveloped in vapors, he sounded the plant evacua tion Carballada requested the Dryer Building Foreman, who was carrying a two-way radio unit, to radio the guardhouse and have the guard inform Art Fox, the tank farm operator to return to the tank farm. The tank farm operator__had been at trhft softie house to weigh a -hank t.nmk when the alar-ms gmiwrlpri. When contacted he was proceeding toward the front gate in accordance with the evacuation procedure. 'He returned to the tank farm where he was met by Carballada and the second Geon poly area foreman, Dale Gregus. Gregus had obtained Scott Air-Paks which were worn bk and Carballada to enter the tank farm area enveloped in the VC1 vapor cloud. They proceeded via the catwalk to the nnl raiding station where the VC1 was escaping. with assistance from Carballada closed the two valves on top of the tank car and the liquid and vapor lines for #5 station* This stopped the release of jyinyi chloride. When Carballada and returned to the roadway, the Foreman radioed the guardhouse informing the guard that the escaping VG1 had been stopped. He requested that plant personnel be kept from the plant until the vapors could be dissipated. The All Clear was sounded at 8*15 A.M. Safety Department personnel who were just reporting to work proceeded to the area where they monitored VC1 concentrations traveling North in a ditch toward the Boiler house* Concentrations in the ditch in the flammable range were noted at a distance of 150 yards from the subject nrfl naming station. At this point they were approx imately 75 yards from the boiler house. REDACTED MAR 121973 NGC 15796 Vinyl Chloride Release at Tank Farm Page 2 The ground area other than in the ditch was clear of flammable concentrations within a few minutes of the time when the Tank Car valves were closed* The boilers ar>d draft fans had been ordered shut down by the boiler house foreman when ha learned of the eactent of the VC1 release and that the wind was causing the vapors to move in the direction of the boiler house. The Safety Department personnel requested a fire hose-crew to apply a water fog pattern close to the ditch to initiate air movement* This helped considerably in dissipating the VC1 concentration in the ditch* The Safety Department requested that the boilers not be restarted until they could be assured the movement of the VG1 vapors in the railroad ditch had been halted and the concentration was reduoed to below a flammable mixture. Approval to restart the boilers was given at about 8:30 A.M. A Board of Review convened at 9:00 A.M. with the following persons in attendance* L.V. Goode - Acting Plant Manager 'W.K.Pember - Industrial Relations Manager L* Carballada - Geon Area Foreman D.P.Gregus - Geon Area Foreman E.C.Foreman - Latex Foreman Tank Farm Operator W.T* Gunning - Sr. Safety Engineer Depositions were received from the tank farm operator and the foremen involved. (See attachments)* Subsequently an investigation was conducted at the scene of the incident by Fred Hess from the Plant Engineering Department and V.T. Gunning, Sr* Safety Engineer* A second meeting was held at 3:00 P,v.> In attendance weret L.V.Goode D.B.Fisk - Plant Engineer A.J.Hess - Engineering Department W.L.Weitzel - Warehousing Supervisor R.W.Vanek - Tank Farm Supervisor E.W.Hemke - Sr. Purchasing Agent W.T.Qunning Fran the investigation and meetings the following facts were established: 1* The tank farm operator had connected the tank car GATX 55311 located on station V #5ifor unloading to the sphere at 700 A*M* a; In making the hook up he had wired down the Ever-Tite copping clanm handles. It* has been a practice during the last 8-10 years to use additional restr aints on the Ever-Tite coupling handles for extra protection* This was initiated by tank farm operators because of an experience with a tank truck company transporting plasticizer whose hose coupling parted because of excessive wear. The wire used on the coupling in question was broken. NGC 15797 Vinyl Chloride Release at Tank Farm Page 3 2. The Bver-Tite coupling that was uncoupled and permitted the VC1 escape, was inspected and found in good condition. 3. When the Ever-Tite company was contacted they agreed that under certain condi tions of vibration, the coupling can part. The tank farm operator stated that. In many instances while unloading tank cars, the excess flow valves in_the oara will ohatter excessively and with a violence that shakes the oar and t-rermfer lines. 