3
Review and Assessment of Process Safety Incidents at Other Chemical Demilitarization Sites

Although the processes to be employed for disposal of chemical munitions at the Pueblo and Blue Grass Chemical Agent Destruction Pilot Plants (PCAPP and BGCAPP) are fundamentally different from those used at earlier chemical agent disposal facilities and vary somewhat among themselves, many similarities exist within and among the processes employed at all of the disposal facility sites. Prominent examples of similarities shared by the incineration sites and PCAPP and BGCAPP include the use of rocket shear machines (at sites where M55 rockets have been stored), thermal decontamination of metal parts, and methods used for waste treatment. The committee believed that evaluating documentation from those other sites concerning process incidents, any process safety metrics used, and process hazards could prove useful and would offer guidance on what process safety metrics might be useful for PCAPP and BGCAPP. Although none of the other chemical agent disposal facilities employed formal process safety metrics, the committee believed that an analysis of chemical events that occurred at those sites could provide insights into those process steps that are most subject to failure and might identify opportunities where the use of leading and lagging metrics could help to prevent failures.1 Thus, there are aspects of the operations of even the baseline incineration facilities that could be useful for deriving process safety metrics for use at PCAPP and BGCAPP.

The National Research Council Committee on Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities (the chemical events committee) reviewed all of the chemical events that had occurred since the commencement of destruction operations through the end of 2001, totaling 81 process and non-process-related incidents at that time. The chemical events committee issued its report, Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities, in 2002. This committee reviewed that report to identify which of the events could be classified as process incidents.2 Interestingly, the chemical events committee found that the causal factors underlying those events were not process related but were independent of any specific process. The chemical events committee’s analysis of causal factors is summarized in Table 3-1.

The following definitions extracted from the report on chemical events apply to the terms used in the tables in this chapter:

  • Standard operating procedure (SOP) deficiencies refer to nonexistent SOPs, inadequate SOPs, or SOPs being circumvented or ignored as a routine operating practice.

  • Equipment malfunction refers to the failure of equipment to function as designed but does not include design deficiencies. Such failures range from the simple tearing of waste bags to break­downs of critical instrumentation such as flow-meters and sensors.

1

“Leading metric” and “lagging metric” are defined in Appendix A.

2

An “event” is any off-normal occurrence. A “process safety incident” is defined in Appendix A.



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3 Review and Assessment of Process Safety Incidents at Other Chemical Demilitarization Sites Although the processes to be employed for disposal Disposal Facilities (the chemical events committee) of chemical munitions at the Pueblo and Blue Grass reviewed all of the chemical events that had occurred Chemical Agent Destruction Pilot Plants (PCAPP and since the commencement of destruction operations BGCAPP) are fundamentally different from those used through the end of 2001, totaling 81 process and at earlier chemical agent disposal facilities and vary non-process-related incidents at that time. The chemi- somewhat among themselves, many similarities exist cal events committee issued its report, Evaluation of within and among the processes employed at all of the Chemical Events at Army Chemical Agent Disposal disposal facility sites. Prominent examples of similari- Facilities, in 2002. This committee reviewed that report ties shared by the incineration sites and PCAPP and to identify which of the events could be classified as process incidents.2 Interestingly, the chemical events BGCAPP include the use of rocket shear machines (at sites where M55 rockets have been stored), thermal committee found that the causal factors underlying decontamination of metal parts, and methods used for those events were not process related but were inde- waste treatment. The committee believed that evaluat- pendent of any specific process. The chemical events ing documentation from those other sites concerning committee’s analysis of causal factors is summarized process incidents, any process safety metrics used, in Table 3-1. and process hazards could prove useful and would The following definitions extracted from the report offer guidance on what process safety metrics might on chemical events apply to the terms used in the tables be useful for PCAPP and BGCAPP. Although none of in this chapter: the other chemical agent disposal facilities employed formal process safety metrics, the committee believed • tandard operating procedure (SOP) deficiencies S that an analysis of chemical events that occurred at refer to nonexistent SOPs, inadequate SOPs, or those sites could provide insights into those process SOPs being circumvented or ignored as a routine steps that are most subject to failure and might iden- operating practice. tify opportunities where the use of leading and lagging • quipment malfunction refers to the failure of E metrics could help to prevent failures.1 Thus, there are equipment to function as designed but does not aspects of the operations of even the baseline incinera- include design deficiencies. Such failures range tion facilities that could be useful for deriving process from the simple tearing of waste bags to break- safety metrics for use at PCAPP and BGCAPP. downs of critical instrumentation such as flow- The National Research Council Committee on Eval- meters and sensors. uation of Chemical Events at Army Chemical Agent 2An “event” is any off-normal occurrence. A “process safety 1“Leading metric” and “lagging metric” are defined in Appendix A. incident” is defined in Appendix A. 23

