CaseStudyKeyLessonsforPreventingInadvertentMixingDuringChemicalUnloadingOperationsChemicalReactionandReleaseinAtchison,KansasMGPIProcessing,Inc.IncidentDate:October21,2016Over140SoughtMedicalAttention,6HospitalizedNo.2017-01-I-KSPublishedDecember,2017U.S.ChemicalSafetyandHazardInvestigationBoardKEYISSUES:•DesignofChemicalTransferEquipment•AutomatedandRemoteEmergencyShut-offs•PipeMarkings•ChemicalUnloadingProcedures•HumanFactors•EmergencyPlanningTheU.S.ChemicalSafetyandHazardInvestigationBoard(CSB)isanindependentFederalagencywhosemissionistodrivechemicalsafetychangethroughindependentinvestigationstoprotectpeopleandtheenvironment.TheCSBisascientificinvestigativeorganization;itisnotanenforcementorregulatorybody.EstablishedbytheCleanAirActAmendmentsof1990,theCSBisresponsiblefordeterminingtherootandcontributingcausesofaccidents,issuingsafetyrecommendations,studyingchemicalsafetyissues,andevaluatingtheeffectivenessofothergovernmentagenciesinvolvedinchemicalsafety.MoreinformationabouttheCSBisavailableatwww.csb.gov.TheCSBmakespublicitsactionsanddecisionsthroughinvestigativepublications,allofwhichmayincludesafetyrecommendationswhenappropriate.Examplesofthetypesofpublicationsinclude:CSBInvestigationReports:formal,detailedreportsonsignificantchemicalaccidentsandincludekeyfindings,rootcauses,andsafetyrecommendations.CSBInvestigationDigests:plain-languagesummariesofInvestigationReports.CSBCaseStudies:examinefewerissuesthanafullinvestigativereport,casestudiespresentinvestigativeinformationfromspecificaccidentsandincludeadiscussionofrelevantpreventionpractices.CSBSafetyBulletins:short,general-interestpublicationsthatprovidenewortimelyinformationintendedtofacilitatethepreventionofchemicalaccidents.CSBHazardInvestigations:broaderstudiesofsignificantchemicalhazards.SafetyVideos:high-qualityoutreachproductsthatsupporttheagency’smissiontoimproveworkerandenvironmentalprotection.CSBpublicationscanbedownloadedatwww.csb.govorobtainedbycontacting:U.S.ChemicalSafetyandHazardInvestigationBoardOfficeofCongressional,Public,andBoardAffairs1750PennsylvaniaAveNW,Suite910Washington,DC20006(202)261-7600Nopartoftheconclusions,findings,orrecommendationsoftheCSBrelatingtoanychemicalaccidentortheinvestigationthereofmaybeadmittedasevidenceorusedinanyactionorsuitfordamages.See42U.S.C.§7412(r)(6)(G).2CSBMGPIProcessingCaseStudyCSBMGPIProcessingCaseStudy3GLOSSARYAcid:asubstancecapableofdonatingahydrogenion(e.g.,sulfuricacid).AsolutionofacidandwaterhasapHlessthan7.Base:asubstancecapableofacceptingahydrogenionfromaprotondonor(e.g.,sodiumhypochlorite).Anaqueoussolutionofabase,oralkali,hasapHgreaterthan7.Abasereactswithanacidtoproduceasalt.BillofLading:adocumentissuedbyacarrierthatdetailsthetype,quantity,anddestinationofthegoodsbeingtransported.Cargotank:atankintendedprimarilyforthecarriageofliquids,gases,solidsorsemi-solidsthatisattachedtoorformspartofamotorvehicle;alsoreferredtoasa“tanker”inthisCaseStudy.Cargotankmotorvehicle:amotorvehiclewithoneormorecargotankspermanentlyattachedtoorforminganintegralpartofthemotorvehicle.1Camleverdustcap:ametalorplasticcapthatattachestothefilllineconnectionpointtopreventdebrisandaccesstothefillline.Thesecapscontainleversthat,whenintheclosedposition,preventtheremovalofthecap.Theleverscanbelockedintheclosedpositiontopreventunauthorizedaccess.Connectionpoint:thepointatwhic...
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