The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

CSB Investigators to Assess Fatal Nitrogen Incident at Valero Delaware City Refinery

Washington, DC, November 7, 2005 - Investigators from the U.S. Chemical Safety and Hazard Investigation Board (CSB) are en route to the Valero oil refinery in Delaware City, Delaware, where two contract workers were overcome and killed this weekend by entry into a nitrogen gas-filled process vessel.

Tow Investigators are expected at the site later this afternoon. The team will gather preliminary information to assess whether the incident warrants further investigation by the CSB.

In August 2002, the CSB completed a year-long investigation of a fatal storage tank explosion at the same refinery, then owned by Motiva Enterprises.

In June 2003, the CSB issued a Safety Bulletin on the hazards of nitrogen asphyxiation, which identified 85 incidents in the U.S. between 1992 and 2002 that resulted in a total of 80 deaths and 50 injuries. The bulletin was prompted in part by the CSB's investigation of a nitrogen asphyxiation incident at a Union Carbide chemical plant in March 1998; one worker was killed and another severely injured when they entered a large process pipe that was being flushed with nitrogen.

More information is available from www.csb.gov, including the full text of the CSB's Nitrogen Safety Bulletin, Union Carbide investigation report, and Motiva investigation report.

This message was transmitted at 1:00 PM Eastern Time (U.S.A.) on November 7, 2005.

The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

CSB Issues Preliminary Findings in BP Texas City Refinery Accident; Investigators Present Data in Public Meeting

Texas City, Texas, October 27, 2005 - In preliminary findings set to be released at a public meeting here tonight, investigators from the U.S.

Chemical Safety and Hazard Investigation Board have identified six key safety issues underlying the March 23 explosions and fire at BP's Texas City refinery, an incident which killed 15 workers and injured 170 others. The six identified safety issues were:

1. Trailers were placed in an unsafe location, too close to an isomerization(isom) process unit handling highly hazardous materials. All the fatalities occurred in and around trailers that were as close as 121 feet from the release. One trailer located 600 feet from the explosions was heavily damaged, and 39 other trailers were either damaged or destroyed.
2. The unit's raffinate splitter should not have been started up due to existing malfunctions of the level indicator, level alarm, and a control valve.
3. The raffinate splitter tower had a history of abnormal startups that included recurrent high liquid levels and pressures.
4. The day of the incident, a blowdown drum vented highly flammable material directly to the atmosphere. The drum was never connected to a flare since its construction in the 1950s. The previous owner of the refinery, Amoco Corporation, replaced the isom unit blowdown drum in 1997 with identical equipment; Amoco refinery safety standards recommended connecting the drum to a flare when such major modifications were undertaken but this was not done.
5. Between 1995 and March 23, 2005, there were four other serious releases of flammable material from the isom blowdown drum and stack that led to ground-level vapor clouds; fortunately none ignited.
6. In 1992 OSHA cited a similar blowdown drum and stack at the Texas City refinery as unsafe because it vented flammable material directly to the atmosphere, but the citation was dropped and the drum was not connected to a flare system.
7. The public meeting is scheduled for 6 p.m., Thursday, October 27, at the Doyle Center, 2010 Fifth Avenue North in Texas City. Following the investigators' presentation, the Board will call for comments by members of the public.

The CSB Chairman said, "The meeting tonight marks an important milestone in the Board's independent investigation of the tragedy at BP Texas City. The preliminary findings we present this evening should be reviewed throughout the industry, which shares the CSB's goal of safer operations in the future. I also commend BP for cooperating with our investigation. BP has provided witnesses and documents on a voluntary basis and has facilitated testing of critical equipment."

CSB investigators released three detailed computer animations of the startup of the isom unit, the vapor cloud formation, and the subsequent explosions.

The simulations showed a vapor cloud that blanketed much of the nearly five-acre isom unit just before the cloud was ignited, most likely by an idling diesel pickup truck.

The process simulation depicts liquid hydrocarbon flows through a complex of piping connecting a heat exchanger, a furnace, the raffinate splitter tower, and the blowdown drum. As the temperature and fluid levels increase inside the tower, the animation shows pressure-relief valves directing overflow to the blowdown drum and attached vent stack. The drum rapidly fills, finally causing a geyser-like release of flammable liquids from the top of the vent stack. The vaporizing liquid falls to the ground, where it forms a vapor cloud.

