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LESSON LEARNED PROCESS SAFETY • ANY INCIDENT OFFERS A CHANCE TO LEARN BUT NOT EVERYONE TAKES THAT OPPORTUNITY. CSB APPLAUDS AIRGAS FOR HAVING LEARNED, AND LEARNED QUICKLY ANYONE CAN MAKE make a mistake. What’s important is what happens afterwards - a proper response often leads to greater respect. It’s a similar situation with accidents: even a well run company can suffer an accident but what marks them out from poorly run companies is how they deal with it. To highlight this, the US Chemical Safety and Hazard Investigation Board (CSB) has recently issued a Safety Spotlight, focusing on the actions taken by Airgas in the aftermath of a fatal accident at its manufacturing facility in Cantonment, Florida in August 2016. Those actions support CSB’s belief that the implementation of safety management systems is key to ensuring a safer chemical industry. The incident happened during the loading of a tank truck with nitrous oxide. The vehicle exploded, killing the only Airgas employee on
RAPID REACTION BY AIRGAS HAS LED TO IMPORTANT CHANGES TO PROCESS SAFETY MANAGEMENT
site and causing severe damage to the plant. CSB’s investigation determined that the most likely cause of the explosion was that, during the loading, a pump heated the nitrous oxide above its safe operating limits, starting a decomposition reaction that propagated from the pump into the trailer. CSB’s investigation also found that Airgas did not have an effective safety management system to identify, evaluate and control process safety-related hazards. However, it quickly embarked on a comprehensive initiative to review the safety programmes at its nitrous oxide production facilities, trucking fleet, and cylinder-filling operations. That initiative included 17 different areas for process safety improvements. As a result of that proactive work initiated by Airgas while the CSB investigation was still underway, the Board issued only a single recommendation to the company, which was to complete its post-incident actions and to continue to implement safety initiatives for its nitrous oxide operations.
WELL DONE AIRGAS CSB applauds Airgas for having embraced this challenge and aggressively pursuing actions to close out its recommendation. “These actions resulted in an approach that now exceeds the quality of a number of similar company safety programmes where such operations are covered by the OSHA Process Safety Management (PSM) standard,” it says. Those actions included the creation of a new industrial risk management programme, a process hazard analysis methodology, a management-of-change procedure, and a project risk identification process. These are now included in written procedures that have been added to the company’s safety manual and incorporated into company operations. Several components of the CSB’s recommendation required literature reviews, third-party engineering assessments, policy development, senior level hiring, audits, training for operations personnel, and the application of new approaches. “Despite the scope and breadth of these activities, Airgas met with the CSB investigation team and members of the CSB Office of Recommendations in March 2019 to discuss status of the recommendation and then provided a formal written presentation. In May 2019, Airgas responded formally to the CSB documenting the successful close-out of the actions taken in response to the CSB’s recommendation,” CSB notes. In a little more than two and a half years, Airgas reengineered its entire approach to managing process safety in its nitrous oxide business. Airgas also increased its efforts to share the lessons learned and good safety practices, both inside the company and with the broader compressed gas industry. In addition, Airgas implemented new information-sharing practices internally, which connected to ongoing engineering assessments, audits, and training for operations personnel. “CSB acknowledges Airgas’s actions to advance chemical safety by identifying and implementing important safety changes even before the CSB investigation concluded,” CSB says. “As a result, Airgas exceeded CSB’s recommended actions by developing and rapidly executing comprehensive process safety changes that have broadly applicable lessons for the entire compressed gas industry.”
HCB MONTHLY | SEPTEMBER 2020