4. The tank farm operator estimates he left the unloading station to go to the scale house at 7:20 A.M. The Latex foreman was alerted and sounded the gas escape alarm at 7*35 A.M. The coupling parted within this 15 minute period. The valves on the tank car were closed at 8:00 A.M. The VC1 release from 35 to 50 minutes in duration, 5* In approaching the tank car to close the valves, the tank farm operator and foreman both noticed the vinyl chloride being emitted in srairta from the viairt pipe connected to the tank car (male end of Sver-Tite coupling'). The fieYih]fl hose with the female end of the oouplinfr una also emitting VQ1 with enmiph pressure to make the flex hose whip violently. (See attached drawing). 6. The gas escape alarm was sounded at about 7:35 A.M followed by the evacuation alarm a few minutes later. The All Clear to re-enter the plant was sounded at 8:15 A.M. and the boileihouse restarted boilers at 8:30 A.M* 7. No VCl entered the plant sewer lines. ACTION TAKEN: ,1*j The tank fara operators have regularly used DuPage screw type hose clamps to ^ retain the 2'? Ever-Tite coupling handles, but had started to use wire on the 3" couplings when they were installed last year* The operators have been instructed to discontinue use ol wire and to use the hose olnmoa nw 1 ny clamp handles. This will be incorporated .in the Tank Farm Unloading Procedure- (2j. The Bver-Tite Company has developed a new coupling which they assure us will eliminate separation of the male ard female sections. This coupling will he evaluated- 0 The GATX Company has been Contacted and will furnish additional information about their excess flow valves. They have been requested to inspect the excess flow valves on GATX 55311 and submit a report. a*. The VCl unloading system transfer lines must be studied to determine if the design prevents the excess flow valves on the tank cars from operating per design* b An engineering study will be made to determine if additional check valves in the system will be an advantage. c* A report of the Engineering Departmentf s study will be distributed when completed. NGC I5798 Vinyl Chloride Release at. Tank Farm Page 4 5. Will review staffing of tank farm operating personnel with regard to attention tiae flaring unloading operations* 6, Notified Division Safety by phone. Ttn-tTtwMred costs of this incident sure estimated at $14*566* W. T. Gunning Sr* Safety Engineer VXQ/aim TA <? jO fCt +% .! (/ U . w ti ^ V qj oct H.Waltemate D.D.Dowell J,L.Nelson-R.D.Scott E.W.Harrington-P.D. Terry D.R. Gray W.E.Brodine G.Pow , R.A^Kelley R.N.Rylande *s t*se-// At q ** <$/? k & < a u j'k ,t,,A, .j'j ' /*.**/' At & J ^ //* 77, y</ S * C -- w / /ft / n f, .w f* * */ a - e* er trt* c . cr; /"< 'v ^ "L- AN // S At v 4^ J* * * /Kt f <? LtJ t * -f e/o^e, d* r,' /,r; ~s't* -j -j~ /c* J'tft~ Ci jr* fr" -tAt V*4 c* iS*L -- 77 ^ ft ^ f "c1 * Ur . // ^ r C?- O w^y-3 / C*^ n /u /e ^ > *'*^k. *'tf ct Ao s <s *. A o* i f-A e ? y If-rj -T/ffv 4Au.JPy ?*, * <s. / * t> -P j et jQ 0 4^/ e- et c/' i v| ^ T1-^ (< -fy'.J/r-. , y ~/S - 7^? NGC 15799 NGC 15800 I OSS l DON / 9^7 J /o B.F.GOODR1CH CHEMICAL COMPANY Inter-Organization Correspondence To Location H. Waltemate Cleveland, Ohio Date From (pril 27, 1973) R. A. Spurlock It S' Subject Near- Miss Incident - Ca^vert City Plant /feet ^^ /K *;jc ftc*c " At 2:45 AM on April I2y 1973 a full blowdown tank of carbopol slurry was discharged to the Second floor and the mezzanine floor above the second floor of the Acrylic Acid building. This charge contained approximately 1200 pounds of carbopol and 8000 pounds of benzene. The next morning, April 13, 1973 the Plant Manager's Safety Committee and people Involved in the accident met to discuss the incident. People attending were: J. K. Koster, D. R. Hise, N. S. Grove, F. R. Carvel1, R. W. Edwards, H. W. Compton, V. S. Wyatt, F. Lynn, I. Jones W. Butler, R. Ivy, Mr. Koster opened the meeting by stating the spillage of benzene had created a very serious safety hazard to personnel and the plant. This meeting was being held, not to try to place blame on anyone, but to determine the cause for the accident and to list corrective actions which would prevent a recurrence. Production General Foreman W. Compton stated that the carbopol slurry was lost during a pipeline transfer from No. 2 blowdown tank to Mo. 6 rotary dryer. A section of two inch piping that had been removed for cleaning permitted the slurry to discharge to the atmosphere instead of the