Investigation of chemical release leads to recommendations on written procedures

Washington — Facilities that produce or handle hazardous chemicals should prepare written procedures and establish policies for evaluating simultaneous operations to ensure “robust safe work practices,” the Chemical Safety Board says.

The recommendations are among 10 outlined in CSB’s final report on a deadly chemical release in November 2020 at the Wacker Polysilicon North American facility in Charleston, TN. 

One worker died and two others suffered serious injuries when they attempted to escape a cloud of toxic hydrogen chloride gas. Unable to see their surroundings, the workers fell 70 feet while trying to climb down a tower near the platform on which they were working. 

CSB says seven contractors from two firms were working on separate projects on the platform.

The agency found that Wacker’s lack of written procedures and lack of control of hazardous energy contributed to the event, as did the lack of a simultaneous operations program and the lack of regulatory and published industry guidance on SIMOPs.

The report highlights four safety lessons:

• Written procedures are a “critical tool for ensuring safe operations and maintenance activities” and “consolidate information required to execute a given task into easy-to-understand step-by-step instructions, with specific reference to safety precautions and critical actions.”
• The control of hazardous energy “should be considered whenever equipment containing hazardous energy is repaired, adjusted, serviced and maintained, not only in situations in which equipment is intentionally opened.” Before work begins on equipment containing hazardous energy, “a risk assessment should always be performed to evaluate the need for energy isolation or other protective measures.”
• “Owners and operators should always consider how simultaneous operations, or SIMOPs, could impact a given operation, whether by influencing a hazard or affecting the risk of the operation.” SIMOPs “should be identified and controlled via a hazard assessment” before an operation or task begins. A well-established system “must be able to document the specific task to be executed, readily coordinate the issued permits and identify scenarios of potential interaction between permitted work groups.”
• “Owners and operators should prioritize the implementation” of process hazard analysis recommendations and employee input “to control hazards that have been identified by those closest and most familiar with facilities and operations.”

Further, CSB recommends that OSHA:

• Create a standard or modify existing standards to require employers to ensure the coordination of SIMOPs involving multiple work groups, including contractors.
• Develop a safety product – not limited to confined space or construction – that provides guidance on the coordination of SIMOPs involving multiple work groups.