The CSB Lead Investigator said, "The first rule of oil refinery safety is to keep the flammable, hazardous materials inside piping and equipment. A properly designed and sized knockout drum and flare system would have safely contained the liquids and burned off the flammable vapors, preventing a release to the atmosphere."The lead investigator said investigators found evidence that BP evaluated connecting the raffinate splitter to a flare system in 2002 but ultimately decided against it. After the March 2005 incident, BP said it would eliminate blowdown stacks that vent directly to the atmosphere at all U.S. refineries.

Investigators presented new details on the 16 previous startups of the raffinate splitter from 2000 onward. They found eight startups with tower pressures of at least double the normal value, and thirteen startups with excess liquid levels. These abnormal startups were not investigated by BP.

"Investigations of these incidents could have resulted in improvements in tower design, instrumentation, procedures, and controls," the lead CBS investigator stated.

In his presentation, the lead CBS investigator said that there was no supervisor with appropriate experience overseeing the startup at a critical time on March 23. Operators did not follow the requirements of startup procedures, including opening the level control valve for the splitter tower. This omission allowed the tower level to rise rapidly for three hours, to fifteen times its normal level. Operators were misled by the malfunctioning level indicator on the tower and a separate high-level alarm which failed to activate. The training and experience of the operators remains under investigation.

Investigators stated that a variety of equipment problems made it unsafe to start up the raffinate splitter on March 23. "Proper working order of key process instrumentation was not checked as required by the startup procedure. Managers turned away technicians and signed off on the instrument tests as if they had been done," the lead CBS investigator said. Investigators also found that BP's traffic policy allowed vehicles unrestricted access near process units. On the day of the incident, there were running vehicles including a diesel pickup truck as close as 25 feet from the blowdown drum.

A total of 55 vehicles were located in the vicinity of the drum, investigators determined, and one likely served as the ignition source for the explosions.

Based on findings from its BP investigation, the CSB earlier this week issued two new urgent recommendations to leading U.S. petrochemical trade organizations. The Board called on the American Petroleum Institute (API) to develop new safety guidance that establishes minimum distances for occupied trailers away from hazardous areas of process plants. The Board also called on API and the National Petrochemical & Refiners Association (NPRA) to immediately contact their members urging "prompt action to ensure the safe placement of occupied trailers away from hazardous areas of process plants," before the new API safety guidance is completed.

A final public report of the investigation is expected in 2006. The Chairman said, "The investigation will continue with further equipment testing, witness interviews, and the analysis of root causes. Most importantly, we will be developing additional safety recommendations to prevent similar incidents at companies around the country. Investigation alone cannot bring back what has been lost, but we can learn from this tragedy and prevent the loss of life in the future."

This message was transmitted at 11:00 AM Eastern Time (U.S.A.) on October 27, 2005.

The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

CSB Issues Case Study on April 2004 Oil Refinery Explosions and Fire at Giant Industries' Ciniza Refinery near Gallup, NM

Albuquerque, NM, October 26, 2005 - The U.S. Chemical Safety and Hazard Investigation Board (CSB) today issued a final Case Study report examining the causes of the April 8, 2004, refinery explosions and fire that seriously injured six employees and caused an evacuation at the Giant Industries'

Ciniza oil refinery in Jamestown, New Mexico, east of Gallup.

The incident occurred in the refinery's hydrofluoric acid (HF) alkylation unit. Alkylation is a standard oil refinery process that combines olefins with isobutane using a catalyst, HF in this case, to produce alkylate.

Alkylate, which is highly flammable, is used to boost the octane rating of gasoline.

The CSB investigation found that the day before the incident, alkylation unit operators performed a regularly scheduled switch of the alkylate recirculation pumps in the iso-stripper section of the akylation unit. When operators attempted to put the spare pump in service, they discovered that it had a leaking mechanical seal and that it would not rotate.

The spare pump was scheduled for maintenance the next day. To isolate the pump for work, plant personnel, using a valve wrench, turned a shut-off valve connecting the pump to a distillation column to what they believed was the "closed" position. CSB investigators determined that the valve was actually open.