intended dryer. There is a complicated piping system that interconnects the seven blowdown tanks and the seven slurry dryers. Three operators per shift have respon sibility for specific blowdown tanks and dryers and, in normal operation, can use transfer piping which keeps each man's operation isolated. On the shift when the accident occurred, a blowdown tank was out of service for repairs and it was necessary to use cross-over lines and one blowdown tank to charge two drvers. Plugging of transfer lines had been a big problem for several days because of having shortened the reactor holdup time and one section of piping had been removed for cleaning. While the Maintenance men, the operator and the foreman involved in cleaning the line were gone from the area, a second operator opened a valve on the second floor to start a slurry transfer to Mo. 6 drver. He was not aware a cross-over valve had been opened and a section of down stream pipe removed. He went to the third floor to watch the filling of his dryer. After a short time he noticed the dryer charging had not started but the odor of benzene had became very strong. About the same time another operator saw the slurry escaping and tried to close the valves. The benzene in the area was too strong for entry and the fire alarm was activated. The fire brigade responded but no water wa6 used because of the nature of carbopol. NGC 15802 APR 30 H* Waltemate April 27, 1973 Page Two In about forty-five minutes most of the building had been cleared of benzene vapors through natural ventilation and the use of additional fans, The next day the carbopol was kept covered with foam as it was shovelled into drums and hauled to the dump* Recommendation to prevent a recurrence of the accident include: 0>. Keep operators informed of any changes that may affect their operations. Stream line and simplify the transfer piping so it can be more easily Identified and traced by operators* Eliminate permanently installed cross connections so the systems of various operators are isolated from each other* 4. Change the polymerization procedure to correct the plugging problem. 5. Upgrade the building ventilation to increase the number of air changes per hour. D R. A. Spurlock RAS/jfr cc: C.L.Woods J.K.Koster F.R.Carvell G.E.Evens P.E.Sanderson N.S.Grove D.R.Hise D.B.Schrock R.W.Edwards R.A.Spurlock W.C.O1Brien J.R.Render C.M. Fischer D*L.Dowell J.L.Nelson-R.D.Scott E.W.Harrington-P.D.Terry D.R.Gray W.E.Brodine G.Pow R.A.Kelley (Akron) B.A,,Healy A4 &* *v* *- A* ~f~a aa. (j./oje/y' ^ <v-A *-. o *F , jr~ v-73 NGC 15803 y Cf 'y.j ~rif/^ ^ c.'^ ^ t Fo Goffidtick Cl&emleal Company InterOrganigation Correspondence To P. A. Wagner --(April 30, 1973^ Location Louisville L' From L* _________ -------------- --------- ^ Z-_____________ ,_____ Louisville Subject Gas Escape^Repetltlve Accident Type No. IQ On<pril23^)1973> at approximately 6:40 p.m., no, ? reactor in Build ingjI1-l was charged with 250 gallons of vinyl chloride with the bottom valve and ^ewer valve open. The sewer hose was still connected to the reactor drain line, and an estimated 1.000 pounds of the vinyl chloride drained to the water recovery system on the first floor. Although a serious hazard was created by this spill, no one was injured, and no equipment damage resulted. An investigation of the accident was conducted and revealed the follow ing: Polys 2 and which are cleaned and charged as a pair, were the first to be cleaned by the 4-12 shift. . a helper with approxi mately eleven months' experience, was working with the HRC operator on the east side of Building 111. It was ~ job to rinse the polys with DM water after they were HRC cleaned, then close the bottom valve, and disconnect the hose. He related that he normally waits until both polys of each pair are cleaned before closing the bottom valve, but that in this instance he had gone to the second floor and closed off the bot tom valve on no. 2 poly while the HRG unit was running in no. 3- He stated that he then put the initial charge water in no. 2 poly at approximately 4:55 p.m. and then proceeded to other work while waiting for no. 3 poly. At.about 5:20 p.m., sometime after the HRC operator had finished with no. 3. he stated that he returned to this poly thinking that he had already closed the bottom valve at the same time that he had closed no. 2. He then put the initial charge water into no. 3 poly^nd con- tinued to other polys. Since the initial water is charged to the