The report also charges that inadequate emergency planning by MFG Chemical, Whitfield County and the city of Dalton contributed to the severity of the event.
More than 200 families were forced to evacuate from their homes and 154 people had to be decontaminated and treated for chemical exposure at a local hospital after toxic allyl alcohol and allyl chloride were released from a reactor at the MFG facility on April 12, 2004.
Thirteen police officers and two ambulance personnel also were treated, and one MFG worker suffered chemical burns.
CSB investigators found that the accident occurred when a self-accelerating or "runaway" chemical reaction rapidly pressurized a 4,000-gallon chemical reactor, activating an emergency vent and releasing allyl alcohol and allyl chloride directly into the atmosphere.
"As the CSB pointed out in its 2002 study of reactive chemical hazards, these accidents often occur when companies do not effectively research the available literature, conduct thorough process hazard analyses, examine possible accident scenarios, and implement appropriate safety controls," CSB Chairman Carolyn Merritt said. "The 2004 accident in Dalton underscores the vital role of communities in preparing for chemical accidents and minimizing the harm to the public. Effective prevention and effective emergency planning go hand-in-hand."
Hazards of TAC Had Not Been Fully Evaluated
The accident occurred during the company's first attempt to make a production-scale batch of triallyl cyanurate (TAC), a chemical used in rubber manufacturing.
Investigators determined that MFG, which was producing TAC under contract with New Jersey-based GP Chemical, had not fully evaluated the hazards of the TAC-producing reaction, including a review of readily available technical literature.
The CSB report points specifically to published reports of two previous runaway reactions and fires that occurred during attempts to produce TAC. CSB's 2002 study estimated that over 90 percent of significant reactive chemical incidents involve hazards that are already documented in publicly available literature.
"MFG did not adequately plan for scaling up the reaction from the laboratory to full production volume or evaluate how much heat the reaction would produce," CSB lead investigator John Vorderbrueggen said. "The process controls, instrumentation and safety systems were not designed to prevent a runaway reaction and uncontrolled chemical release. If MFG had followed the good engineering and safety practices described in federal regulations, this accident likely would not have occurred."
Vorderbrueggen added that the process MFG was attempting was covered under OSHA's Process Safety Management standard and EPA's Risk Management Program rule.
Inadequate Emergency Response Planning Played a Role
Inadequate emergency response planning by the city of Dalton and Whitfield County was a contributing cause of the injuries and exposures among the public and responders, according to CSB.
None of the responding police officers had the proper training or protective equipment to safely enter the toxic vapor cloud, according to CSB. The city had no automated emergency notification system or evacuation plan, and police officers were instructed to drive into the chemical cloud to alert neighborhood residents to evacuate.
After the toxic vapor forced the unprotected police officers to retreat, firefighters wearing special breathing apparatus were eventually called in to complete the evacuation.
The report notes that the federal Emergency Planning and Community Right-to-Know Act (EPCRA) of 1986 requires the establishment of Local Emergency Planning Committees (LEPCs) throughout the country.
Under the statute, LEPCs are responsible for helping develop comprehensive emergency response plans that identify hazardous chemical facilities and describe emergency notification, response and evacuation procedures.
According to CSB, the state of Georgia has not defined clear responsibilities for implementing important requirements of EPCRA, and Whitfield County does not have an LEPC.
CSB Calls on MFG and Local, State Officials to Make Changes
CSB's report makes a total of 16 new safety recommendations, including that:
- MFG Chemical improve its process safety programs and emergency response planning;
- The city of Dalton establish, equip and train a hazardous materials response team and improve its emergency operations planning and fire and police department procedures and training;
- Whitfield County form an LEPC;
- The governor of Georgia clearly designate responsible agencies for implementing federal emergency planning and risk management requirements;
- Lyondell Chemical Co., which supplied MFG with the toxic allyl alcohol, more closely examine the chemical process safety programs of potential new customers; and
- The Synthetic Organic Chemical Manufacturers Association, of which MFG Chemical is a member, develop new safety guidance for "tolling" the practice of contracting out the production of specific chemicals.