An operator disconnected the pump's vent hose to verify that no pressure was in the pump, and witnessed some alkylate flow through the hose. After the flow subsided, he believed the pump had been de-pressurized and was ready for removal. The study concluded that the vent line was plugged, not de-pressurized. As the mechanics were removing the pump alkylate was suddenly released at high pressure and temperature, producing a loud roar that was audible throughout the refinery. One of the mechanics was blown over an adjacent pump and broke his ribs. About 30 to 45 seconds after the initial release, the first of several explosions occurred. The plant operator was covered in alkylate that quickly ignited and seriously burned him. Other personnel suffered burns and eye injuries.

CSB lead investigator described several findings related to this explosion: "Giant's mechanical integrity program did not effectively prevent repeated pump seal failures. Problems were addressed when equipment broke down, not in a preventive manner. The design of the valve wrench made it easy to remove and reposition onto the valve stem in different directions, and this led to a potential hazard because operators sometimes determined whether the valve was open by its wrench position, rather than the valve position indicator. In this incident, the valve wrench collar had been installed in the wrong position. Operators depended on the wrench position and mistakenly determined the valve was closed."

The study also found that the valve had been modified in the past to replace a hand wheel method of opening and closing it with a bar-type hand wrench.

If the company had performed a management of change analysis before modifying the valve, they could have recognized the hazard of identifying the valve position that this modification caused. In addition, Giant operators did not effectively verify that the pump involved in this incident had been isolated and depressurized before beginning to remove it.

Under Lessons Learned, the CSB urges management of change analyses for any valve modifications; effective "lock out tag out" programs to ensure equipment has been isolated, depressurized, and drained; and proper mechanical integrity programs to prevent breakdown maintenance. The study said Giant should have determined the cause of the frequent alkylate recirculation pump malfunctions and implemented a program to prevent them.

A CSB Board Member said, "Proper mechanical integrity programs and effective management of change analyses are essential components of safe operations at any refinery. The Board plans to disseminate this Case Study to other refineries and trade organizations to help make incidents like the one at Giant less likely to occur in the future."

This message was transmitted at 12 noon Eastern Time (U.S.A.) on October 26, 2005.

The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

CSB Issues Urgent Recommendations to U.S. Petrochemical Industry, Calls for Safer Placement of Trailers for Workers in Wake of BP Tragedy

Washington, DC, October 25, 2005 - On a unanimous vote, the U.S. Chemical Safety and Hazard Investigation Board (CSB) today issued two new urgent safety recommendations in its investigation of the March 2005 refinery disaster at BP Texas City, calling for the safer placement of trailers for workers at petrochemical facilities throughout the U.S.

The full text of the Board's resolution issuing the new recommendations was posted on the agency's website, www.csb.gov.

In the incident at BP Texas City, fifteen workers died in and around trailers that were located too close to hazardous process equipment that released flammable hydrocarbons during startup. The urgent recommendations were announced in advance of an October 27 Board public meeting in Texas City concerning the BP investigation.

The Board directed the urgent recommendations to two leading national trade organizations, the American Petroleum Institute (API) and the National Petrochemical & Refiners Association (NPRA), which represent most major domestic oil and petrochemical producers. API develops recommended safety practices that influence operations at thousands of petrochemical facilities around the country.

The first recommendation calls on API to develop new industry guidance 'to ensure the safe placement of occupied trailers and similar temporary structures away from hazardous areas of process plants.' The Board noted that the existing safety guidance, API Recommended Practice 752, does not prohibit the placement of trailers in close proximity to hazardous process units. The guidance, entitled 'Management of Hazards Associated with Location of Process Plant Buildings,' is widely used by U.S. oil and chemical companies to assess siting hazards, a regulatory requirement under OSHA's Process Safety Management standard.

'We are calling on the industry to establish minimum safe distances for trailers to ensure the safety of occupants from fire and explosion hazards,' said CSB Chairman. 'The tragedy at BP's Texas City refinery warrants changes in safe siting practices across the nation.' Under Board procedures, the requested measures should be completed within 12 months, at which time the Board will consider closing the recommendation based on 'acceptable' or 'unacceptable' actions by the recipients.

On March 23, 2005, fifteen workers were killed and more than 170 were injured when explosions and fire erupted during the restarting of a process unit at BP's Texas City refinery, the third largest in the U.S. All of the fatalities occurred in and around a group of nine trailers involved in maintenance work unrelated to the restart. Some trailers were as close as 121 feet from the unit that experienced the release of flammable hydrocarbons. Over 40 trailers were damaged in the incident.

