ABSTRACT

Investigation Report: Chlorine Release, Contaminated Antimony Pentachloride Exposure, and Hydrogen Fluoride Release   [open pdf - 4MB]

"The U.S. Chemical Safety and Hazard Investigation Board (CSB) incident investigation determined root and contributing causes for the three incidents. An overall analysis revealed common deficiencies in the following management systems: Hazard analyses did not ensure a review of all equipment, procedures, and likely scenarios. The safeguards listed were generic and, in many cases, relied too heavily on administrative procedures; Nonroutine situations were not always recognized and reviewed to ensure that work could proceed safely; and Work practices at the plant did not always strictly follow written operating procedures. CSB determined that guidance and standards for design and maintenance of positive pressure control room systems were lacking in the U.S. chemical industry. CSB also found that manufacturers and users of hydrogen fluoride could benefit from sharing of best practices on draining equipment and maintenance operations for hydrogen fluoride."

Report Number:
Report No. 2003-13-I-LA
Publisher:
Date:
2005-08
Copyright:
Public Domain
Retrieved From:
U.S. Chemical Safety and Hazard Investigation Board: http://www.csb.gov/
Format:
pdf
Media Type:
application/pdf
URL:
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