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CSB Safety Video: Mixed Connection, Toxic Result

Key Lessons from the 2016 Chemical Release at the MGPI Processing Facility in Atchison, KS

U.S. Chemical Safety Board, January 3, 2018

The U.S. Chemical Safety Board (CSB) has released a new 11-minute safety video describing the events leading up to the October 21, 2016 toxic chemical release at the MGPI Processing plant in Atchison, Kansas.  The video, titled "Mixed Connection, Toxic Result" details key lessons from the CSB's investigation into the 2016 incident.  

The MGPI facility produces distilled spirits and specialty wheat proteins and starches. The chemical release occurred when sulfuric acid was inadvertently unloaded from a tanker truck into a fixed sodium hypochlorite tank at the plant. The two materials combined to produce chlorine gas and other by-products that sent over 140 individuals, both workers and members of the public, to area hospitals, and resulted in shelter-in-place and evacuation orders for thousands of local residents. 

Chairperson Vanessa Allen Sutherland said, “High risk operations, like the delivery and handling of hazardous chemicals, require strict adherence to safety protocols. An inadvertent mixture can result in a chemical reaction with extremely dangerous consequences. Our findings reaffirm the need for facilities to pay careful attention to the design and operation of chemical transfer equipment to prevent similar events.”

  • The CSB’s final report includes 11 key lessons and outlines clear safety improvements that can be implemented at similar facilities across the country.  Among these are facilities should evaluate chemical unloading equipment and processes and implement safeguards to reduce the likelihood of an incident, while taking into account human factors issues that could impact how facility operators and drivers interact with equipment. 
  • Facility management should evaluate their chemical transfer equipment and processes and, where feasible, install alarms and interlocks in the process control system that can shut down the transfer of chemicals in an emergency.

Lead Investigator Lucy Tyler added, “Facilities need to work collaboratively with their chemical distributors to conduct a risk assessment and develop and agree upon procedures for chemical unloading to ensure responsibilities are clearly defined.
 
The CSB’s investigation found that on the morning of the incident, a tanker truck arrived at the MGPI facility to deliver sulfuric acid. A facility employee escorted the driver to the locked loading dock and unlocked the gate to the fill lines and the sulfuric acid fill line. But unknown to the operator, the sodium hypochlorite fill line was also unlocked. And the two lines, which were only 18 inches apart, looked similar but were not clearly marked. The driver inadvertently connected his truck’s sulfuric acid hose to the sodium hypochlorite line and sulfuric acid began flowing inside. As a result of the incorrect connection, thousands of gallons of sulfuric acid from the tanker truck entered the facility’s sodium hypochlorite tank. The resulting mixture created a dense green cloud that traveled northeast of the facility until the wind shifted the cloud northwest towards a more densely populated area of town. 
 
Chairperson Sutherland said, “Every day facilities throughout the country receive bulk amounts of chemicals by cargo tank motor vehicles. Industry needs to review their own safety practices to ensure that such every delivery is executed safely.
 
The CSB’s final report issues safety recommendations to the companies involved in the incident, as well as the County’s department of emergency management. The recommendations focus on proper guidance regarding unloading procedures, planning, and training for personnel as well as emergency responders. The case study also reiterates an existing recommendation for ventilation guidance for control buildings.

CLICK HERE TO VIEW FINAL REPORT

 

About the Chemical Safety Board 

The CSB is an independent, non-regulatory federal agency whose mission is to drive chemical safety change through independent investigations to protect people and the environment. The agency’s board members are appointed by the President and confirmed by the Senate. CSB investigations look into all aspects of chemical incidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems. For more information, contact public@csb.gov. 


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