Chemical Safety Board releases case study on fatal Goodyear accident

ERJ staff report (LMH)

Washington DC - The US Chemical Safety Board (CSB) has released a case study on a fatal 2008 accident at a Goodyear Tire and Rubber Plant in Houston, Texas.

The plant makes synthetic rubber, not tyres.

The case study, based on the heat exchanger rupture and ammonia release at the plant in Houston, Texas, identifies gaps in facility emergency response training and calls for increased adherence to existing industry codes.

The study was carried out by the CSB, an independent federal agency charged with the investigation of serious chemical accidents.

The accident occurred on 11 Jun 2008, when an overpressure in a heat exchanger led to a violent rupture of the exchanger, hurtling debris that struck and killed a Goodyear employee walking through the area. The heat exchanger contained pressurised anhydrous ammonia, a colorless, toxic chemical, used as a coolant in the production of synthetic rubber; five workers were exposed to ammonia released by the rupture.

The CBS investigation uncovered a number of issues surrounding the event, including a lack of information about maintenance work carried out on the heat exchanger which led to the rupture, as well as problems with the employee tracking system, making it difficult to account for all employees. As the fatally injured employee had been a member of the emergency response team, her absence from the evacuation muster point was not considered unusual.

“The absence of this worker had not been noted due to the lack of training and drills on worker headcounts. Plant personnel were not provided with the proper training to effectively manage this emergency,” said CSB chairperson, Rafael Moure-Eraso, adding: “Company procedures called for routine evacuation and shelter-in-place drills four times a year, but such drills were not held for several years prior to the incident.”

The CSB's final report outlines several lessons learned including the need to adhere to existing American Society of Mechanical Engineers (ASME) Boiler and Pressure Vessel Code.

“We found the accident likely would not have happened had operators followed the ASME code. It's crucial that workers continuously monitor an isolated pressure relief system throughout the course of a repair and reopen blocked valves immediately after the work is completed,” said CSB investigations supervisor Robert Hall.

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Press release from CSB