As currently written, API 752 allows individual companies to define their own risk and occupancy criteria for trailers. Prior to March 23, BP had defined trailers used for short periods of time as posing little or no danger to occupants and approved the location of the trailers at the Texas City facility.

According to findings accompanying the Board's urgent recommendation, the explosions in Texas City injured workers in trailers as far as 480 feet from the source of the release, and trailers up to 600 feet away were heavily damaged. Subsequent to the incident, BP announced it would relocate trailers at least 500 feet away from potential hazards and move nonessential workers into office space outside the refinery.

'In many cases, trailers are positioned for convenience during maintenance and are not essential for facility operations,' the board member said. 'They can be easily relocated to safe distances.' The board member noted that the permanent buildings in refineries and chemical plants are often heavily reinforced to resist blast and fire damage, while most trailers and temporary structures provide little protection for occupants.

A separate urgent recommendation, directed jointly to API and NPRA, called on the organizations to immediately contact their members urging 'prompt action to ensure the safe placement of occupied trailers away from hazardous areas of process plants,' before the new API safety guidance is completed.

The recommendations were only the second and third designated as 'urgent' of more than 300 issued in the Board's eight-year history. The CSB's first urgent recommendation, issued on August 15, 2005, called on BP to form an independent panel to examine its safety culture and oversight of its five North American refineries. On Monday, BP announced formation of the independent panel, chaired by a former U.S. Secretary of State.

This message was transmitted at 10:38 AM Eastern Time (U.S.A.) on October 25, 2005.

The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

Statement of CSB Chairman on BP's Formation of an Independent Refinery Safety Review Panel, October 24, 2005

On August 15, 2005, the CSB issued an urgent safety recommendation to the BP Global Executive Board of Directors, calling on the BP Group to 'Commission an independent panel to assess and report on the effectiveness of BP North America's corporate oversight of safety management systems at its refineries and its corporate safety culture.'

The Board took this unprecedented step based on evidence of systemic management lapses that contributed to the tragic explosion at BP's Texas City Refinery on March 23, which cost 15 lives and more than 170 injuries. It was the first urgent recommendation issued in the Board's eight-year history.

Last week, the CSB received a number of documents from BP related to the recommendation. These documents included a charter and preliminary operating procedures for the independent panel as well as biographical sketches for ten named panelists, including the panel chairman, former U.S. Secretary of State.

I commend BP for their efforts to cooperate with the Board's investigation and to constitute this important panel. BP has selected a diverse and distinguished panel and chair to examine its safety culture and oversight of its North American refineries. I anticipate that Secretary of State, his fellow panelists, and the panel staff will conduct a thorough, impartial, and effective examination of these issues and report their findings to BP and the public.

The scope of the panel review includes all five of BP's North American refineries in Texas City, Texas; Carson, California; Whiting, Indiana; Cherry Point, Washington; and Toledo, Ohio. BP has agreed to fully fund the panel and provide it with the budget and authority to hire any required outside staff, counsel, or expert consultants. The panel is to receive 'full and broad access to relevant documents, information, facilities and personnel' including information gathered during BP's own investigation of the March 23 accident.

As recommended by the Board and as chartered by BP, the panelists are to work independently from any outside influence. Panel members are required to disclose, resolve, and make public any material conflicts of interest that would compromise the independence of the panel. According to the panel charter, 'Only the Independent Panel acting by a majority vote is authorized to remove a sitting member for good cause' and the panel 'will be solely responsible for the final content of its written report.' While BP may facilitate the panel's operations, its role with respect to the panel's final report is limited to commenting and seeking correction of any factual inaccuracies.

Under the charter, the panel is authorized to conduct public meetings and is required to act by majority vote, subject to a quorum requirement, and is required to make public its operating rules. The final report as well as any and all recommendations of the panel will be made public. These provisions will afford the public an opportunity to understand and examine the effectiveness of the panel.

BP has selected a panel of ten members, including six with documented expertise in process safety or in the safe management of high-risk enterprises outside the petrochemical sector. BP has also conferred with its principal labor union, the United Steelworkers of America, in selecting appropriate panelists. Consistent with the timetable established in the Board's urgent recommendation, BP has asked the panel to 'use best efforts to complete its final report within 12 months from its establishment.'

BP's overall response describes planned actions that, when faithfully implemented, will satisfy the objective of the Board's recommendation. Accordingly, on October 21, 2005, the Board voted to designate this recommendation as 'Open - Acceptable Response.'