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24 PROCESS SAFETY METRICS AT THE BLUE GRASS AND PUEBLO CHEMICAL AGENT DESTRUCTION PILOT PLANTS TABLE 3-1 Frequency of Causal Factors in the 81 • esign deficiency applies to equipment or facili- D Chemical Events Reviewed by the Chemical Events ties found to perform their operating functions Committee in 2002 inadequately as a result of poor design. • nexplained human error refers to human actions U Number of that were wrong for no reason recorded in the Times a Causal Percentage of investigation reports or for which there is no Factor Was Instances of Causal Factor Identified Causal Factors a pparent explanation. One example is when an operator assembled a piece of equipment SOP deficiencies 30 29.4 Equipment malfunction 12 11.8 incorrectly. Human error 7 6.8 • indset refers to the mental attitude people have M Design deficiency 16 15.7 about the process of disposal and the state of the Mindset 15 14.7 system during processing. One example is when Improper technique 12 11.8 a person assumes an agent alarm is false because Failure of communication 10 9.8 of a historical pattern of frequent false alarms. 102 100.0 • mproper technique refers to a manner of per- I NOTE: There is not a 1:1 correspondence between chemical events forming tasks that causes either a hazard or a and instances of causal factors. Most events involved more than one malfunction. An example is using equipment for causal factor, and for some events, it was not possible to determine causal factors. purposes other than those dictated by design. • ailures of communication refer to failure to F communicate essential information, failure to TABLE 3-2 Frequency of Causal Factors in the 121 heed communicated information, and inadequate Events at Chemical Agent Disposal Facilities Since communications systems. 2001 This committee requested an update on process- Number of Time a Causal Percentage of related chemical events from all operating sites and Factor Was Instances of the two sites that completed destruction since the Causal Factor Identified Causal Factors end of 2001. In all, 147 events were reported to the SOP deficiencies 31 27.4 committee,3 of which 26 were reviewed by the chemi- Equipment malfunction 29 25.7 cal events committee in 2002. This committee evalu- Human error 29 25.7 ated the remaining 121 incidents for frequency of event Design deficiency 6 5.3 type, process activity involved (e.g., maintenance, Mindset 6 5.3 waste handling, weapons transfer, and agent transfer), Improper technique 7 6.2 Failure of communication 5 4.4 consequence, and causal factors. The frequencies of 113 100.0 incident types, activities, and causal factors mirror those that were noted in the 2002 Chemical Events NOTE: There is not a 1:1 correspondence between chemical events and instances of causal factors. Most events involved more than one Report. A summary of the causal factors for these 121 causal factor, and for some events, it was not possible to determine events is presented in Table 3-2. causal factors. “SOP deficiencies” was the most frequent causal fac- tor, followed by “equipment malfunction” and “human error.” Significantly, almost all of the events were noted happened during maintenance activities. Only two to have had multiple causal factors, as is evidenced by incidents happened during munitions transfer and two the fact that 215 causal factors were identified for 147 during agent transfer; however, not all agent trans- events (also see notes to tables). fer incidents were tabulated. Twenty-five incidents The activities that had the most incidents and events occurred in the rocket shear machine, but the causes of were maintenance and waste handling. Thirty-one 21 of these were not, or could not be, assigned. events happened during waste handling, including In summary, it appears that the frequency, types, hydrolysate transfers and spills. Twenty-two events and causal factors of process safety events in chemical agent disposal facilities could not be correlated with the type of facility (neutralization or incineration), type of 3Personal communication between Carl Anderson, ACWA, and chemical weapon (blister agent or nerve agent), or how James Myska, BAST Senior Research Associate, on July 20, 2010.

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25 REVIEW AND ASSESSMENT OF PROCESS SAFETY INCIDENTS AT OTHER CHEMICAL DEMILITARIZATION SITES the agent is stored (in assembled munitions or bulk stor- Destruction Pilot Plant and the Blue Grass Chemi- age). Consequently, PCAPP and BGCAPP can reason- cal Agent Destruction Pilot Plant can reasonably be ably expect to experience the same types of events with expected to experience the same types of events hav- similar causal factors. Because of the unique nature of ing causal factors similar to those experienced at the the processes to be employed at PCAPP and BGCAPP, Chemical Materials Agency sites. Also, there may be however, and the extensive use of first-of-a-kind equip- an increase in the frequency of events and a shift in the ment, it may be reasonable to expect more events in relative frequency of causal factors. the early part of operations and, based on the data in Tables 3-1 and 3-2, a shift in the relative proportion of Causal factors for process safety events are dis- causal factors. For example, design deficiencies might cussed further in Chapter 4. be more prevalent in new facilities than in older or second-generation facilities. REFERENCE Finding 3-1. The causal factors involved in past events NRC (National Research Council). 2002. Evaluation of Chemical Events at Army Chemical Agent Disposal Facilities. Washington, D.C.: The at chemical agent disposal facilities are not process National Academies Press. specific. Consequently, the Pueblo Chemical Agent