Document mqBJK60E8dZM2oYxw5obpdx2Z

June 7, 1993 The Geon Company Avon Lake Technical Center S# Board of Inquiry VCM Release - 55 liter Poly, Resin Pilot Plant Experience Value The purpose of a Board of Inquiry is to explore all possible causes of an incident, to correct safety problems, to determine disciplinary action where appropriate, and to report incidents of experience value to others. Summary On Tuesday, June 1, 1993, at approximately 05:27, a VCM release occurred from a 55 liter poly through the vacuum system. The equipment is located in Building 414. Approximately 36.5 pounds of VCM were released. There were no injuries or equipment damage as a result of this release. Board of Review A board of Inquiry was held on June 1, 1993 to discuss the facts surrounding the incident. The following were in attendance: J. Bialko J. Griffin M. Kelling C. Lee K. Reading A. Shah Supervisor, Pilot Plant Operations Site SH&E Manager Environmental Engineer Geon Plant Manager Operator Eng. and PP Group Leader Director, Intermed. & Resin R&D REDACTED NGC 13636 Description of Incident Or the morning of the incident, the operator charged 36.5 pounds of VCM to a 55 liter poly to run a polymerization. Later, the operator aborted the polymerization because there was no pressure in the poly. Jerry Bialko, the pilot plant supervisor, noticed the aborted charge and investigated to learn why there had been no pressure. He determined that the VCM had most likely been vented through the building vacuum system to the atmosphere. Bialko contacted J. Griffin and advised him of the suspected release. Griffin called the appropriate governmental agencies. After the appropriate agencies were notified, it was determined that the VCM must have been accidentally vented through die vacuum system due to operator error. There was no other path for the VCM to leave the poly. Facts Surrounding the Incident 1. The operator was familiar with the equipment and procedures in his pilot plant, and had followed established SOFs, which call for isolating the poly by closing specific valves before charging VCM. 2. The pilot plant polys are run open-poly, that is, they are opened and cleaned after every charge. The poly is then pressure tested, vacuum tested, and inerted by completing three vacuum-N2 pressure cycles before a new charge is started. 3. The poly is put under vacuum before VCM is charged. 4. The operator did not remember if he had left the vacuum valve on the manifold open while charging VCM to the poly, or if he had closed the vacuum valve after charging VCM to the poly. 5. It was determined that die VCM did not exit the poly through any other process connections on the piping manifold. There were no VCM excursions detected in the building during the release, so the VCM could not have been released to the room. 6. The emergency notification procedure was followed. Conclusions and Findings 1. The release occurred because the vacuum valve to the poly was left open during VCM charging. NGC 13637 Corrective Action 1. Add a checklist to the SOPs that details the step on isolating this and other pilot plant polys prior to charging VCM. (K. Reading 6/5/93) 2. Investigate mechanical means to verify the vacuum header is closed before a poly is charged. (K. Reading 7/15/93) 3. Review with die operators environmental policy E-101 regarding prompt notification of supervision when a VCM release is suspected. (J. Bialko 7/1/93) 4. Appropriate disciplinary action was taken. (J. Bialko 6/1/93) NGC 13638