The Chemical Safety Board will continue to track and monitor the activities of the independent panel throughout its tenure. At the end of the process, the Board will evaluate the entirety of the panel's work and issue a determination whether the CSB recommendation should be designated as 'closed' and under what terms, such as 'acceptable' or 'unacceptable.'

When completed, we believe this independent review and report can provide invaluable information to industries that have the potential for catastrophic accidents. We hope that the panel's work will not only benefit the safety of BP facilities but also will serve everyone who works to prevent such accidents. Without BP's cooperation, this vital work could not proceed.

While the panel's work unfolds, the Chemical Safety Board will be continuing its independent root-cause investigation of the March 23 incident. We will be issuing our preliminary findings at a public meeting in Texas City later this week on October 27, and we will be pursuing our efforts thereafter until all the causes of this tragedy are known.

This message was transmitted at 10:23 AM Eastern Time (U.S.A.) on October 24, 2005.

The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

CSB Determines Fatal 2003 Incident at Hayes Lemmerz Plant in Indiana Most Likely Caused by Explosion in Dust Collection System; Company Did Not Identify or Control Hazards of Aluminum Dust

Huntington, Indiana, Oct. 5, 2005 - The fatal explosion and fire at the Hayes Lemmerz International, Inc., aluminum wheel plant was caused by the ignition of fine powdered aluminum in a dust collection system in which hazards were neither identified nor adequately addressed, the U.S. Chemical Safety and Hazard Investigation Board (CSB) said today in issuing its final report on the incident.

The explosion, which occurred around 8:30 p.m. Oct. 29, 2003, caused fatal burns to a mechanic working near an aluminum melt furnace, severely injured a second mechanic nearby, and caused lesser burns to a third worker. Four other workers suffered minor injuries.

CSB investigators determined that the dust that exploded originated in a scrap system at the facility. A high concentration of aluminum dust, when suspended in air, is highly combustible. The CSB determined the dust was a byproduct of the process in which aluminum chips and scraps -- which are created as the wheel castings are machined -- are dried prior to being sent to a furnace for re-melting. Dust from the scraps is conveyed into a dust collector outside the building. The CSB determined that an explosion in the collector sent a pressure wave through the system ductwork and back into the building. A fireball then erupted inside the building, which lofted and ignited further aluminum dust that had accumulated on rafters and equipment.

The Board found the company did not address why the chip drying system was releasing excess dust, and did not identify or address the dangers of aluminum dust ignition, despite having a history of small dust fires inside the factory. The CSB also determined that Hayes Lemmerz did not ensure the dust collector system it ordered was designed in accordance with guidance in a prominent fire code published by the National Fire Protection Association.

The CSB Chairman said, "This accident followed a classic syndrome we call 'normalization of deviation,' in which organizations come to accept as 'normal' fires, leaks or so-called small explosions. The company failed to investigate the smaller fires as abnormal situations needing correction or as warnings of potentially larger more destructive events. The CSB almost always finds that this behavior precedes a tragedy."

The CSB Chairman noted that aluminum dust collection systems are at particular risk. "The report indicates that aluminum dust is among the most explosive of all metal dusts and the conditions in dust collectors that are not properly designed, installed or maintained present the ideal environment for an explosion and fire," she said.

The report refers to the National Fire Protection Association's NFPA 484 code as an important prevention document for companies to use to reduce the risk of such an explosion. "In this circumstance, NFPA 484 provisions were not being followed and the risk of such an explosion at this facility was extremely high," the CSB Chairman said.

The CSB Chairman cited chemical dust as a particularly insidious danger needing careful hazard analysis and treatment. Noting the CSB is conducting a separate, comprehensive study of the hazards of dust in the workplace following the Hayes Lemmerz incident and two other dust explosions the CSB investigated in Kentucky and North Carolina, the CBS Chairman said, "As has happened in other plants, combustible dust can accumulate on rafters, above false ceilings, on top of equipment, in ventilation ducts and dust collectors just waiting for the right conditions of suspension and ignition.

Processes where such dust is created are at risk and must take special care to eliminate the combustible dust hazard."

Because of the destruction, the CSB was not able to identify the exact ignition source that started the explosion chain. One of the Investigators said, "Any number of sources can set off an explosion, including hot surfaces, electrostatic discharges, or burning embers. What's important to note is that when that much dust accumulates, and becomes suspended in air, it takes very little energy to set off an explosion."

