The U.S. Chemical Safety and Hazard Investigation Board (“CSB”) has issued its report following the investigation into the deadly explosion that occurred at KMCO in Crosby, Texas on April 2, 2019. During the incident, isobutylene leaked from piping at the facility, resulting in a vapor cloud. An explosion occurred when the vapor cloud ignited, killing one worker at the facility and injuring at least 30 others.
Following the investigation, the CSB identified the likely cause of the explosion:
The CSB determined that the cause of the isobutylene release was a brittle overload fracture of the cast iron ystrainer driven by internal pressure. The y-strainer was installed in a segment of the isobutylene piping that was not protected from the high-pressure conditions that developed within this equipment, most likely from liquid thermal expansion. The isobutylene vapor cloud was most likely ignited by electrical equipment within a poorly sealed, nearby building.
The CSB also found faults with the company’s hazard evaluation program:
KMCO’s hazard evaluation programs, including process hazard analysis, pre-startup safety review, and management of change, also contributed to the incident. KMCO’s hazard evaluations consistently overlooked or misunderstood that its y-strainer was made from cast iron, a brittle material that existing industry standards and good practice guidance documents either prohibit or warn against using in hazardous applications, such as the company’s isobutylene system. In addition, none of KMCO’s hazard evaluations identified the potential for liquid thermal expansion or other possible scenarios to develop high-pressure conditions within the piping system that included the y-strainer. As a result, unlike other portions of KMCO’s isobutylene piping, this piping section was not equipped with a pressure-relief device to protect it from potential high-pressure conditions.
Plant workers put their lives at risk in a dangerous industry every single shift. Ultimately, incidents like this one are preventable. Workers face risks and hazards that must be adequately discussed and planned for before work begins.
In order to help other companies, the CSB also issued key lessons that were learned from this horrific explosion:
1. Cast iron is widely recognized as a brittle material that should not be used in hazardous applications, including applications that involve flammable or toxic chemicals.
2. Piping systems should be equipped with protection from high-pressure conditions, where liquid thermal expansion or other scenarios can create a hazard. For example, API 521 recommends installing a pressurerelief device if liquid thermal expansion is a credible hazard.
3. Reliable facility alarm systems can help ensure effective emergency communication to alert people of danger and inform them of what actions are needed to protect life and health.
4. Where remote isolation is not provided or is otherwise not available, clear policies and effective training are needed to help ensure that workers do not put themselves in danger to stop a chemical release.
5. Emergency response plans, including procedures and training, need to effectively distinguish between incidents that plant workers should respond to and emergency events that must be handled by a qualified emergency response team.
6. The goal of keeping workers safe and the goal of quickly isolating releases to minimize the consequences of an incident should not be mutually exclusive. Both can be achieved by applying robust safety systems and establishing effective emergency response programs. Providing remotely operated emergency isolation valves in strategic locations can allow workers to stop a release quickly from a safe location.
7. Previous incidents can provide a warning sign of problems that exist in a system. Companies can prevent future incidents by effectively recognizing and acting on these earlier warnings to identify and correct the underlying issues.
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