Process Safety Moments from CCPS

Wrong material in the wrong

tank: A fatal reactive
chemistry incident
Date: June 2010
Issue Number: 001
AIChE © 2010. All rights reserved. Reproduction for non-commercial,
educational purposes is encouraged. However, reproduction for the
purpose of resale by anyone other than CCPS is strictly prohibited.
 Process Safety Moments
2

It is sincerely hoped that the information presented in this work will lead to
even more innovation and advancement for the entire industry; however,
neither the American Institute of Chemical Engineers, its consultants, CCPS
Technical Steering Committee and Subcommittee members, their
employers, their employers' officers and directors, the presenter of this
work, the creators of this work, their employers, nor their employers'
officers and directors, warrant or represent, expressly or by implication, the
correctness or accuracy of the content of the information presented in these
Guidelines. As between (1) American Institute of Chemical Engineers, its
consultants, CCPS Technical Steering Committee and Subcommittee
members, their employers, their employers' officers and directors , and (2)
the user/viewer of this work, the user/viewer accepts any legal liability or
responsibility whatsoever for the consequence of its use or misuse.

CCPS Process Safety Moment No. 001 2

What happened?
3
A company operated a location that had several chemicals
stored in tanks in various places in the plant.

Plant procedure was for the shift supervisor to authorize the

tanker driver to off load chemicals.

Water solutions of sodium hydrosulfide and ferrous sulfate

were among the chemicals received by truck and unloaded into
storage tanks.

CCPS Process Safety Moment No. 001 3

Plant Layout
4
The truck of sodium
hydrosulfide was supposed
to be unloaded to these
tanks

It was actually hooked up

and unloaded to the ferrous
sulfate tanks at this location

CCPS Process Safety Moment No. 001 4

What happened?
5
Shift supervisor was expecting a delivery of Ferrous Sulfate.

A tank truck containing Sodium Hydrosulfide arrived at the

plant.

The driver had never been to the plant before.

The Shift Supervisor escorted the driver to the Ferrous Sulfate

tank and authorized him to off load without inspecting the
trucker’s paperwork.

The driver connected to the tank and began offloading Sodium

Hydrosulfide through a connection marked “Ferrous Sulfate”.

CCPS Process Safety Moment No. 001 5

Incident Scene
6
Unloading arrangement

CCPS Process Safety Moment No. 001 6

Incident Scene
7
Unloading connection

CCPS Process Safety Moment No. 001 7

What happened?
8
The two chemicals (sodium hydrosulfide and ferrous sulfate)
react and produce hydrogen sulfide (H2S), a colorless gas which
is highly toxic at 800ppm.

An operator noticed an unusual odor and passed out.

The operator recovered sufficiently to notify others to call 911.

The truck driver was found unconscious and later pronounced

dead at the scene.

CCPS Process Safety Moment No. 001 8

Plant Layout
9
The truck driver was
found unconscious at
this location and
died from hydrogen
sulfide exposure

An operator passed
out at this location,
but fortunately
recovered in time to
get help.

CCPS Process Safety Moment No. 001 9

Why did this happen ?
10
The Shift Supervisor assumed the contents of the delivery
based on experience, and what he was expecting to receive.

Plant procedure for oversight of the delivery of chemicals was

not followed.

The truck receiving and unloading procedure was not written.

No plant employee observed the off-loading.

CCPS Process Safety Moment No. 001 10

Why did this happen ?
11
There was no method of communication at the unloading area.

Piping at the off-loading point was properly labeled (ferrous

sulfate) but did not match the material listed on the shipping
papers (sodium hydrosulfide).

Nobody checked that the material in the truck was the same as
the material marked on the piping where the truck was
connected.

CCPS Process Safety Moment No. 001 11

Can this happen at your plant?
12
Do you have a written procedure for receiving chemicals?

Does it include safety instructions and a step to verify that the

correct materials are being unloaded to the correct tanks?

How do you confirm that tank trucks, railroad tank cars, or

other containers being unloaded actually contain the material
that you think they contain?

Do you know the consequences of improperly mixing two of

the materials you receive by truck or other bulk container by
pumping one of them into the wrong tank?

Are you certain that tank vents are directed to a safe place so
people will not be exposed to vapors vented from the tank?
CCPS Process Safety Moment No. 001 12
Can this happen at your plant?
Are unloading connections and piping clearly labeled with the 13

material name and flow direction?

Is the unloading connection secured to prevent unauthorized
off-loading?
If your plant allows truck drivers to unload materials, how do
you know that they are properly qualified, and understand your
plant’s safety rules and procedures?
What is your plant’s procedure for how to deal with the arrival
of a shipment of any chemical at an unexpected time?
Can you communicate to get help if there is an emergency at
the places where you unload or transfer chemicals?

CCPS Process Safety Moment No. 001 13

Points to discuss
14
If the Supervisor was too busy, what should have been done?

How well trained on chemical hazards can you expect a truck

driver to be?
In particular, think about potential reactions with other chemicals in YOUR
plant.

How are chemical deliveries managed at your plant?

How is this kind of incident addressed in your Process Hazard

Analyses (PHA)?

How are the hazards and necessary controls communicated to

the operators and other plant staff following the PHA?

CCPS Process Safety Moment No. 001 14

Points to discuss
15
What safeguards could be implemented to prevent a
reoccurrence?

Should we make further improvements to prevent a similar

event?

Do you know of any incidents in your plant or somewhere else

in your company which were similar to this one?
An incident which resulted in a serious incident, chemical reaction,
material release, injury, or other significant consequence?
A “near miss” incident which did not have any consequence other than
material contamination or financial loss?

CCPS Process Safety Moment No. 001 15

For more information:
16
References:

CCPS Process Safety Beacon,

March 2009 (“Read only”
copy available for download
at www.sache.org)

United States National

Transportation Safety Board
(NTSB) Hazardous Materials
Accident Brief, Accident No.
DCA99MZ006, Whitehall,
Michigan, June 4, 1999.

CCPS Process Safety Moment No. 001 16

Get more information:
17
CCPS books and resources on reactive chemistry hazards:
Essential Practices for Managing Chemical Reactivity Hazards (2003)
Individual Hardcopy Book
CCPS Electronic Library (Knovel)
Guidelines for Process Safety Fundamentals in General Plant Operations
(1995)
Individual Hardcopy Book
CCPS Electronic Library (Knovel)

CCPS Member Companies: Volunteer to Serve on a CCPS

Committee

Not a CCPS Member Company? Learn about the benefits

CCPS Web Site: www.aiche.org/ccps

CCPS Process Safety Moment No. 001 17