CSB Safety Video: Vinyl Chloride Explosion and Fire

Summary

On April 23, 2004, an explosion at the Formosa Plastics Corporation in Illiopolis, Illinois, tragically killed five workers and injured several others. The explosion occurred when a worker made a critical mistake while cleaning a reactor, bypassing safety protocols, leading to the release of highly flammable vinyl chloride. The CSB investigation revealed multiple safety failures, including poor training, inadequate evacuation procedures, and faulty equipment design. The incident highlighted the need for better safety systems and prompt evacuation protocols to prevent such catastrophic errors in the future.

Takeaways

• 😀 On April 23, 2004, an explosion at Formosa Plastics in Illiopolis, Illinois resulted in five deaths and several injuries, including a husband and wife.
• 😀 The explosion was caused by a worker mistakenly opening a valve on a pressurized reactor, leading to a release of highly flammable vinyl chloride.
• 😀 The accident occurred due to a combination of human error and system design flaws, such as inadequate safety measures and insufficient training for employees.
• 😀 The lack of safeguards, such as locks or devices to prevent opening critical valves under pressure, contributed to the severity of the incident.
• 😀 Formosa Plastics failed to adequately address near-miss incidents, such as previous valve misuses at other plants, which could have indicated a need for stronger safety controls.
• 😀 Employees did not have proper communication tools, such as radios or intercoms, to check reactor status with operators, increasing the risk of errors.
• 😀 The explosion resulted in significant destruction to the plant, including damage to the laboratory, safety offices, and reinforced concrete floors.
• 😀 The Chemical Safety Board (CSB) concluded that better training, drills, and more thorough evaluations of hazards could have saved lives during the emergency evacuation.
• 😀 CSB recommended that Formosa review and improve the design of all its U.S. facilities, focusing on minimizing the consequences of human error and enhancing safety systems.
• 😀 The accident emphasized the need for a comprehensive approach to chemical safety, taking into account both human error and system limitations in safety designs.
• 😀 CSB's safety recommendations included improving safety interlocks, better hazard analysis, and ensuring prompt evacuation with periodic drills to avoid similar incidents in the future.

Q & A

What caused the explosion at the Formosa Plastics Corporation facility?

The explosion was caused when an operator mistakenly opened the bottom valve of Reactor 310, which was pressurized and in mid-cycle, releasing highly flammable vinyl chloride.

How many people died as a result of the explosion, and what were the consequences for the workers?

Five workers died, including a husband and wife. Three others were severely injured, and two workers later died from their injuries. The explosion caused significant physical and emotional harm to the workers and their families.

What was the main industrial product produced at the Formosa Plastics plant?

The plant produced polyvinyl chloride (PVC), a common plastic used in various products such as credit cards, clothing, pipes, siding, and flooring.

How did the CSB investigate the incident and reconstruct the events?

The CSB used physical evidence, documents, and testimonies from surviving witnesses to reconstruct the events leading up to the explosion. They also created a computer simulation to visualize the sequence of events.

What safety procedure was bypassed by the operator that led to the explosion?

The operator bypassed the safety interlock system designed to prevent the opening of the reactor's bottom valve when it was pressurized. Instead of checking why the valve wouldn’t open, the operator attached an emergency air supply hose, which allowed the valve to open, releasing vinyl chloride.

What were some of the deficiencies in the safety practices at the Formosa Plastics plant?

Deficiencies included insufficient training and evacuation drills for employees, lack of safeguards like locks or devices to prevent critical valves from opening under pressure, and inadequate communication systems for operators on different levels of the plant.

What were the consequences of the explosion for the surrounding community?

The explosion had serious economic consequences for the surrounding community. The plant, which employed 139 workers, did not reopen after the incident, resulting in job losses and economic downturn for Illiopolis, Illinois.

How did the lack of communication between workers contribute to the tragedy?

The lack of communication between workers on different levels of the plant, particularly the absence of radios or intercom systems, meant operators could not quickly check the status of reactors, leading to confusion and delayed actions during the emergency.

What safety recommendations did the CSB make to prevent similar accidents in the future?

The CSB recommended that Formosa Plastics review the design and operation of its U.S. facilities, improve control of safety interlocks, evaluate high-risk hazards more thoroughly, and implement better emergency actions, including prompt evacuations and periodic drills.

What role did previous near-miss incidents play in the accident?

Previous near-miss incidents, such as the one in Baton Rouge, Louisiana, and another in Illiopolis, should have served as warning signs of potential risks. However, Formosa did not act swiftly enough to implement the necessary safety improvements before the explosion occurred.