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The purpose of an investigation report is not only to examine the possible causes of an incident but also to make evident the potential solutions that will prevent further complications from happening. Following a set of established rules and standards, the authors of a report are capable of pinpointing the flaws in the safety procedures of any establishment. This paper is a study of a report by the U.S. Chemical Safety Board, which explores the fatal explosion at the Airgas facility. The purpose of this case study is to reveal the deficient elements in the safety management of the manufacturing plant and to suggest possible actions that can help prevent the occurrence of further accidents.
A truck with liquid nitrous oxide exploded at the Airgas manufacturing plant on August 28, 2016, in Cantonment, Florida ( Airgas final investigation, 2017). This explosion resulted in the death of the only present employee and the closedown of the facility due to the equipment damage. Airgas informed the author of the report that during the weekends and night shifts only one employee works at the facility. According to the final report, it is possible that two trucks were involved in the accident, as one of the trailer trucks exploded and its splinter hit the second trailer, compromising the integrity of its container and causing the liquid nitrous oxide to explode ( Airgas final investigation, 2017). It is possible that the first trailer exploded because it was not properly coated with a protective layer of liquid nitrous oxide before being filled completely ( Airgas final investigation, 2017).
The report reveals that several elements of Process Safety Management were most likely executed improperly. First of all, the usage of ineffective safeguards during the transfer of the liquid nitrous oxide to one of the containers might have caused the explosion ( Airgas final investigation, 2017). This fact shows that there are two possible Process Safety Management elements that were not followed by the management of the Airgas facility: pre-start-up safety review and mechanical integrity (Saravanan, 2017). The report informs that Airgas did not check the fire preventive capabilities of the safeguards, namely the strainers filled with steel wool, before implementing these parts into the working process ( Airgas final investigation, 2017). According to the report, the Airgas manufacturing manual explicitly states that the use of steel wool in the strainers is prohibited; however, the material is still being used as a safety measure ( Airgas final investigation, 2017). It is a deficient element of the pre-start-up safety review because the employers did not make sure that the equipment on the plant was in complete accordance with the safety specifications for use with liquid nitrous oxide ( Airgas final investigation, 2017; Saravanan, 2017).
Secondly, the report states that the steel wool inside the strainers may have deteriorated before the accident, which falls under the mechanical integrity element of Process Safety Management ( Airgas final investigation, 2017; Saravanan, 2017). There were also multiple issues connected to Airgas giving the incorrect information to the manufacturers of pumps and other parts of the equipment involved in the accident ( Airgas final investigation, 2017). The erroneous information may have created further complications, as Airgas was most likely equipping their manufacturing tools with unsuitable parts. In addition, some operating procedures were not in regulation with manufacturers instruction. According to the report, Airgas failed to consider the recommendations of the companies that had made the equipment and Airgas did not provide clear and concise instructions to the workers in case of emergency situations ( Airgas final investigation, 2017). It is a violation of the operation procedures element as the workers did not have clear instructions for using the strainers as flame arrestors.
The other protection system, employed by Airgas, is a run-dry safety interlock, a system that prevents the pump from running low amounts of nitrous oxide and from drying out ( Airgas final investigation, 2017). Based on the information from employees, it becomes clear that this particular Airgas system does not follow the regulatory standards of handling and storage of the liquid nitrous oxide ( Airgas final investigation, 2017). In addition, the report states that Airgas performs a check-up of the systems without following any testing procedure and, thus, not acting in accordance with the process hazard analysis element of the Process Safety Management ( Airgas final investigation, 2017; Saravanan, 2017). Airgas employees do not have a concise method to evaluate the state of the pumps and determine whether the usage of this equipment is safe. Moreover, this lack of instructions leads to another failure to comply with the Process Safety Management, namely the element of emergency planning and response. The report states that Airgas did not adequately monitor the safety of the employees exposed to the nitrous oxide and did not implement a working system for emergency situations ( Airgas final investigation, 2017).
It is possible for Airgas employers to prevent the reoccurrence of the problems mentioned above by performing a number of corrective actions (Hafey, 2009). First of all, Airgas should modify the safety equipment according to the regulations, which were proposed by the manufacturers. That includes changing the steel wool filtration system to a material suitable for use with nitrous oxide, giving the manufacturer correct measurements for the equipment production and complying with the instructions for this equipment. Second, Airgas can compose a definitive guide to avoiding hazardous situations during work. That will allow employees to act according to the rules and understand the instructions more clearly. Third, the employers should consider the option of adding more employees to the night shifts and on the weekends, to prevent the employees from being unable to consult someone in a difficult situation. Finally, developing a method to determine the state of the equipment and conducting scheduled hardware inspections will also benefit the safety of the employees and the integrity of the facility.
The incident at the Airgas manufacturing plant occurred due to multiple reasons, connected to one main problem of not following the process safety management procedures. All in all, five elements of the Process Safety Management were incomplete: pre-start-up safety review, mechanical integrity, operation procedures, process hazard analysis, and emergency planning and response. The lack of clear instructions and thorough inspections from the employers, as well as failure to follow manufacturers recommendations, lead to the incident that significantly damaged the facility and resulted in a death of an employee. There are preventative actions that can create safer working conditions for the Airgas workers. To prevent further incidents from happening, Airgas can modify the safety equipment and redesign the operating procedures for the employees. Moreover, it is advisable for Airgas to create more concise and full instructions not only for operating but also for examining the machines and other hardware.
References
Airgas final investigation report. (2017). Web.
Hafey, R. (2009). Lean safety: Transforming your safety culture with lean management. Boca Raton, FL: CRC Press.
Saravanan, R. (2017). Process safety management systems in accident prevention. In Disaster, Risk and Vulnerability Conference 2017 (p. 50). Trivandrum, India: University of Kerala.
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