re actors through a meter, it is not necessary to check the level. Asia Page, charging operator with approximately two years' experience, was charging the polys on the east side of the building on the evening of the accident. He stated that prior to charging polys 2 and 3 He proceeded to the second floor to check the bottom valves on the two polys and hang the "Do Not Open11 tags on the valves. He stated that he hung the tag on no. 2 poly but saw that the valve was open on no. 3 and returned to the third floor. Then at approximately 5:^5 p.m. he put the pigments into no. 2 poly and headed it up. At that time he also noted that was putting water into no. 3 reactor. N0C 15804 REDACTED MAYS 1973 2 Page said that at about 6:15 p.m. he looked in no. 3 reactor and saw that it had water in it, and he proceeded to add the pigments and'"Read it up. Ife stated that he then pulled vacuum on no. 3 reactor for a period of about ten minutes and obtained a 23 in Hg vacuum on the re actor^At approximately 6:40 p.m. he started the vinyl chloride to the poly* Page said that when he started the vinyl chloride to no. 3 poly the HRC operator was cleaning no. 11 reactor and that when cleaning of the reactor was complete he noticed vinyl chloride blowing upwards out of no. 15 reactor. At this point he said he realized what had happened and immediately shut off the vinyl chloride and proceeded to the second floor to shut off the bottom valve on no. 3 reactor. When he arrived on the second floor, he found his foreman, John Baker, and the recovery operator, , were already closing the bottom valve. The specific cause of this accident lies in the failure of the helper to close the bottom valve on no. poly and the failure of the charging operator to check and tag the bottom valve prior to charging it. How ever, there are several things about the accident that remain unex plained, such as: 1. Page stated that he saw the helper putting water into no. 3 reactor at 5i^5 p.m. and that there was still water in it at 6:15 p.m. when a he put the pigments in. This was evidenced by a visual inspection and by the fact that the agitator was not banging on the bottom steady bearing as is does in an empty poly. How could the water still be in the poly thirty minutes after it was put in with the bottom valve open? .2 Page stated that he obtained a 23 in Hg vacuum on the poly over a e ten-minute period. How is this possible with the bottom valve open? He did not say that ha held the vacuum for the specified time. 3* Page stated that he charged no. 2 poly on time (6:15 p.m.) but because of problems could rot get no. 3 charged until 6:40 p.m. He couldn*t say what the problems were. All operators have been instructed not to charge a poly more than ten minutes past its * charging time (6:25 p.m. in this case). What were the problems which delayed the charging of no, 3 poly? Corrective action taken: The helper was reprimanded for failure to close the bottom valve on the reactor. The operator was suspended for five working days for failure to check and tag the bottom valve before charging the reactor. This suspension followed a reprimand on 1-18-7^ for the same offense. x The operator, who has a history of repeated safety violations, was J) transferred to the packer classification. NGC 15805 -3- dD The poly tagging system has again been strongly emphasized to all charging operators. 0), This accident will be reviewed in all departmental safety meetings, and we will again emphasize the rule that no poly is to be charged more than ten minutes late, in order to prevent accidents caused by hastineBa, R. S. Kinnamon ru r ^ a U 7*^ C. at V e ~t O >t /y ^ * j o cd o <- *r o ^ u * *. * 3 NOC 15806 /9?3 ft?/o c.Uc~4 7 0: W. T. Gunning LOCATION: Safety Department B.F.GOOERICH CHEMICAL COMPANY Avon Lake General Chemical Plant FROM: J. R. Shellenberger DATE: May 25, 1973 SUBJECT: Near Miss - Repetitive Accident Type #10 - Fill Building with Explosive Mixture INTRODUCTION: On May 21, 1973 at 1440 hours, 370 gallons of Vinyl Chloride monomer discharged Into the Geon West Pearl Building and filled the building with vapors. The building was evacuated for 10 minutes while the source of the discharge was found, stopped and the building cleared of the vapors* The discharge was the result of an operator error. He charged the wrong poly. A departmental Board of Review was held immediately after the "all clear" was sounded* The Board of Review was composed of: - Charge Operator Larry