That is the backdrop for an animation just released by the Chemical Safety and Hazard Investigation Board (CSB) for the 2018 fire that injured 23 workers at the Kuraray America, Inc. EVAL plant in Pasadena, Texas.
The animation shows the events leading up to the incident, including how the blast occurred during the startup of a chemical reactor system following a scheduled maintenance shutdown. High pressure conditions developed inside the reactor and activated the reactor’s emergency pressure relief system, discharging flammable ethylene vapor through piping into an area where contractors were working.
Among the 23 workers injured during the incident, two were life-flighted from the facility, one of whom remained in critical condition for several days because of burn injuries. As many as 19 others were transported to the hospital by emergency responders for various injuries.
The animation depicts the incident and the events leading up to it.
The CSB determined that the cause of the incident was Kuraray’s emergency pressure relief system design that discharged flammable ethylene vapor from the reactor through horizontally aimed piping into the air in an area near workers. If Kuraray’s emergency pressure relief system had been designed to discharge the vapor to a safe location, the flammable ethylene gas should not have harmed any workers.
Screen capture shows a high pressure released after conditions developed inside the reactor and activated its emergency pressure relief system, discharging flammable ethylene vapor through piping into an area where contractors were working. Shortly after the release a fire and explosion rocked the facility.
Source: CSB
The CSB’s investigation report details a chain of process safety management failures that led to the build-up of excessive pressure inside the reactor. The emergency pressure relief system discharge design is just one of the 17 safety issues identified by the CSB in the report. The additional 16 safety issues are:
- Presence of Nonessential Workers During Startup and Upset Conditions
- Hazardous Location
- Recognized and Generally Accepted Good Engineering Practices
- Process Hazards Analysis Safeguards
- Process Hazard Analysis Recommendations
- Warning Signs
- Equipment Design
- Operating Procedures
- Operator Training
- Abnormal Operating Conditions
- Safety Interlock Disabling
- Alarm Management
- Process Alarm Response
- Safe Operating Limits
- Environmental Permit Limits
- Safety Management System Self-Assessment Audits
Click here to view the video.