The CSB listed among 22 key findings the company's "inadequate housekeeping" in the foundry area and "insufficient maintenance" of the chip processing equipment, leading to the dust accumulation that fueled the secondary explosion. In particular the findings noted the dust collector filters were infrequently cleaned, some ducts leaked dust because they were eroded, maintenance workers were not wearing flame-retarding clothing at the time of the accident, and the company did not have formal written maintenance procedures or employee training in place for the dust collector system.

The Board further noted that fire inspectors in Indiana have not been trained on recognizing or preventing combustible dust hazards.

The Board issued formal recommendations to the company, urging among other things that it develop and implement a means of handling and processing aluminum chips that minimizes the risk of dust explosions, and implement regular training on such hazards. The CSB recommended the Indiana Occupational Safety and Health Administration develop and distribute an educational bulletin on metal dust explosion prevention, and urged the Indiana Department of Fire and Building Services provide training for fire inspectors on recognition and prevention of combustible metal dust hazards.

This message was transmitted at 10:00 AM Eastern Time (U.S.A.) on October 5, 2005.

The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

CSB Deploys Investigation Assessment Team to Site of Formosa Plastics Explosion in Point Comfort, Texas

Washington, DC, October 6, 2005 - The U.S. Chemical Safety and Hazard Investigation Board (CSB) is deploying a five-person assessment team to the site of an explosion and fire at the Formosa Plastics plant in Point Comfort, Texas, on the Texas coast.

According to early media reports, the incident injured several workers and required residents in Point Comfort and nearby Port Lavaca to shelter in place by staying in their homes -- closing windows and shutting off air conditioning systems due to potentially toxic fumes in the area. Reports also indicated that authorities closed roads and Port Lavaca causeway, State Highway 35 and Farm-to-Market Road 1593. The blast occurred about 3:30 p.m., according to witnesses. A company spokesperson was quoted as saying the plant employs 1,100 people, about 500 of whom work on site at any given time.

The CSB team will fly to South Texas tomorrow, Oct. 7, and plans to arrive on site late afternoon or early evening. The Investigation team leader will be accompanied by four investigators. They will assess the severity of the incident after which the Board will decide whether to begin a formal investigation.

Formosa Plastics Corp. USA is based in Livingston, N.J. It is a plastics and petrochemicals company. Besides Port Comfort, Formosa has plants in Baton Rouge, La., Delaware City, Del., and Illiopolis, Ill. The CSB currently is investigating a serious accident at the company's Illinois site which occurred on April 23, 2004. Five workers were fatally injured and two others were seriously injured when an explosion occurred in a polyvinyl chloride (PVC) production unit. That explosion apparently followed a release of highly flammable vinyl chloride, which ignited. The explosion forced a community evacuation and lighted fires that burned for several days at the plant.

This message was transmitted at 10:00 AM Eastern Time (U.S.A.) on October 7, 2005.

The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

In Wake of Hurricane Katrina, CSB Issues Safety Bulletin Urging Oil and Chemical Facilities to Take Special Safety Precautions During Startups

Washington, DC, September 8, 2005 - The U.S. Chemical Safety and Hazard Investigation Board (CSB) today issued a Safety Bulletin urging oil and chemical facilities to take special precautions when restarting in the wake of shutdowns due to Hurricane Katrina.

The CSB three-member board voted to approve the Safety Bulletin this afternoon, and the full text of the Bulletin has been posted on the agency website, www.csb.gov. It notes that the startup of major processes at chemical facilities is a hazardous phase, saying, "Facilities should pay particular attention to process safety requirements during this critical period to assure a safe and expeditious return to operation."

The Bulletin says that, as the industry recognizes, starting up a complex petrochemical process requires and receives a higher level of attention and care than normal processing, because numerous activities are occurring simultaneously and many automatic systems are run under manual control.

Noting that many facilities - after being forced to shut down during the hurricane and subsequent floods - will be restarting over the coming weeks and months, the CSB said, "This is a time to make sure that no more lives are claimed by this tragedy and no further delays occur in the production of essential transportation fuels and chemicals."

The CSB Chairman said, "From our past investigations we know first-hand the dangers of catastrophic incidents during startup. The nation can not afford another serious petrochemical plant accident, especially in this crucial time of tight fuel supplies. We are urging facilities to follow established startup procedures and checklists prior to restarting."