Kemer - B/461 Foreman Gerry Rodgers - B/461 Day Supervisor . John Shellenberger - General Foreman incident: -It 1440 when the incident occurred, the Charge Operator, _ was in the process of charging polys 101 and 102* The condition of these two polys along with the third reactor involved is as follows: A. Poly 101 - reactor had been charged in the normal manner by addition of pigments and water, closing the manhead, pulling vacuum, and charging 450 gallons of vinyl chloride* B* Poly 102 - reactor was charged with water and pigments, the manhead closed, and the poly under vacuum. This is normal to the point of VC1 addition. C, Polv 103 - reactor was dirty and had been recently blown down* The manhead was closed while the bottom valve and wash down lines were open. This is the normal state for a poly that needs to be cleaned. The wash down lines drain from the bottom of the polv and are open to the blend tank on the first floor. stated that he had charged Poly 101 without incident. After he added the VC1 to Poly 101, he closed the VC1 charge valve on this poly. He then opened the VC1 charge valve on Polv 103 rather than on Polv 102* (The attached sketch shows the floor plan relationship of the three polys). He then pumped 370 gallons of VC1 monomer into poly 103. All of the vinyl chloride charged into poly 103 flowed down the wash down lines and into the blend tanks on the first floor* The gas alarm was sounded from the first floor by the blowdown operator* When w heard the gas alarm he shut off the vinyl chloride meter with 80 gallons to go and evacuated from the building. REDACTED NGC 15807 MAY 29 ttfft Avon lake General Chemical Plant Near Miss - Repetitive Accident Type #10 - Fill Building with Explosive Mixture Page 2 ADDITIONAL FACTS: T) The charge Operate admitted the incident was the result of his error. He stated that he had Poly 103 on his mind, although he also knew he was charging Poly 102, 2. The uninsured loss from this incident was $292. RECOMMENDATIONS; We will change the blowdown and recovery procedure to require the VC1 charge line inspec tion pl^te to be removed immediately after blowdown and recovery are completed. The poly will then he recorded "ready for cleaning". With this change, the Charge Operator will be alerted that the oolv is not ready for charging as he approaches the vinvl chloride valve. 2. We have publicized the incident throughly within the department. 3. The operator was given a letter of poor performance for his error. The letter will be placed in his personnel file. JRS/alm cc: H.Waltemate D.L.Dowell J.L.Nelson-R.D,Scott E.W.Harrington-P.D.Terry D.R.Gray W.E.Brodine G.Pow R.A.Kelley R.N.Rylands Department Managers General Foremen John R. Shellenberger General Foreman C +-o . & *3 HGC 15808 TF+t&& <=>f? -Ft-GO f? _FX/e; >&vT~ NOC 15809 / * '? ^ r^ to JT*C J*-* .-.' TO FROM UflJCCT '> -> -' -rv.J R. S. Mather R. C. Kaminski <r.Jd i- fitLO foiw on : '.oj'MiiMV.m r* m.DO.HO, ALGC Plant FlClP POINT OR AKRON OtTAMTmRMT A ML DO, HQ. AlfiC Plant - Geon West Near Miss - Repetitive Accident Type #10 Vinyl Chloride Release Into Building 46l ------ DATT YOU urTi'K '' I PATE 1 MIS UCTTEA July 18, 1973 On Sunday, July 15, 1973 at 0625, approximately 500 pounds of vinyl chloride was discharged into an open, cleaned 3300 gallon reactor in the Geon West Pearl building. The vinyl escaped the open reactor to within a distance of 30 feet of the poly. A gas alarm was sounded and within 5 minutes the source of the vinyl chloride emitting from the open manhead was identified and corrected. The incident occurred when a G-92 charge in Poly 142 was having the water pumped in for phase inversion. Vinyl chloride from Poly 142 backed through the water inversion line to Bely lkl which had the water valve and top charging valve open. ISee attached sketch.) A Board of Review was held on Monday at 0800 and also at 1615. The following people reviewed the incidents R. Rylands W. T. Gunning R S. Mather D. Gregus L. Kemer Glen Evans Incident On July 14, 1973, Poly l4l was charged at 1640 by operators ___ and At approximately 1900, the batch inversion water was started into Poly 141 and finished at 2000. The operators stated that both the water inversion valve and top charge valve were closed. The charge in Poly l4l was blown down at 0300, and the poly was HRC cleaned from 04l0 to 0510 by Chemical Operator helpers _ Poly l4l was set up for cleaning by He stated he didn't note, whether the water inversion valve was