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A grim message from Chairperson Vanessa Allen Sutherland of the US Chemical Safety Board reads-

“The U.S. Chemical Safety Board (CSB) is disappointed to see the President’s budget proposal to eliminate the agency.  The CSB is an independent agency whose sole mission is to investigate accidents in the chemical industry and to make recommendations to prevent future accidents and improve safety.  For over 20 years, the CSB has conducted hundreds of investigations of high consequence chemical incidents, such as the Deepwater Horizon and West Fertilizer disasters.  Our investigations and recommendations have had an enormous effect on improving public safety.   Our recommendations have resulted in banned natural gas blows in Connecticut, an improved fire code in New York City, and increased public safety at oil and gas sites across the State of Mississippi.  The CSB has been able to accomplish all of this with a small and limited budget.  The American public is safer today as a result of the work of the dedicated and professional staff of the CSB.  As this process moves forward, we hope that the important mission of this agency will be preserved. ”     -posted 3/20/17

I want to voice my support generally for this elite group of accident investigators. As a chemical safety professional myself I am disappointed to see the CSB regarded low enough by the President’s budget writers to warrant being in the proposal for elimination. The job of the CSB is to investigate the cause(s) of chemical, petrochemical, or other facilities that handle materials having the potential to produce serious accidents. Having done accident investigations myself, albeit at much reduced scale from a petrochemical refinery, I appreciate what a difficult job this is and the great value of the disseminating findings to the industry.

The value of any given CSB report is the story of how an accident is initiated, how it propagates, and how it may couple with diverse systems. As a crucial part of the report is a detailed dissection of the relevant operational systems and human/machine interfaces and how they may have coupled to the event. It is educational and very useful for the safety community to learn how unfamiliar failure modes initiate and how knock-on effects may steer the accident in directions that are difficult to predict.

Planning for process safety involves input from the fields of chemistry, engineering and operations. Importantly, it requires imagination because planning safe operations is about predicting the future. Shutting down CSB investigations will deprive the engineering and safety community of a valuable resource detailing subtle or non-obvious ways in which complex systems can fail.

Recall the Apollo 1 fire or the Challenger explosion and how inquiry into those events lead to better appreciation of failure modes and the layers of protection that can be put in place to prevent the failure. If this kind of investigation is kept confidential, the advance of safe system design will stagnate.

The US Chemical Safety Board (CSB) has publically expressed dismay and disappointment in a letter to Tesoro Corporation in San Antonio, TX. It is in regard the apparent unwillingness of the company to allow CSB investigators to come on site and continue with the investigation of an industrial accident or, if you prefer, incident. Apparently two workers were splashed with sulfuric acid and had to be choppered out for treatment.

From what I gather from the CSB letter, Tesoro doesn’t believe that the incident rises to the level of seriousness to justify a CSB investigation. That is my own interpretation.

At first blush it would seem that Tesoro has a point. While it is something that OSHA would cover, does it really necessitate attention by the CSB? By itself it seems questionable. But when you consider that Tesoro had an 7-fatality explosion and fire at its Anacortes refinery in April of 2010, perhaps the scrutiny seems less unreasonable.

The refinery explosion was determined to result from high temperature hydrogen attack within a 40 year old shell and tube heat exchanger. Catastrophic structural failure on startup after a scheduled tube cleaning resulted in an explosion and fire with immediate and delayed fatalities.

It seems to me that the failure of a high temperature heat exchanger after 40 years of service handling hydrogen and naphtha has more to do management policy on equipment service life than anything else. This speaks to prudent administrative and engineering controls on plant safety. A shell and tube heat exchanger has no moving parts to fail. It just sits motionless doing it’s function. There are no failing parts to replace other than leaky tubes and valves. Perhaps no one considered that the inherent nature of the gas and thermal cycling was deleterious to the integrity of the metal shell? Perhaps there was no enthusiasm to define official hours of operating life. Plant managers are always under pressure to minimize operating costs. This is especially true of plants producing high volume low margin commodities.

But here is the rub. Everything has a failure rate. This is especially critical for equipment under high temperature and pressure. The first layer of administrative control is for management to make allowances for materials in extreme environments. Anacortes is not the only recent incident where component failure has occurred in equipment performing under demanding conditions. Before the engineers can make equipment specifications for this, management has to conform to the notion that some parts of a plant should have better definition on service life. They should demand it of their design people and support engineering when the time comes to replace a component.

If the CSB believes that a company has weak administrative controls that influence plant safety, then I think they should investigate.


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