![\"Worker](\"http:\/\/jordanbarab.com\/confinedspace\/wp-content\/uploads\/2018\/01\/MGPI-300x198.jpg\")
Seems like no matter how well a government report describes, some reporters persist in blaming workers’ “mistakes” and “gaffes” for chemical releases and other incidents.<\/p>\nSeems like no matter how well a government report describes, some reporters persist in blaming workers’ “mistakes” and “gaffes” for chemical releases and other incidents.<\/p>\n
Last week, the Chemical Safety Board released a final report<\/a> on a major chemical release at MGPI Processing Inc., in Atchison Kansas in October 2016,\u00a0 due to the inadvertent mixing of sulfuric acid and sodium hypochlorite.\u00a0The two materials combined to produce chlorine gas that sent over 140 workers and members of the public to the hospital and required thousands of local residents to evacuate or shelter-in-place.<\/p>\n A lazy worker not paying attention?\u00a0 No, but it seems like blaming workers is always the first thought of some reporters and others.<\/p>\n Last April, when the CSB released preliminary findings, I criticized<\/a> an AP article whose headline read:\u00a0\u201cFeds: Human error, labeling led to chemical cloud in Kansas.\u201d\u00a0 Again, following the release of the CSB report, a headline from the Kansas City Business Journal<\/a> proclaims “That toxic fog spread over Atchison because of a gaffe with locks, report says,” and the first sentence of the article reads “A federal agency attributed\u00a0a toxic fog that enveloped Atchison in 2016<\/a>\u00a0to a mistake by plant employees in unlocking chemical storage tank pipelines.”<\/p>\n Interestingly, if you read the 48 page report, the words “gaffe” or “mistake” never appear.\u00a0 What does appear is a serious analysis of a series of significant problems with the design of chemical transfer equipment, lack of automated and remote shut off systems, and faulty chemical unloading procedures at the plant.<\/p>\n Early on the morning of October 21, 2016, a driver from Harcros Chemicals pulled up to MGPI to deliver 4,000 gallons of sulfuric acid. The MGPI operator unlocked a delivery pipe and went back to the office. The truck driver then hooked his hose up to an unlocked pipe and turned on the valve. Within a few minutes heavy clouds of chlorine gas descended on the truck, got sucked into the control room and began drifting over the heavily populated area. It turns out there were two unlocked pipes, right next to each other and the driver hooked the delivery line into the wrong pipe and got back in the truck to do the paperwork.\u00a0 By the time he noticed the cloud, he wasn’t able to access the valves on the back of the truck to turn off the flow. The operators in the control room couldn’t access their emergency respirators fast enough\u00a0 because they were locked in their locker and they weren’t able to open the combination locks with chlorine gas pouring into the room. Because neither the control room operators nor the truck driver could access the shut-off valves, it was 45 minutes before a HazMat team could arrive and finally close the discharge valve on the tanker truck.<\/p>\n This event was not unique. Pipeline and Hazardous Materials Safety Administration\u00a0(PHMSA) incident data from 2014 through 2017 and found that unloading incidents involving hose connections to incorrect tanks occur frequently but most commonly involve compatible materials and result in tank overfills. Less common are incidents similar to the MGPI incident where two incompatible materials are inadvertently mixed due to incorrect tank connections. However, since January 1, 2014,156 eight incidents similar to the MGPI incident have occurred involving incompatible materials and resulting in a chemical reaction. These incidents resulted in 44 injuries and the evacuation of 846 individuals.<\/p>\n I’ll summarize here, but read the report<\/a> or at least check out the video below.<\/p>\nWhat Happened<\/h2>\n
Why?<\/h2>\n