open or closed. He stated that if the poly was being prepared for entry, all the valves in the charge header would have been checked closer. After the HRC cleaning; went to the second floor to clean out chips from the bottom valve while back flushed the charge header. M. i stated he tried to flush water in through the top charge valve. The water trickled in indicating either a plugged valve or possibly low header pressure. The operating people stated that the batch water line isn't used for header flushing. At 0545 batch water was started into Poly 142, it usually takes an hour. At 0625, a plug of PTC 3" diameter x 7" long blew out of the Poly l4l charge valve permitting the pressure on Poly l42 to bleed VC1 back through the batch water line and valve on Pbly 141. then through the open charge water valver into the poly and out the manhead. Operator - . w who was nearby heard and saw the escaping gas and turned in the gas alarm. He put an evacuation hose in the poly and then went to the second floor to check to see if the bottom yijn*V. L1TMQ, IN U.a.A, REDACTED NGC 15810 20 7973 Near Miss - Repetitive Accident Type #10 -2- July 18, 1973 valve "was left open. Foreman D. Gregus returned to the third, floor and found the open -water valve and closed it. About 5 minutes lapsed, and an appreciable concentration of VC1 was evident within 30 feet of the poly. It is estimated less than 500 pounds of vinyl chloride were released. The majority of this VC1 was evacuated from Poly l4l through the evacuation hose inserted into the manhead. The charge in Poly lU2 reacted normally. Conclusion and Recommendations The batch water valve on Poly l4l was open while waiting to be charged. This valve was to be closed after batching; also all valves on the charge header are to be closed when preparing the poly to be cleaned. 3. Revise the poly cleaning check sheet to more clearly denote closing all valves in the charge header when preparing to enter or HRC. 4* Review this incident with aVI operating personnel. RCK/Jdn Attachment cc: H .Waltemate GdfcteSl!'* J. L.Nelson-R.D .Scott E .W .Harrington-P.D .Terry D.R.Gray W.E.Brodine G.Pow R,A.Kelley R.N.Rylands Department Managers General Foremen Bruce Healy R. C. Kaminski a r/, a * tf i'j 0y 4- .-// A a u . g q d-i ke J, tfc./ j-c? i/~ a - J 4 A `J jooj t'-f-1" /ft 9 - 46 7J NGC 15811 0FVYC-H V.-ip J- X . Xcr'' Poly mi (Opf/) -f> t ^-JH f* ^ ?Lfc~r 0-&s.v.\T : Paly /H) NGC 15812 V fw ^j^1(. r Sr-fe'-W- 1 i it .;,* ! V; h'er~un Waltemate F.G, Dilley mWa '' "f ... .. 'f"-*'- s S> . ;; ?- r .i* "*.-,., *9+r % D/54 50 Cleveland. OCHT OH AK NON O^PA** 'At Safety Long Beach VCL Release Into Process Building ,SL<?C! * U?* *-1 */Q /=", (/ tS*c.'to&^y r* /o ' . 5 KP August 21, 1973 XL- * * > r* / X. ^ v r -Av. 4 Description At 1;00 PM on August 16, 1973 approximately 100 lbs, of Vinyl Chloride was discharged into the Polymerization Building, The emergency alarm was sounded and the Plant was immediately evacuated. Investigation Approximately 100 lbs, of VCL was released into the building from Poly 12 through the bottom Hansen j- inch fitting on the rupture disc assembly (see attached drawing,). As soon as l;he~Ieak was detected the building was evacuated. A decision was made, due to the presence of several contractors working in the area, that a plant evacuation was necessary. After a quick employee head count the Resin Foreman and one operator doned Air Cubs and returned to the building to plug the leaking fitting. The all clear was sounded approximately 15 minutes after the evacuation alarm. Through an operational error Polr 12 was over charged with VCL. and when heated the poly went hydroful and blew the bottom disc. The relief valve vented for only a few seconds before it reseated. At the instant the rupture disc blew, the Hansen fitting uncoupled releasing VCL into the process room. It was de termined that the coupling was not properly seated when the rupture discs were last replaced. Estimated cost of this incident is $200.00 Recommendations (l) Once per shift a check will be made of all rupture disc assemblies, to insure that the Hansen couplings are secure. 2. An evaluation will be made to determine if unions should be installed to replace the Hansen couplings. 3. Proper operating procedures will be reviewed with all charge operators. A.W. Clements J.L. Nelson - R.D. Scott E.W. Harrington D.R. Gray W.E. Brodine REV, l/jO l.lTHO. IN U.S.A. G. Pow R.A. Kelley B.A. Healy r NGC 15813 AUG 23 19/3