The Safety Bulletin points to three catastrophic startup incidents investigated by the CSB that occurred at U.S. petrochemical plants since the agency began operations in 1998. These resulted in a total of 22 deaths, more than 170 injuries, and lengthy shutdowns in production units. Other tragic incidents investigated by the CSB occurred during the startup of batch process and during maintenance operations that followed a power outage. Detailed information about these and all CSB investigations can be found at www.csb.gov.

The Safety Bulletin suggests specific procedures to assure safe restarts under the headings, "Rely on Established Safety Systems"and "Check Process Equipment Thoroughly." For example, facilities are urged to follow established startup procedures and checklists, and to recognize that "human performance may be compromised due to crisis conditions." Board Chairman Merritt added that "Many employees in the region have lost homes or loved ones in the hurricane, adding to the stress of an already difficult work situation."

The Bulletin calls on facilities to check bulk storage tanks for evidence of floating displacement or damage, and to examine insulation systems, sewers, drains, furnace systems, electric motors and other equipment, including warning systems, to make sure they are fully functional.

This message was transmitted at 5:20 PM Eastern Time (U.S.A.) on September 8, 2005.

The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

Ruptured Transfer Hose Caused August 11 Chlorine Release at Honeywell Plant in Baton Rouge; Rapid Shutoff Attributed to Upgraded Safety Systems

Washington, DC, August 12, 2005 – A three-person assessment team from the U.S. Chemical Safety and Hazard Investigation Board (CSB) said that a ruptured chlorine transfer hose, which was being used to unload a railroad chlorine tank car, resulted in the chlorine release yesterday morning at the Honeywell International plant in Baton Rouge, LA. Investigators Lisa Long, Allen Smith, and Katherine Leskin conducted interviews with employees today and will continue their work on Saturday.

The Lead Investigator said that Honeywell records indicate the hose – which shows visible signs of being ruptured – was installed at the facility in recent weeks. The lead Investigator said the hose will be tested under a joint agreement with Honeywell. She said the chlorine release lasted 45 seconds. During the release, eleven contract workers nearby were exposed as they evacuated. The contractors were decontaminated before being transported to the local hospital for treatment. The contractors were treated at the hospital for their exposure and released the same day.

The incident occurred approximately 24 hours following a news conference in Baton Rouge at which CSB Chairman and the Lead Investigator presented the final CSB Investigation Report on three Honeywell toxic chemical releases, including a chlorine release in July 2003. In that incident, more than three and one-half hours elapsed before the chlorine leak could be stopped. The CSB found numerous shortcomings in Honeywell’s chlorine detection and emergency shutdown systems. The CSB made several safety recommendations to prevent a recurrence.

The lead CSB Investigator said that this time, owing to improvements recommended by the CSB, the shutdown was rapid after the hose burst without warning. “Honeywell operators in the control room responded to chlorine detection alarms by pushing the emergency shutoff button, activating shutoff valves on the rail car and on the plant side of the failed hose. These new systems, which were not present during the 2003 release, succeeded in sharply reducing what could have become a much bigger release.”

The CSB Chairman credited Honeywell for installing new equipment based on the CSB’s preliminary findings while the final recommendations to the company were being drafted. “We consider any release of chlorine, a highly toxic chemical, to be serious,” the CSB Chairman said. “However, we are pleased to see that shutdown equipment installed in response to our findings apparently prevented a larger release. It’s our hope that all chlorine handlers and producers will review our recommendations in the Honeywell investigation and take similar steps to prevent accidents or limit the damage from ones that do occur.”

The CSB Chairman said, “We are concerned about the cause of the hose failure. In 2002 the Board investigated an extremely serious chlorine release in Festus, Missouri, that also involved a chlorine transfer hose rupture. When shutdown systems failed in that event, 48,000 pounds of chlorine were released over three and one-half hours. Because of the hazards of chlorine, it is extremely important to maintain the integrity of emergency equipment and all critical transfer equipment.”

The full investigation reports for both the previous Honeywell incident and the chlorine release from DPC Enterprises in Festus, Missouri, may be found at www.csb.gov

This message was transmitted at 6:56 PM Eastern Time (U.S.A.) on August 12, 2005.

The CSB is an independent federal agency charged with investigating industrial chemical accidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in safety management systems.

The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Please visit our website www.csb.gov